Mixing Instructions For Injectable Medications

Mixing instructions for hCG

You will be given specific instruction as to when you are to take this medication. The evening that you are to take the hCG, you will not take your Gonal-F, Follistim, Bravelle, Menopur, or Lupron, unless instructed otherwise. Your dosage is 10,000 units of hCG. The proper timing of this medication is critical!

Do not give hCG earlier than you are instructed to!
hCG comes in a glass vial with a rubber stopper. The package contains a vial of diluent with 10cc’s of water and a vial of powder which contains hCG. You will only need 2cc of the water to mix the hCG. Do not use the whole vial of water or you will have to get multiple IM injections to receive the correct dose!!!

Remember to use only 2cc of the diluent!!

Please follow these steps to mix and inject hCG:

1. Clear a clean work area on your counter or table to mix your medication.
2. Wash your hands.
3. Open the box and remove both vials (medication vial and water vial) from the box.
4. Check carefully the NAME, DOSAGE, and EXPIRATION DATE of all the vials.
5. Use the thumb to lift the plastic lid or thumbnail to lift the tab off of the vials, wipe the rubber stopper with an alcohol swab or cotton ball soaked with alcohol. Do not remove the metal ring that holds the stopper in place.
6. Remove a 3cc syringe with a 22G 1½ inch needle attached from the package. Tighten the needle onto the barrel with a twisting motion.
7. Pull back on the plunger to the 2cc mark to draw air into the syringe. Then insert the needle through the rubber stopper of the vial of the diluent (sterile water). Push the air into the vial, turn the vial upside down and keeping the needle below the fluid level, withdraw 2cc of water into the syringe. Pull the needle out.
8. Inject 2cc of diluent into the vial of hCG (powder). Swirl or tilt (DO NOT SHAKE) the vial until the medication is mixed. It takes 2-4 minutes to completely dissolve. The mixture is completely clear when ready to use. Draw all of the mixture into the syringe, flick the syringe with your finger to force air to the surface of the mixture and slowly expel the air out of the syringe. Remember to invert (turn the vial upside down) and keep the tip of the needle in the medication to draw it into the syringe.
9. Give the entire injection INTRAMUSCULARLY at the exact time you are instructed to do so.

*If the uncovered needle touches any surface other than the inside of the medications vial prior to injection, it is contaminated. Twist off the needle and replace with a sterile needle. Use all needles and syringes for one injection only, then promptly discard carefully into a container.

Mixing/Injection Instruction for Stimulation Medication

Please follow these instructions for mixing and injecting your medication:

1. Clear a work area on your table or counter top and wash your hands.|
2. Take out the number of vials of medication you have been instructed to use (i.e. Bravelle 2 powders, Menopur 1 powder) and 1 vial of the diluent (water). Put aside the remaining vials so there will be no confusion as to how many vials were drawn up.|
3. Check carefully for NAME and EXPIRATION DATE of each vial.
4. To open the vial, use your thumb to lift the plastic lid on top of the vial. Wipe the rubber stopper with an alcohol swab or a cotton ball soaked in alcohol. Do not remove the rubber stopper or the metal ring that holds the stopper in place.
5. Open the needle package (3cc syringe with 22G 11/2” needle). Remember to tighten the needle onto the barrel of the syringe by turning clockwise.
6. Insert the needle through the rubber stopper of the vial, turn upside down and draw up 1cc of the diluent making sure the tip of the needle is in the fluid. Flick the syringe with a finger to force the air to the surface of the fluid within the syringe, then push the plunger up to expel the air from the syringe making sure you still have 1cc of fluid to mix with. Mix the diluent with the 1st vial containing the powder (it dissolves instantly) and draw up all of the medication mixture (1cc). If additional medication is required, add the same medication mixture in the syringe to the 2nd vial of medication and withdraw the entire 1cc. Continue this process until the prescribed number vials has been mixed. Draw up all of the mixture (1cc) and expel the air, cover the needle, and change needle to a 27G ½ inch needle for a subcutaneous injection of Gonal-F, Follistim, Bravelle, Menopur, or Repronex. At the end of this process you may have a LITTLE less than 1cc for injection but not more than 1 small line less. If you only have ½ cc of fluid in the syringe you have not removed all of the medication from the vials and are not getting the correct dose. Go back to the vials and remove the remaining fluid until you have close to 1cc.
7. Locate injection site and cleanse the skin with an alcohol swab or cotton ball soaked in alcohol. (see: giving subcutaneous injection)
8. Stabilize the skin around injection site with non-dominant hand by pinching the skin up with forefinger and thumb. Insert the needle quickly in a “dart-like” motion (all the way in). Inject the entire contents of the syringe by depressing the plunger fully.
9. Continue holding the surrounding skin while removing the needle quickly. You may notice a small amount of blood or fluid leaking from the injection site when you pull the needle out, this is normal. Wipe with clean tissue or apply band-aide if necessary.
10. Dispose of the syringe properly, without recapping the needle, in a sharps container.
11. Alternate injection sites with each injection

