faculty - proces3.proce.com/res/pdf/fertility/fert3.pdf · controlled ovarian stimulation (cos) 7...

1

Infertility: Protocols and Patient Management

Module 3

Ann Scalia, BSN, RN, CNORManager‐Clinical Education Specialists

Mary Vietzke, BSN, RNSenior Clinical Educational Specialist

Walgreens

Faculty

Ann Scalia, BSN, RN, CNORManager‐Clinical Education Specialists

Mary Vietzke, BSN, RNSenior Clinical Educational Specialist

It is the policy of ProCE, Inc. and NASP to ensure balance, independence, objectivity and scientific rigor in all of its continuing education activities. Faculty must disclose to participants the existence of any significant financial interest or any other relationship with the manufacturer of any commercial product(s) discussed in an educational presentation.

Disclosure: Ann Scalia and Mary Vietzke are employees of Walgreens.There will be discussion regarding off‐label use of medications during this activity.

2

Objectives

• Discuss recommended appropriate non‐pharmacologic and pharmacologic plans to address infertility

• Identify monitoring parameters for a patient undergoing treatment for infertility

• Discuss the different commonly used medication protocols used in an ART cycle

Infertility Treatments

Varies depending on:• Evaluation outcomes• Day of cycle• Goals of treatment

3

Surgical Pretreatments

• Transvaginal cyst removal

– Rescued corpus luteum

– Large anovulatory follicle(s)

– Endometrioma (“Chocolate cyst”)

• Laparoscopy

– Fibroids

– Adhesions

– Endometriosis

– Hydrosalpinx

Song Xm, et al. Journal of Obstetrics and Gynaecology Research. 2017;43(1):122‐127.Karasu T, Ola B. Reproductive Surgery in Assisted Conception: Springer; 2015:37‐41.

Menstrual Cycle

Luteal PhaseFollicular Phase

Day 1 Day 28Day 14 Day 20‐24

FollicularRecruitment LH Surge

Day 7

Selection ofDominant Follicle

Window of Receptivity for implantation

Speroff , Fritz . Clinical Gynecologic Endocrinology and Infertility. 2005:188.Stauss, Barbieri. Yen & Jaffe’s Reproductive Endocrinology: physiology, pathophysiology, and clinical management. 2014: 159‐160.

4

Non‐Pharmacologic Treatment Cycles

• Natural cycle + timed intercourse

• Natural cycle + Intrauterine insemination (IUI)

Non‐pharmacologic

Biological Markers

• Menstrual cycle

• Cervical mucus

• Basal Body Temperature (BBT)

• Urinary hormones

Pasha H, et al. Iranian journal of reproductive medicine. 2013;11(6):495Martin PL. American journal of obstetrics and gynecology. 2016;46:53‐62

5

Luteinizing Hormone (LH) Levels

• One‐step urinary kits that measure LH

• Easy to use at home

• Used clinically for timing for intercourse or intrauterine inseminations

Martin PL. American journal of obstetrics and gynecology. 2016;46:53‐62

Intrauterine Insemination

• Treatment and monitoring is similar to timed intercourse

• Sperm sample is specially prepared

• Sperm are introduced into the uterine cavity via a catheter

• Used to help overcome negative cervical mucus environments or mild male factor


6

Cervical Mucus Changes During Ovulation Phase

BeginningEstrogen causes cervical mucus production

GrowthDominant follicle maturation and estrogen production increases

PeakThe corpus luteum produces progesterone which dries up the mucus and causes the temperature rise

EndThis is the after window of receptivity


Non‐IVF Ovulation Induction and

Controlled Ovarian Stimulation(COS)

7

Controlled Ovarian Stimulation (COS)

• Carefully monitored stimulation of ovaries to produce multiple follicles (which contain eggs)

• First step in IVF process

• Protocols designed to decrease risk of OHSS

• Generally involve 3 classes of medications

– GnRH analogs (agonist or antagonist)

– FSH or FSH containing LH gonadotropin

– hCG final maturation of eggs inside the follicle

Assisted reproductive technologies: a guide for patients. American Society for Reproductive Medicine Web site.http://www.asrm.org/uploadedFiles/ASRM_Content/Resources/Patient_Resources/Fact_Sheets_and_Info_Booklets/ART.pdf

Monitoring Methods

• Transvaginal Ultrasound Scans

– Follicular diameter and count

– Endometrial thickness

• Hormone Assay

– Estrogen levels (baseline and during COS)

– LH levels (baseline)

– FSH levels (baseline)

