Friday, September 24, 2010

A LOT To Take In (Not for the faint at heart or weak at stomach)

I am going to be brutally honest and just say that yesterday when my nurse emailed me with my list of meds and then the pharmacy called to confirm my list of meds- I got a little dizzy and nearly had a panic attack! Just look at the names of these things? When the pharmacy called I was jotting down notes in Microsoft Word thinking the spell check would correct them and I misspelled over half of the meds! I got a little worried when the email came and this is what it said: (Keep in mind my hubby will be the one administering these shots!!!!!)

The Sher Institutes for Reproductive Medicine

Medication Administration Guidelines



  • An ml = cc
  • Needles are STERILE, do not touch them before using them to inject and only use them ONCE
  • Rotate injection sites from one side of the abdomen to the other, and from one thigh to the other
  • With a multi-dose medication vial, swab the top of the medication vial with an alcohol swab before each use
  • When in doubt about medication dosage or injection, PLEASE call the office for clarification. DO NOT GUESS!
  • There is a nurse on call through the service after office hours. Please call 702-892-9696 before 11pm and the service will promptly page the nurse on call
  • Read all of the medication labels before taking the medication to ensure that you are taking the correct medication
  • Report all medication errors and unusual reactions to your coordinator as soon as possible

Dexamethasone 0.75 mg Tablet or Prednisone 10 mg

  • This is a steroid tablet
  • This is given to decrease inflammation and reduce the inflammatory response of your body to foreign bodies (your embryo) before embryo transfer
  • Take once a day in the morning with your breakfast to decrease GI upset and other potential side effects
  • Potential side effects are insomnia, increase in appetite and bloating.

Lupron (Leuprolide Acetate)

  • Lupron is taken to suppress your hormones at the pituitary level, it does NOT suppress your ovaries
  • Injection to be given subcutaneous in either the upper thigh (up by panty line) or in the abdomen (stay 1 inch away from belly button) in the AM (between breakfast and lunch) with a few hour flexibility between days (See diagram on page 5)
  • The medication comes in a multi-dose vial
  • Use the insulin syringes with the orange cap to draw up dose and inject
  • Refer to your calendar for dosage and measure units (U) on the syringe
  • The most common side effect is hot flashes, this will be relieved by the start of your hormone medication (i.e., E2V or Gonal-F or Follistim


  • To be taken like Lupron, subcutaneous in AM
  • Also like Lupron, it is being taken to suppress your own hormones and has a better long term effect with fewer side effects
  • Given at ½ dose (125 mcg) rather than prepackaged dose of 250 mcg (same as 0.25 mg)
  • Ganirelix:
    • To split Ganirelix (prefilled in a syringe) use a 1 cc syringe that does not have a needle and pull down plunger to 0.25 cc.
    • Then inject 0.25cc from the prefilled Ganirelix syringe into the 1 cc syringe you have just prepared.
    • Place a 27 gauge ½ inch needle on the 1 cc syringe to inject.
    • Save the remaining 0.25 cc in prefilled syringe for next morning’s shot.
    • Keep refrigerated.
  • Cetrotide:
    • To split Cetrotide fill the vial of powder with the prefilled water (1 cc) in kit.
    • Now you will have 2 doses in vial.
    • Use same orange cap syringe that you used for the Lupron and withdrawal 50 Units (½ cc) of Cetrotide for first morning’s injection.
    • Save the remaining 50 Units (½ cc) in vial for next day’s injection.
    • Keep refrigerated.
    • Second dose may only measure up to 35 or 40 Units. This is normal, do not mix up another vial just inject whatever is left for the second dose.

E2V = Estradiol Valerate = Delestrogen

  • Not all protocols involve E2V, so if this is not on your calendar then omit instructions.
  • This is given to “prime” the receptors on the ovaries to improve response the following week to the stimulation medications.
  • This is an IM (intramuscular) injection given in the PM (between dinner and bedtime) in the upper outer quadrant of the buttock (See diagram on page 5)
  • Give while lying down to relax the muscle
  • Verify that your Delestrogen concentration is 20 mg/ml
  • Use a 1 cc syringe without a needle (NOT a Lupron syringe) and attach a 18 gauge 1 ½” needle to draw out the medication to 0.2 cc or the dosage in which you have been instructed to take. Switch needle to a 22 gauge 1 ½” to then inject intramuscularly.