* If the uncovered needle touches any surface other than the inside of the medication ampule/vial prior to injection the needle is contaminated. Twist off the needle and replace with a sterile needle. Use all needles and syringes for one (1) injection only, then promptly discard syringes and needles.
injectiion1 injection2
Subcutaneous Injection Technique (Gonadotropins, Lupron, Ovidrel)

1. If the formulation you are using is not premixed, mix powder(s) with 1cc of diluent. Change to a 27G ½ needle after mixing medication.
2. Select injection site.
3. Cleanse the area with sterile alcohol wipe.
4. Insert the needle briskly into site while pinching skin up with the other hand.
5. Release skin.
6. Inject medication slowly.
7. Remove needle.
8. You may gently massage area to promote medication absorption.
9. If a small amount of bleeding occurs, do not be alarmed – gently wipe clean and apply a band aid.
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Intramuscular Injection Technique (hCG and Progesterone)

1. For hCG reconstitution, mix powder with 2cc diluent. Change needle after mixing is complete.
2. Select injection site at the upper, outer quadrant of the (R) or (L) buttock.
3. Cleanse area with sterile alcohol wipe.
4. Insert needle briskly into site while holding skin taut with other hand.
5. Hold syringe with one hand and pull back slightly on plunger with other hand. If blood does NOT return, inject medication at slow steady pace. If blood appears in the syringe when plunger is pulled back, DO NOT INJECT THE MEDICATION, and PULL SYRINGE OUT, CHANGE TO A NEW NEEDLE AND REINJECT INTO THE OPPOSITE SIDE.
6. After medication is injected, remove needle.
7. Massage area to promote absorption.
8. Do not be alarmed if a small amount of blood or fluid appears. Wipe the site clean with a dry cotton ball, and apply slight pressure for a minute.

To learn more visit our website

Infertility Insurance

Insurance Plans we participate with:

Aetna US Healthcare
Beech Street
CHN
Cigna
Devon
First Health
Great West
Horizon BC BS of NJ
Local 825
Medicare
Multiplan
Oxford
Qualcare
United Healthcare
Wellchoice

Credit Cards we accept:

American Express
Diners Club
Discover
MasterCard
Visa

We also participate with Advanced Reproductive Care, Inc (ARC). ARC offers convenient financing that makes leading edge fertility treatment more affordable with very manageable monthly payments.

The Financial counselors here at University Reproductive Associates will gladly review all payment options with you. Please feel free to give them a call.

To learn more visit our website

Infertility FAQ’s

For new patients

When am I ovulating?
Ovulation happens when the egg is mature and ready to be fertilized. This usually happens on day fourteen of your menstrual cycle if your menstrual cycle is 28 days. Menstrual cycles are counted from the first day of one period to the first day of the next one. However, if you do not have regularly spaced menstrual cycles or your cycles are not 28 days apart, it can be more difficult to tell when you are ovulating. We sometimes use urinary ovulation kits or ultrasound monitoring coupled with testing of blood hormone levels to determine ovulation.

When is the fertile period?
The fertile period is the time when intercourse is most likely to result in a conception. This period is centered around the time of ovulation. Because the exact time of ovulation can be difficult to determine, it can be difficult to determine the fertile period. However, the fertile period is generally 3-5 days before ovulation to up to one day after.

Why might I be having trouble getting pregnant?
There are many reasons when conception may not be occurring. Achieving pregnancy requires that many different biological systems are working correctly and at the same time. Common reasons for difficulty getting pregnant include anatomic abnormalities (fallopian tubes blocked by scar tissue or endometriosis, or distortion of the uterine cavity by fibroids, scar tissue or endometrial polyps), lack of ovulation or hormone imbalances, and poor sperm quality. A complete workup is usually needed to determine the exact problem. The participation of BOTH partners is vital here, as the majority of our couples have more than one problem identified!

