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Patient Education: In Vitro Fertilization (IVF) Fresh Cycle, Using GnRH Antagonist Protocol

CHR's patient education for IVF with GnRH Antagonist (Antagon) consists of the following components:

1. What is an IVF? - a brief description of the procedure
2. Pre-cycle checklist - a list of pre-cycle tests and preparations
3. Timeline of IVF at CHR - what needs to be done and when
4. Medications - pharmaceutical company's instructions and information on medications used
5. Consent Forms
6. FAQs
7. Completion/Question Form - let CHR know you've read it, and ask questions

Please read each item carefully, and make a list of questions you might want to ask. This way, you will be more prepared when you meet with your nurse coordinator for your training session. When you are unsure about something along the way, you can always come back to this page to refresh your memory.

Every cycle stimulation may have to be individualized and, therefore, may end up deviating from the here described routine. Please always follow the instructions, given by the CHR staff. When in doubt, call CHR at 212-994-4400, rather than taking the wrong step. Our staff is available for inquiries 24 hours a day, 7 days a week.

Once you have read through all the relevant material according to the type of IVF you will be going through, please complete the Completion/Question Form.

1. What is IVF?

IVF is a procedure that can offer a chance of parenthood to women who have blocked or absent fallopian tubes, or men with low sperm counts. In an IVF cycle, you will use injections and other medications to encourage your ovaries to produce more than one mature egg. You will be closely monitored using ultrasound and blood tests to determine when your eggs are mature. Once your doctors have determined that your eggs are ready, your retrieval will be scheduled. Retrieval is a short in-office procedure for which you will be given light sedation. After your eggs are retrieved, they will be mixed with sperm (inseminated). The following day, our embryologists will check to see if the eggs accepted the sperm, and if they are fertilized. Three to five days later, some of the resulting embryos will be placed in your uterus (embryo transfer), bypassing the fallopian tubes. Two weeks after the embryo transfer, you will find out if you have achieved pregnancy by having a blood test.

OPTIONAL: If you need more general information on IVF, you can continue on to read about IVF. (A new window or tab will open.)

2. Pre-Cycle Checklist

A series of tests are required before an IVF cycle can take place, on both female and male partners. Specific requirement may vary depending on various factors, but please briefly look through the Checklist, and bring it with you for your appointment with your nurse coordinator.

Download the Pre-Cycle Checklist. (A downloadable PDF will open in a new window or tab.)

3. Timeline of IVF Using Standard Antagon Protocol

After the initial consultation with a physician (which determines the type of treatment you will be undergoing), you will need to complete all the required pre-cycle tests (please refer to the Pre-Cycle Checklist). After your checklist is complete and before starting a cycle of treatment, you should carefully review the material on this web page and schedule an appointment with one of our clinical nurse coordinators to review instructions for preparing and injecting your medications, in a step we call a "Teach."

This appointment will be an opportunity for you to address any questions that you may have after studying the information provided on this page. For this appointment, please bring a copy of the completed questionnaire provided at the end of this material. This visit will also provide an opportunity for you to receive necessary prescriptions and to initiate any required pre-authorization from your insurance carrier, if applicable.

At CHR, if you are using an "GnRH Antagonist Protocol," you will return for a blood test and sonogram about 10 days before your next anticipated menstrual period (about day 18 to 19 of a normal 28 day cycle). If your tests confirm that you have ovulated, you will begin using estrogen patches (see the medication list for more detail). About 10 days after beginning your estrogen patches, your normal menstrual period will start. On day 1 of flow, you need to call CHR to schedule another sonogram and blood test for the following day.