– Progesterone levels (specific days of cycle)


8

Follicular Ultrasound Monitoring• Follicle growth documentation

• Results plotted to observe progression of growth

• Allows for the most accurate assessment for hCG administration

• Other documentation

– Early signs of OHSS such as abdominal fluid, ovarian enlargement, too many follicles

– Ovarian pathology such as endometriomas or other cyst


Hormone Assay• Baseline done around cycle‐day 3

– Estrogen, (FSH, LH and progesterone levels may also be evaluated)

– Helps decision of dose and type of gonadotropin

• Throughout ovarian stimulation

– Estrogen levels

• Assess ovarian response

• Dosage adjustments

• hCG Administration

– Based on estrogen levels with ultrasound


9

Monitoring for COS

• Transvaginal Ultrasound

– Follicle diameter 16‐20mm (typical)

– Follicle count depending on patient

– Endometrial thickness >7mm

• Hormone Assay

– Estrogen (estradiol) levels coincide with follicle diameter and number

ASRM. Fertil Steril. 2015;103(6):1379‐1618.

Protocol Guide

• Various protocols used

• Based on patient, type of cycle (non‐IVF, IVF) and physician preference

• Monitoring is required

• Avoid Ovarian Hyperstimulation Syndrome (OHSS)

• Goal is safe treatment to achieve birth of healthy singleton baby

Alper MM, et al. Reproductive biomedicine online. 2017.

10

Ovarian Reserve

Adapted from: Speroff. Clinical Gynecologic Endocrinology and Infertility. 8th ed.

Describes a woman’s reproductive potential with respect to ovarian follicle

number and oocyte quality

Response TypesNormal Responder

• Typically 10‐20 follicles

• Normal ovarian function

• Good prognosis (but still limited by maternal age)

Poor/Low Responder

• Usually <4 follicles

• Typically related to “ovarian” age factor

• Possible increased chance of poor outcome

Hyper/High Responder

• Typically >20 follicles

• Some women at higher risk

• “Low and Slow” approach

La Marca A, et al Human reproduction update. 2013:037.

11

Oral Contraceptive Pills (OCP)• Oral contraceptive pills, may be prescribed to regulate a

patient’s menstrual cycle

• In an ART cycle:

– Used to “suppress or downregulate” activity in the ovaries in the prestimulation phase

– Allows manipulation of the patient's cycle to fit into a set schedule (Batching)

• Combination hormonal OCP

– Progestin component of a combination pill prevents ovulation by inhibiting gonadotropin secretion of LH; also alters endometrium

– Estrogenic component suppresses FSH

Stauss, Barbieri. Yen & Jaffe’s Reproductive Endocrinology: physiology, pathophysiology, and clinical management. 2014: 895.

GnRH Analogs

GnRH Agonists• Binds to a receptor and exhibits

a desired response

GnRH Antagonists• Binds to a receptor and inhibits

another molecule from binding to the receptor, thus inhibiting the desired response

Leuprolide Acetate Cetrotide®

Ganirelix Acetate

GnRH

Prapas Y, et al. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2013;166(1):43-46.

12

Downregulation and Flare Effect• Downregulation

– Process of decreasing cells sensitivity to specific hormones

– Specific drugs “turns off” ovaries temporarily gaining control over ovarian function

• Flare Effect

– Initial "flare‐up" response (FSH and LH release) from pituitary gland occurs first 3 days of agonist administration

– Continuing agonist > 3 days temporarily suppresses pituitary gland


GnRH Agonist

• Loss of response to continued stimulation

• Downregulation of GnRH receptors

• Uncoupling of GnRH receptors from intracellular signaling mechanisms

FollicularLuteal

E 2 , P4 LH, FSH

0

10

20

30

DaysStart Administration

Flare Effect


13

GnRH Antagonist E 2

, P4 LH, FSH

0

10

20

30

Start Administration

Hours

NO Flare Effect


Gonadotropins

FSH and/or LH injectable medications

Two

formulations

Urinary extractsRecombinant

FSH

ASRM. Medications for Inducing Ovulation: Patient Information Series: 2012:1‐10.

14

Human Chorionic Gonadotropin (hCG)

• Pregnyl®

– Urinary derived

• Novarel®

– Urinary derived

• Generic hCG

– Urinary derived

• Ovidrel®

– Recombinant technology

CHORIONIC GONADOTROPIN [prescribing insert]. Fresenius, Kabi, Lake Zurich, IL February 2016.Pregnyl® (chorionic gonadotropin for injection) [prescribing information]. Parsippany, NJ: Ferring Pharmaceuticals Inc.; January 2015. OVIDREL® PreFilled Syringe (choriogonadotropin alfa injection) [prescribing information]. Rockland, MA: EMD Serono, Inc., September 2014. NOVAREL® (chorionic gonadotropin for injection) [prescribing information]. Parsippany, NJ: Ferring Pharmaceuticals Inc.; September 2016.