When should I consult a fertility specialist?
Infertility is defined as 1 year of unprotected intercourse that does not result in a conception. We usually suggest consultation sooner than one year (after 6 months of unprotected intercourse) for women over the age of 35 or at any point if your doctor recommends it.

What are the available treatments?
There are many available treatments, which must be specifically tailored to your particular problems. There is no universal infertility treatment, because the treatments only work if they are addressing your specific problems. Having the female partner take fertility drugs, for example, will not help when the problem is poor sperm quality.

Many of our couples need and/or choose to use IVF as a method of achieving pregnancy in the most expeditious fashion. We offer an outstanding embryology laboratory which uses the latest technology to provide the best possible pregnancy rates. Our IVF Program is unique, however, in that we also place a premium upon safety as well as success. A major complication of IVF is multiple pregnancies, which deters many couples from pursuing this extremely effective treatment. We have made it our mission to maintain outstanding IVF pregnancy rates, while keeping the chances of multiple births to an absolute minimum. Our incidence of high-order multiple pregnancy (triplets or more) is about 2% of IVF pregnancies, as compared to the national average of about 8%.

We are a training site and perform minimally-invasive surgery (hysteroscopy and laparoscopy), along with traditional open surgery for removal of fibroids and for microscopic tubal sterilization reversal. Our couples are also offered simpler treatments, such as artificial insemination (intrauterine insemination or IUI), in natural cycles or with oral or injectable fertility drugs. Some couples with more severe problems avail themselves of our extremely successful egg or sperm donor programs, or utilize the services of a gestational carrier if the female partner is unable to carry a pregnancy.

What does IVF mean?
IVF is an acronym that stands for in vitro fertilization. This means that the egg is fertilized by the sperm in a laboratory instead of the female reproductive tract.

What does the IVF process entail?
IVF involves the stimulation of the ovaries with to produce multiple eggs at one time. These eggs are removed from the ovaries during a minor surgical procedure then fertilized in a laboratory where they grow into embryos. The embryos are returned to the uterus 3 to 5 days later.

What are your IVF success rates?
See our success rates page >>

I’ve seen other IVF clinics success rates. How do yours compare?
Our IVF livebirth rate is better than the national average. Keep in mind that you must make sure that you are comparing apples to apples, and not apples to oranges. For example, consider the following scenario:

Clinic A advertises an IVF Success Rate of 70%. They are giving the number of patients who developed a clinical pregnancy (a pregnancy sac within the uterus on ultrasound) divided by the number of women who received an embryo transfer.

Clinic B’s Website lists their live birth pregnancy rate per initiated cycle as 50 %.

Which clinic is better?
Clinic B is better! Why?
Clinic A is advertising an IVF Success Rate of 70%. In small print at the bottom of the ad, they explain that they are giving you the number of patients who developed a clinical pregnancy (a pregnancy sac within the uterus on ultrasound) divided by the number of women who received an embryo transfer.

Clinic B is providing the number of women achieving a living child divided by the number of women who started stimulation with fertility drugs. This is the method of explaining pregnancy rates which is endorsed by the American Society for Reproductive Medicine (ASRM) and the Society for Assisted Reproductive Technology (SART) as the preferred and most legitimate method for reporting pregnancy rates after IVF.
Clinic

Clinic A is using clinical pregnancies over # of embryo transfers 49/70 = 70%.
Clinic B is using live births over number of starts 50/100 = 50%.

If Clinic A had presented the same ratio, their �pregnancy rate� would have been 40% instead of 70%.

Because of different practice patterns, you can see that the two Clinics have different cancellation rates (the number who stop the process prior to egg retrieval), and also different rates of not having an embryo transfer. Some Clinics are quick to cancel women who do not have a perfect response, or to not transfer embryos if they seem less than perfect, because it gives them a higher pregnancy rate per embryo transfer. That is not our approach at URA.

If the same 100 couples went to each clinic, 10 more would have living children if they went to Clinic B, which seemed� to have a lower pregnancy rate.