E2V 2 mg suppositories

  • Not all protocols use the Estradiol Valerate vaginal suppositories
  • These are given to ensure that the uterus is being supplied with enough estrogen
  • Insert vaginally at bedtime
  • These may or may not be continued after CD9.
  • Make sure you are inserting the E2V 2mg (Estradiol Valerate) suppositories NOT the suppositories used after embryo transfer which are Estradiol Valerate 1 mg/ Progesterone 50 mg suppositories (or E2V/ P4). If you use the latter in error your cycle will be immediately cancelled.
  • Keep refrigerated

Folic Acid 1mg tablet

  • Prescription strength folic acid dose (over-the-counter dose is only 400 mcg).
  • These tablets are taken to prevent Spina Bifida-type problems in fetus.
  • No side effects and can be taken anytime.
  • You may opt to take a Prenatal Vitamin instead of straight Folic Acid, this is fine as long as it is prescription strength

SDF (Viagra) Suppositories

  • Given to increase blood flow to endometrial lining
  • Take vaginally 4 times daily
  • No side effects, except possible vaginal irritation from so many suppositories.
  • Place the suppositories over the course of a day (with the last at bedtime, unless you are taking E2V suppositories as well) and that it doesn’t have to be exactly a certain amount of hours apart.
  • You may wish to wear a panty liner since not all of the wax absorbs and you may experience slight oozing.
  • You should try to at least be sitting for 15 minutes after each insertion.
  • Keep refrigerated

Terbutaline 5 mg Tablets

  • Given to relax the uterine muscle which will allow more blood flow through the uterine vessels
  • Starts with SDF suppositories.
  • One tablet three times a day
  • You will experience the side effects of nervousness, shakiness and a racing heart! If your heart rate is over 120 beats per minute, please skip a dose
  • Your body will adjust to the Terbutaline in 2-5 days and you will no longer experience the side effects

Heparin 5,000 IU / Lovenox 30 mg

  • Only use if indicated on your calendar
  • Twice a day injections, to be given in the AM with Lupron/Cetrotide and in the PM with stimulation medications/hormone injections
  • Subcutaneous injection given with a ½ cc or 1 cc insulin (Lupron) syringe
  • Verify the concentration of your Heparin. If 10,000 units/ml then your dose twice a day is 5000 units or ½ ml (which is equivalent to 50 units on the insulin syringe).
  • You may also use Lovenox 30 mg one a day subcutaneously anytime in the day in lieu of heparin.
  • You may experience some bruising at injection site, do not rub vigorously

Gonal F / Follistim

  • This is FSH (Follicle Stimulation Hormone) or stimulation medication
  • This is given subcutaneously anytime in the evening anytime between dinner time and bed time
  • Please refer to packet instructions for reconstitution as can come in multidose vial, single dose vial and Pen form
  • Your coordinator will go over instructions with you or you may contact Fertility Lifelines (1-866-538-7879) for Gonal-F product support 24 hours a day


  • This is pure Luteinizing Hormone (LH)
  • To be given as a separate injection in the PM with your stimulation medication
  • This is given subcutaneously
  • The dose is always 1/2 vial (37.5 IU) as indicated on your calendar
  • Use the 3ml syringe with 22 gauge 1 ½” needle to draw up 1 cc of diluent
  • Inject full 1 cc into vial of powder (this is now 2 doses)
  • With same syringe/needle, withdrawal only ½ cc (0.5 ml) and refrigerate remaining ½ cc for next evening’s dose
  • Change needle to the 27 gauge ½ “ to inject subcutaneously.

Progesterone in oil

  • This medication will be given in one of two dosage amounts, 50 mg (1cc) or 100 mg (2cc). See your calendar for your dosage.
  • This is an IM (intramuscular) injection given in the PM (between dinner and bedtime) in the upper outer quadrant of the buttock (See diagram on page 5)
  • Give while lying down to relax the muscle.
  • Use a 3 cc syringe with an attached 18 gauge 1 ½” needle (or 20 gauge) to draw out the medication to the dosage in which you have been instructed to take. Switch needle to a 22 gauge 1 ½” (or 25 gauge 1 ½” needle if your product is made in ethyl oleate oil) to then inject intramuscularly.

Final Comments

  • On CD9 (cycle day 9 when monitoring in our office begins) you will be given a new calendar and instructions once we have determined how you are progressing
  • There will be medications you have received that are not on your calendar at this point (i.e., Cipro, hCG 10,000 units, progesterone in oil, Clindamycin suppositories, E2V/ Progesterone suppositories). These will be used post CD9.


Injections sites

Intramuscular injection sites

Subcutaneous Injection Site (use upper thigh or lower abdomen)




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