Human Chorionic Gonadotropin (hCG)

• Referred to as a “trigger” shot

• Mimics LH surge for final oocyte (egg) maturation

• Very time‐sensitive medication

• Ovulation occur within 36‐40 hours after injection

• Egg retrieval is scheduled 36 hours after injection

• Too soon or too late will negatively impact cycle

resulting in cancellation

Costello M, et al. Manual of Ovulation Induction & Ovarian Stimulation Protocols. 2016:454.

15

Leuprolide Trigger

• Alternative type of trigger that may be ordered by a fertility office if the patient is responding too well to medications

• May also be referred to as “Lupron” trigger

• Pituitary gland is capable of producing an LH surge sufficient for maturation of follicles in response to a Leuprolide trigger as long as premature ovulation was being prevented by the use of an antagonist like Ganirelix or Cetrotide


Leuprolide trigger protocol

• Most common dosages in a prefilled syringe or vial

• 1 mg (20 units)

• 2 mg (40 units)

• 4 mg (80 units)

• 5mg (100 units)

• Some physicians in addition may order a small amount of hCG (such as 1000 or 1500 units) along with the Leuprolide injection to reduce the risk of inadequate maturation of follicles and still keep the risk for OHSS low


16

• May be prescribed for additional support for the uterine lining, embryo implantation and resulting pregnancy

• Used in IVF cycles, before and after a frozen embryo transfer and in pregnancy

• Available formulations:

– Estradiol valerate injection (intramuscular injection)

– Estradiol tablets (oral and occasional inserted vaginally)

– Estradiol patch (Estradiol transdermal system)

Endometrial Support: Estrogen

Role of Progesterone

• Progesterone for luteal phase support of the endometrium is needed in stimulation cycles

• Used to build up lining of endometrium for successful implantation

• Administration begins the day of egg retrieval and continues until pregnancy test

• If pregnancy occurs the patient will continue on progesterone support

Stauss, Barbieri. Yen & Jaffe’s Reproductive Endocrinology: physiology, pathophysiology, and clinical management. 2014: 704‐706Lockwood G, Griesinger G et al. Fertil & Steril. 2014;101(1):112‐113.

17

Non‐IVF Ovulation Induction / Stimulation

Day 1 Day 28

Clomiphene Citrate / Letrozole Non‐IVF

Start eitherClomiphene Citrate/

LetrozoleDays 3‐7. 4‐8, 5‐9

LH monitoring Possible hCGinjection

Menses

IUI / intercourse 36‐40 hrs after positive LH kit or hCG injection

Day 7 Day 14

Follicular Phase

Al‐In any H, et al. Manual of Ovulation Induction & Ovarian Stimulation Protocols. 2016:260.

Luteal Phase

Stimulation 5 Days Progesterone support

Pregnancy test ~14 days after IUI or intercourse

18

Gonadotropin Stimulation~10 Days

Day 1 Day 28

Gonadotropin Protocol Non‐IVF

Start gonadotropin stimulation Cycle Day 3

hCGinjection

Menses

IUI or intercourse 36‐40 hrs after hCG

injection

Luteal Phase

Day 7 Day 14

Follicular Phase

Al‐In any H, et al. Manual of Ovulation Induction & Ovarian Stimulation Protocols. 2016:260.

Progesterone support

Pregnancy test ~14 days after IUI or intercourse

IVF Cycle Protocol Phases

Prestimulation Downregulation Phase

Stimulation Phase

Supportive Phase

• Starts with cycle day one of menses

• Baseline monitoring• Ovarian suppression

• Oral contraceptive pills (OCP)

• GnRH agonist

• Baseline monitoring • Start of gonadotropin

stimulation medications• Development of ovarian

follicles• Control premature LH

surge with GnRH analog• Periodic monitoring with

blood assays and transvaginal ultrasounds for medication adjustments

• “Trigger” shot • Egg retrieval

• Sometimes referred to as “Luteal Phase Support”

• Focused on uterine environment for embryo(s)

• Embryo/Blastocyst Transfer

• Medication support • Progesterone • Estrogen

19

Supportive Phase

Embryo transfer

• The ET procedure is the last one of the IVF process.