Are fertility medications safe?
Fertility medications have many but mostly controllable side effects. The most common are multiple pregnancies (more than one baby at a time) and bloating and cramping. Other, rarer, side effects include ovarian hyperstimulation syndrome and ovarian torsion. During treatment with fertility medications, all of our patients are closely monitored to watch for any of these complications.

Do I have to do the injections myself for IVF?
Yes, the patients and their partners perform most of the injections used during IVF. Patients go to a medication administration class to learn how to use the injectable fertility medications and perform the injections.

For current patients

Which specialty pharmacies do you recommend?

* Pharmacy lists and phone numbers >>

Where can I find a review of the injection procedures?
Click here >>

When can I expect a call to review my instructions for this evening?
The medical staff will call you back by 5:30 pm on the same day as your ultrasound or morning bloodwork. If you do not receive a call or voice message by this time, please call the office for instructions.

What time can I come in for my ultrasound or bloodwork?
Morning ultrasounds and bloodwork are done between 7 and 8 am in the morning, seven days a week. The visits are done on a first-come, first-serve schedule. Please make sure that you come in before 8 am to ensure that your laboratory results are ready on the same day.

What financing options do you have for my fertility treatments?
The billing department will review your particular insurance benefits. If your insurance company does not provide full coverage of your treatment plans, the billing department can give you the details of the many financing options available. To the best of our ability, we try to make sure that all couples �regardless of their circumstances- are able to afford the help they need to achieve a healthy child.

To learn more visit our website

Success Factors

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Success Factors

There are many factors that contribute to a successful pregnancy. At URA, we are committed to meticulous diagnosis to provide our patients with the best chance of success.

The Age of the Woman

Fertility can be significantly affected by the age of the woman. For women who reach the age of 35, the live birth rate decreases significantly when the woman is using her own eggs. The older the woman, the lower the chance of success and the higher chance of miscarriage and chromosomal abnormalities.

• For most women, the ability to conceive and carry a baby to term begins to decline at age 30, and declines most rapidly after age 40.
• Women are more likely to have a miscarriage as their age increases.

Egg Quality

A common cause of infertility in women is poor egg quality. If you have poor quality eggs, you will probably have a difficult time getting pregnant and staying pregnant. The impact of poor quality eggs is reflected in the general decline in pregnancy rates as women age. Egg quality and age are only a few factors that may contribute to infertility. Other factors include baseline FSH level, prior ovarian surgery, moderate to severe endometriosis, multiple unsuccessful previous cycles, uterine abnormalities (such as congenital abnormalities or myomas), tubal factors (such as hydrosalpinx), and genetic factors all will influence how successful a procedure may

To learn more visit our website

Understanding Success Rates

The success of the IVF program at University Reproductive Associates (URA) is related to many factors including the experience of our dedicated physicians, our seasoned laboratory team and the advanced breakthrough medical technologies that we utilize.

What makes URA different and able to achieve such extraordinary results is the fact that we are dedicated not only to excellent patient care, but also to the advancement of knowledge through clinical and basic research.

Our physicians are faculty members in Obstetrics, Gynecology, and Women’s Health at UMDNJ – New Jersey Medical School. We also participate in cutting-edge REI research projects funded by the National Institute of Health (NIH), as well as private industry. We draw upon our experience and expertise to ensure that our patients receive the latest and safest fertility treatment protocols available to get them on their way to a new family life.

Talk to one of our physicians and nurses or contact us today to learn more about our success rates.

To learn more visit our website

Our Results

Results matter! At University Reproductive Associates, we take great pride in our outstanding results in helping couples achieve the ultimate success of having a healthy baby.

IVF livebirth rate at URA higher than the national average

In addition, due to advances we have made in In Vitro Fertilization, (IVF), we have made great strides in reducing high order multiple pregnancies.

A clinical pregnancy means that a pregnancy sac can be seen within the uterus on ultrasound.

A comparison of clinic success rates may not be meaningful because patient medical characteristics and treatment approaches vary from clinic to clinic.

Understanding Success Rates | Success Factors

Female Age (years)	Livebirths per Started IVF Cycle in 2006 at URA	Livebirths per started IVF cycle in 2006 National average
< 35	51%	38%
35 -37	43%	30%
38 – 40	26%	20%
41 – 42	20%	10%
> 43	0%	4%

From the Society for Reproductive Technology (SART)

To learn more visit our website

IVF Refund Program

Our IVF refund program provides financial peace of mind for couples without insurance benefits to pay for In Vitro Fertilization treatment. In many cases you might need more than one cycle of IVF to be successful; our program insures you financially because our fee is earned only when you give birth to a living child.