Antagon Cycles
Click on the image for a larger version of the cycle card.
Step 1	10 days before your next period	Visit CHR for a blood test and ultrasound to confirm that you have ovulated. If you don't have regular menstrual cycles, we will give you specific instructions. Start Estrogen patch as directed. If you have irregular menstraul cycles, we may have you start the Estoren patches even if you haven't ovulated.
Step 2	Day 1 of your next period	Call 212-994-4400 to make an appointment for baseline tests (ultrasound and blood work) the next day. This is also the last day for the Estrogen patch.
Step 3	Day 2 or 3of your next period in the in the morning:	Visit CHR for baseline ultrasound and blood work, as scheduled. You will meet with your nurse coordinator to go over the medications. We call this step a "Teach." You will also review the informed consent with the nurse coordinator. You will have an opportunity to ask questions and sign the forms. You will be told when to return for further monitoring. Start your injections as instructed.
Step 4	5 days after the start of injections	Visit CHR for ultrasound and blood work. After this day, your physician will adjust the dosage depending on your response to the medications.
Step 5	7-10 days after the start of injections	You will visit CHR one or more times (as instructed), for monitoring (blood work and ultrasound). When your follicles are ready, your physician will instruct you to start GnRH antagonist (Antagon) injections (see the medication list for more detail). You may be asked to increase your dose of hMG.
Step 6	7 - 16 days after the start of FSH and hMG	When we have determined that you are ready, based on your monitoring results, we will instruct you when to take your hCG injection (see the medication list for more detail). It is crucial that you administer this injection at the precise time that your nurse coordinator instructed you. The evening of your hCG is teh last time your partner should ejaculate until after your retrieval, unless you are using frozen sperm.
Step 7	Morning after hCG injection	Visit CHR between 8 am and 10 am for blood test. Start other medications as instructed (antibiotics, increase prednisone, etc.)
Step 8	Approximately 34 hours after hCG injection	Visit CHR one hour before the scheduled time for egg retrieval. You will need to be accompanied by an adult who will assist you returning home. Your husband will produce semen sample at CHR unless you are using frozen sperm. Your eggs will be retrieved through ultrasound-guided needles in a 10-minute procedure. Retrieved eggs will be inseminated with the semen sample. Appointment for embryo transfer is given at this time. You will need to rest for 1 hour at CHR, then 1 day at home. After the procedure, the staff will give you specific discharge instrucitons regarding medications.
Step 9	Day after the retrieval	Our staff will call you to inform you of the results of fertilization and of the embryo transfer schedule.
Step 10	3 - 5 days after egg retrieval	Visit CHR for embryo transfer at the scheduled time, usually between 10 am and 2 pm. You will need to be accompanied by your partner or friend. Embryos will be transferred to your uterus through a catheter. Appointment for pregnancy test, two weeks later, is given at this time.
Step 11	16 days after the embryo transfer	Visit CHR for pregnancy test.

4. Medications

For IVF cycles using the Antagon Protocol, there are five main medications. Brand names of the medications you use will vary, so we've listed the generic name on the left-hand column, with general information on each medication at the top of the right-hand columns. For usage instructions of the specific brand-name medication you will be using, click on the icons below ( & ).