• Critically important to choose the best quality embryo.

• Either day 2 or 3 after oocyte retrieval

Blastocyst transfer

• Transferred on day 5 of oocyte retrieval.

• ↑ Chance of selecting best quality embryo for ↑ chance at pregnancy.

• ↑ eSET

Freeze all

• Center preference

• Option for those with OHSS

• Banking embryos for future use

ASRM. Fertil Steril. 2012;97 (4):835‐842.

Ovarian Stimulation Protocols• Most commonly used

– Long Luteal (GnRH Agonist Downregulation)

• Oral Contraceptives optional

– GnRH Antagonist

– Oral Contraceptives optional

• Poor/Low responders/Advanced Maternal Age (AMA)

– Microdose Flare

– GnRH Antagonist

– Luteal Estradiol Protocol (Estrogen Priming)

– Mild Stimulation Protocol (Clomiphene Citrate Priming)

• Hyper/High responders

– Long Luteal (GnRH Downregulation)

20

Long Luteal Protocol

Leuprolide Acetate0.5 (10U) or 1.0 (20U) mg/day


Progesterone Hormone Assay ~Cycle Day 21

Day 21

Menses

Gonadotropin stimulation~10 Days hCG

Injection

Egg Retrieval 36 hrs after hCG injection

Prestimulation Downregulation Phase Stimulation Phase

Alper MM, et al. Reproductive biomedicine online. 2017.Costello M, et al. Manual of Ovulation Induction & Ovarian Stimulation Protocols. 2016:454.Fukuda A. Ovarian Stimulation Protocols: Springer; 2016:113‐119.La Marca A, et al. Human reproduction update. 2013:dmt037

Baseline Monitoring

Long Luteal Protocol Using Oral Contraceptive Pills (OCPs)


Leuprolide Acetate 0.25 (5U) or 0.5 (10U) mg/day

Menses

Start OCPs first week mensesminimum of ~14 days

Prestimulation Downregulation Phase

Menses

Stimulation Phase

Gonadotropin stimulation~10 Days


Start Leuprolide Acetate Overlap OCPs for 3 days


Baseline Monitoring

hCG

21

GnRH Antagonist Protocol

GnRH Antagonist start when

dominant follicle ~12‐14 mm

hCG

~Stimulation Day 5 First monitoring check

GnRH Antagonist continued daily

Menses


Stimulation Phase


Start gonadotropin stimulation Cycle Day 3

Gonadotropin stimulation ~10 Days

Baseline Monitoring

GnRH Antagonist Protocol Using OCPs

hCG

MensesMenses






~Stimulation Day 5 First monitoring check

Start OCPs first week menses~14‐21 days

Baseline Monitoring


Gonadotropin stimulation ~10 Days

OCPs Stopped

22

Microdose‐Flare Protocol

Start Microdose Leuprolide Acetate 40 mcg or 50 mcg/10 units twice daily

after 3 days of no OCPshCG

MensesMenses

On third day of microdose Leuprolide acetate Start gonadotropins



OCPs Stopped


Start OCPs first week menses~14‐21 days

Baseline Monitoring


dominant follicle 12‐15 mm

Stimulation Day 5 First monitoring

check

Luteal Estradiol Protocol

hCG

MensesMenses

Gonadotropin Stimulation




Estradiol 1mg 2 tablets bid

Cycle Day 21 Start Estradiol

Baseline Monitoring


23

Mild Stimulation Protocol

Menses

Stimulation Phase

hCG

Ferraretti AP, et al Mild ovarian stimulation with clomiphene citrate launch is a realistic option for in vitro fertilization. Fertility and sterility. 2015;104(2):333‐338.

Start eitherClomiphene Citrate/ Letrozole

Days 3‐7 for 5 Days

Gonadotropin stimulation




Day 5 of Gonadotropin

First monitoring check

GnRH Antagonist continued daily with IVF Cycle ONLY

Baseline Evaluation Cycle Day 3

Gonadotropin Stimulation Start Check

Supportive Phase: All Fresh IVF Protocols

Embryo/Blastocyst Transfer 3‐6 Days after Retrieval

Supportive Phase

hCG

Egg Retrieval 36 Hours after

hCG

Progesterone support started day of retrieval

Pregnancy Test ~14 Days after Transfer

Possible Estrogen support started day of retrieval


24

Frozen Embryo Transfer Protocol


Leuprolide Acetate 0.25 (5U) or 0.5 (10U) mg/day

Menses

Day 15 of Estradiol Start Progesterone

Day 21

Fukuda A. Ovarian Stimulation Protocols: Springer; 2016:113‐119.La Marca A, et al. Human reproduction update. 2013:dmt037