With our IVF Refund Program, you pay one flat fee, which covers the cost of up to four completed IVF cycles. Also included is the cost of cryopreservation (freezing) of embryos from those four cycles and their later transfer. Should the results of the four fresh cycles and transfers of frozen-thawed embryos be unsuccessful, 100% of your fee is refunded enabling you to pursue other family building options.

No one is locked into treatment and either party, couple or physician, can stop at any time before four cycles for any reason and receive 100% refund of fees paid. Listed below are details about eligibility, inclusions, exclusions, screening tests, cost and cost comparison concerning the IVF Refund Program.

How does the IVF Refund Program work?

Once a decision is made to utilize IVF as infertility therapy and the medical screening process is underway, investigation into financing the IVF cycle is initiated. Our Financial Counselors, working directly with you, explore applicable insurance benefits you may have for IVF treatment. If you do not have insurance coverage for IVF, you may elect to pay our traditional fee-for-service option or you may request consideration for our IVF Refund Program.

If you elect to apply for the IVF Refund Program, a committee of physicians reviews your medical records and IVF prescreening tests. If you meet the IVF Refund Program criteria discussed below the IVF Refund Program payment is made by the initiation of your first cycle. With this single payment you have up to four fresh IVF cycles and possibly four frozen-thawed embryo transfers to have a baby. Only then if you deliver a baby have we earned our fee.

The fee paid for the IVF Refund Program is greater than you would pay for a single fee-for –service IVF cycle and if you have a baby after the first IVF cycle you will have paid more for that single cycle than if you elected the fee-for-service option. But if you don’t have a baby you can proceed with a second, third or fourth cycle without additional financial burden.

If you have a baby as a result of the second through fourth IVF cycle or as a result of subsequent transfers of embryos cryopreserved during the four fresh cycles we then earn our fee. But you will have paid far less for those cycles than using the full fee for each cycle of IVF.

We define success in IVF the same way you do; the delivery of a baby. Neither a cancelled cycle, a biochemical pregnancy, clinical miscarriage, nor pregnancy loss following any of your IVF cycles qualifies us to earn our fee. In the event of pregnancy loss after discharge from our office you must supply your obstetrical records for our review. At any time you may withdraw from the program and receive a full refund of your original investment. This refund serves as insurance against treatment failure for you to use for different family building options.

Who is eligible for the IVF Refund Program?

Our physician committee will review eligibility based on:

• Patient age, maximum for female, 37 years and younger.
• Whether there is a medical indication for IVF treatment.
• Whether the female will be able to complete the four fresh IVF cycles and possible four frozen transfers, if available, before her 39th birthday.
• Your medical records, including previous IVF cycles.
• Your completed IVF prescreening tests including:
• Whether the female has normal day 3 hormonal studies.
• Whether the female has a normal uterine cavity

What are the current costs for the IVF Refund Program?

$24,950.00 for four completed IVF cycles; this includes ICSI, cryopreservation of embryos and frozen-thawed embryo transfers from the four completed IVF cycles.

IVF Refund Program cost compared to Pay per cycle IVF fees.

$9,500.00 is the current package fee for medical and laboratory services for one complete cycle of IVF. This package doesn’t include cryopreservation of embryos (an additional $700.00 fee per cycle if performed) and $3,200.00 for each frozen-thawed embryo transfer performed.

What’s included in the Program?

The IVF Refund program includes all cycle monitoring for 4 fresh cycles (from the start of gonadotropin medications for ovarian stimulation) and 4 frozen-thawed embryo transfers (from start of estrogen supplementation) with office visits, ultrasounds, injection class, IVF orientation class, professional fees, blood hormone assays performed here at URA, egg retrieval, embryo transfer, laboratory fees associated with the retrieval and transfer, cryopreservation of embryos, AZH (Assisted Hatching) and ICSI (Intracytoplasmic Sperm Injection) if medically necessary, until HCG results are available.

What’s excluded?