Follicle Stimulating Hormone (FSH)	Follicle Stimulating Hormone (FSH) is used in IVF cycles to stimulate your ovaries to produce multiple mature eggs. FSH is taken as subcutaneous injections daily. Take FSH as directed.
	Brand Name	Printable Instruction	Video Instructions	Prescribing Information
	Bravelle®	N/A
	Follistim®		N/A
	Gonal-f®
Human Menopausal Gonadotropin (hMG)	hMG contains natural follicle-stimulating hormone (FSH) and luteinizing hormone (LH). In IVF cycles, hMG is used to regulate ovulation and encourage growth of multiple eggs when clomiphene citrate did not work well. hMG is taken as subcutaneous injections daily. Take hMG as instructed.
	Brand Name	Printable Instruction	Video Instructions	Prescribing Information
	Repronex®
	Menopur®	N/A
Ganirelix Acetate (GnRH Antagonist)	In IVF cycles, Ganirelix Acetate (often called Antagon, even though it's a brand name--a bit like Band Aid and Hoover) is used to prevent premature ovulation. Ganirelix Acetate suppresses Luteinizing Hormone, which would normally let your ovary to release the mature egg (i.e., ovulation). Ganirelix Acetate is taken as subcutaneous injections.
	Brand Name	Printable Instruction	Video Instructions	Prescribing Information
	Antagon	N/A	N/A
Human Chorionic Gonadotropin (hCG)	hCG is similar to LH. In an IVF cycle, one-time injection of hCG is used to trigger ovulation to get your mature eggs ready for insemination. You should wait until you are instructed specifically to administer this injection. Take one injection when instructed. Timing for this injection is critical!
	Brand Name	Printable Instruction	Video Instructions	Prescribing Information
	Novarel™	N/A
	Pregnyl	N/A	N/A
	Profasi	N/A	N/A	N/A
	Ovidrel
Progesterone	Progesterone is used to thicken your endometrium (lining of the uterus) so that the implantation of fertilized egg(s) will be easier. Medications used in ovarian stimulation can suppress progesterone levels in your body, so it is important to supplement it with exogenous progesterone. You will be taking both Progesterone injections and Prometrium vaginally. Inject 50 µg Progesterone once a day. Insert 2 capsules (200mg) Prometrium in your vagina 3 times a day.
	Brand Name	Printable Instruction	Video Instructions	Prescribing Information
	Prometrium®		N/A
	Progesterone		N/A	N/A
Micronized Estradiol	Micronized estradiol helps maintain and build your uterine lining so that the transferred embryos will find a comfortable environment there. Insert a 2mg tablet in your vagina 3 times a day.
	Brand Name	Printable Instruction	Video Instructions	Prescribing Information
	Estrace	N/A	N/A
Micronized DHEA	DHEA improvers the quality of eggs and embryos. Take one 25mg pill orally, 3 times a day with meals. Continue until the positive pregnancy test.
	Brand Name	Printable Instruction	Video Instructions	Prescribing Information
	FERTINATAL®		N/A	N/A
Baby Aspirin	Aspirin helps increases blood supply to your uterus and ovary. It also prevents clotting. Take one 81mg pill daily.
Prenatal Vitamins	Prenatal vitamins, such as Folate, will help prevent neural tube defects. Iron will build up your blood count. Calcium helps build your babies' bones and will help you maintain yours. Take one pill a day.
Prednisone	Prednisone suppresses male hormones and immune function. Take one 10mg pill daily until further instructions.
	Brand Name	Printable Instruction	Video Instructions	Prescribing Information
	Prednisone	N/A	N/A
Doxycycline	Doxycycline is an antibiotic used to prevent infection after the egg retrieval. Take one 100mg pill twice daily, for 5 days. Wait for specific instructions.

5. Consent Forms

All signed informed consent documents are required prior to any procedures performed at CHR. Please read through the following informed consent forms according to your planned treatment(s) so that you are well informed by the time you meet with your nurse coordinator for further explanation and signing of the form(s). You should NOT sign the consent form(s) until you meet with your nurse coordinator.

• Download the Affirmation of Sexual Intimacy Form.
• Download the Comprehehsive Informed Consent for IVF, ICSI, AZH and Embryo Cryopreservation.

If you are using donor sperm:

• Download the Informed Consent for Sperm Donor Inseminaton.

6. FAQs

Why am I using Antagon (GnRH antagonist)?
--This type of cycle is used if you have had poor results using other, more conservative, protocols. Your doctor may also choose an antagonist protocol if your laboratory tests indicate very poor ovarian reserve. All IVF cycles use some medications to protect against spontaneous ovulation.

What does GnRH antagonist do?
--The GnRH antagonist prevents your pituitary gland from secreting LH. Preventing a mid-cycle LH surge will protect you from ovulating too soon.

Why don't I take GnRH antagonist from the beginning of the cycle?
--We have you start the GnRH antagonist later in the cycle, because it's a strong medication that might prevent your normal response to fertility medications.

What are the possible problems in an antagonist cycle?
--Even with careful monitoring, you might ovulate spontaneously.

7. Completion/Question Form

For future reference, we recommend printing this page (a printer-friendly version is here. Please click here for the Completion/Question Form where you will be asked to answer a few questions on this IVF training material, as well as have an opportunity to ask additional questions, if you have any. After you have submitted the Completion/Question Form, you will be asked to print out a certificate, so that you can bring it in with you the next time you have an appointment with CHR.

Written by David Barad, MD

Last updated: April 9, 2013