• Initial consultation
• Initial physical examination
• Standard IVF prescreening and screening tests, including blood tests, sperm testing, hydrosonogram, or office hysteroscopy.
• Surgery other than egg retrieval and embryo transfer.
• Medications
• Costs associated with complications or non-IVF surgery, procedures or care, such as hospitalizations, D&C for miscarriage, fluid aspiration for ovarian hyperstimulation, and surgery or medication treatment of tubal (ectopic) pregnancy.
• Surgical sperm retrieval procedure.
• Anesthesia professional fees.
• Blood tests sent to outside labs.
• Non-IVF care in between treatment cycles.
• Embryo storage and embryo transfer of frozen-thawed embryos after the IVF Refund contract ends with delivery of a living child or withdrawal from the Program.
• All male testing (blood and sperm testing)
• Obstetrical services (including ultrasounds, blood tests, office visits, medications hospitalization, surgery, or any other care provided after the positive blood pregnancy test) are not covered as part of this program.

What are the penalties for withdrawal before all cycles are completed?

There are none. You will receive a full refund regardless of how many of the cycles you complete unless you deliver a live born child.

Just as you have the right to withdraw we also have the right to withdraw you from the program, for instance if you have an unexpectedly poor ovarian response to stimulation. In this event, the same 100% refund is paid to you as if you withdrew on your own.

To learn more visit our website

URA Fast Facts

URA FAST FACTS

• Our in vitro fertilization success is among the best in the world.

• First-class, individualized treatment, providing the most advanced and confidential care.

• One of a handful of programs nationwide determined to have the necessary expertise to train physicians in the specialty of reproductive endocrinology and infertility.

• Affiliation with the University of Medicine and Dentistry of New Jersey (New Jersey Medical School), Hackensack University Medical Center, Mountainside Hospital.

• Academic, group practice specializing in reproductive medicine with a major focus on fertility issues.

• Located in a quiet, easily accessible, suburban setting in Northern New Jersey.

To learn more visit our website

On-site Laboratories

Having our own on-site state of the art laboratories and expert laboratory staff provides our patients with additional expertise and access to necessary tests easily and conveniently.

Three state-of-the-art fertility laboratories are fully accredited for diagnostic testing and therapeutic procedures:

Endocrinology Laboratory
• Diagnostic Tests

• Estradiol
• Progesterone,
• Follicle Stimulating Hormone (FSH)
• Luteinizing Hormone (LH)
• Human Chorionic Gonadotropin (hCG)

Embryology Laboratory

• Therapeutic Procedures

• Oocyte Collection
• Fertilization using Standard Insemination or Assisted Fertilization (ICSI)
• Assisted Hatching
• Extended culture to the Blastocyst Stage
• Embryo Biopsy for Preimplantation Genetic Diagnosis
• Preparation for Embryo Transfer
• Embryo Cryopreservation/Thawing

Andrology Laboratory

• Diagnostic Tests

• Semen analysis
• ART preparation a trial of sperm preparation – helpful in deciding which couples should try intrauterine insemination and which should proceed to IVF
• Postejaculate urinalysis

• Therapeutic Procedures

• Preparation of sperm for insemination [sperm washing]
• Retrieval of sperm from retrograde ejaculation
• Electroejaculation
• Epidydimal aspiration
• Testicular biopsy
• Sperm cryopreservation

To learn more visit our website

Treatment Services

After an appropriate workup and thorough diagnosis, your URA physician will discuss the array of treatment options available to you based on your diagnosis. Our approach is to find the best option to achieve your goal of a healthy child.

Treatment options can be broken down into several main categories:

• Medical management of ovulation without assisted reproduction

• Ovulation-facilitating medications (Clomiphene citrate or gonadotropins)
• Intrauterine (artificial) insemination (IUI)

• Medical management of ovulation with assisted reproduction

• In-vitro Fertilization (IVF): entails fertilizing oocytes (eggs) by sperm in the laboratory. IVF may be coupled with one or more of the following techniques.
• Intracytoplasmic Sperm Injection (ICSI)
• Assisted Zona Hatching (AZH)
• Blastocyst Culture
• Preimplantation Genetic Diagnosis (PGD)
• Cryopreservation of embryos for frozen-thawed embryo transfer.

• Use of donated oocytes or sperm, both for known and anonymous donors.

• Surgery for uterine problems, adhesions, or endometriosis.

To learn more visit our website