Progesterone Hormone Assay ~Cycle Day 21

Baseline Monitoring

Estradiol 1mg 2 tablets bid or sliding scale

Endometrium Lining & Estradiol Level

Monitoring

Embryo/Blastocyst Transfer 3‐6 Days after Progesterone Start

In vitro fertilization (IVF)

Ovarian stimulation

(daily injections of fertility hormones) Retrieval of

oocytes/eggs

Eggs and partner or donated sperm

combined (through IVF)

in lab Fresh embryo transfer or freezing of

embryos/oocyte

ICSI to assist in fertilization

2017 Walgreens Co. All Rights Reserved

25

Prevention of Multiple Gestation

• The goal of any infertility treatment is a healthy SINGLE full term birth

• Number of embryos transferred impacts multiple gestation rates

• With non‐IVF treatments no control over how many eggs will fertilize

• IVF use of elective single embryo transfer (eSET) is increasing

Gerris J. Complications and Outcomes of Assisted Reproduction. 2017:33.

Review of Objectives• Discuss recommended appropriate non‐pharmacologic and pharmacologic plans to address infertility

– Thorough evaluation required so the best individualized plans of treatment can be utilized

• Identify monitoring parameters for a patient undergoing treatment for infertility

– Blood assay draws and transvaginal ultrasounds are required for all treatment protocols to minimize risk of developing OHSS

• Discuss the different commonly used medication protocols used in an ART cycle

– Many different protocols used and each protocol is applied individually to optimize positive outcome potentials

26

Thank You

References• Song Xm, Jiang H, Zhang Wx, Zhou Y, Ni F, Wang Xm. Ultrasound sclerotherapy pretreatment

could obtain a similar effect to surgical intervention on improving the outcomes of in vitro fertilization for patients with hydrosalpinx. Journal of Obstetrics and Gynaecology Research. 2017;43(1):122‐127.

• Karasu T, Ola B. Endometrioma and Infertility: Principles and Techniques of Management. Reproductive Surgery in Assisted Conception: Springer; 2015:37‐41.

• Mastroianni L, Jr., Laberge JL, Rock J. Appraisal of the efficacy of artificial insemination with husband's sperm and evaluation of insemination technics. Fertility and Sterility. 1957;8(3):260–26

• Speroff L, Fritz MA. Clinical Gynecologic Endocrinology and Infertility. 7th ed. Philadelphia, PA : Lippincott Williams & Wilkins; 2005:1143,1147‐1151.

• Stauss, Barbieri. Yen & Jaffe’s Reproductive Endocrinology: physiology, pathophysiology, and clinical management. 2014: 159‐160.

• Pasha H, Faramarzi M, Esmailzadeh S, Kheirkhah F, Salmalian H. Comparison of pharmacological and nonpharmacological treatment strategies in promotion of infertility self‐efficacy scale in infertile women: A randomized controlled trial. Iranian journal of reproductive medicine. 2013;11(6):495

• Martin PL. Detection of ovulation by the basal temperature curve with correlating endometrial studies. American journal of obstetrics and gynecology. 2016;46:53‐62.

27

References

• Alper MM, Fauser BC. Ovarian stimulation protocols for IVF: is more better than less? Reproductive biomedicine online. 2017.

• Costello M, Koch J, Ledger W. Recombinant LH, Recombinant hCG and GnRH Agonist to Trigger Ovulation: A Critical Evaluation. Manual of Ovulation Induction & Ovarian Stimulation Protocols. 2016:454.

• Fukuda A. Ovarian Stimulation for Poor Responders. Ovarian Stimulation Protocols: Springer; 2016:113‐119.

• La Marca A, Sunkara SK. Individualization of controlled ovarian stimulation in IVF using ovarian reserve markers: from theory to practice. Human reproduction update. 2013:dmt037.

• Prapas Y, Petousis S, Dagklis T, et al. GnRH antagonist versus long GnRH agonist protocol in poor IVF responders: a randomized clinical trial. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2013;166(1):43‐46

• Costello M, Koch J, Ledger W. Recombinant LH, Recombinant hCG and GnRH Agonist to Trigger Ovulation: A Critical Evaluation. Manual of Ovulation Induction & Ovarian Stimulation Protocols. 2016:454.

References• Al‐Inany H, El‐Mazny A. The Efficacy of Clomiphene Citrate in Preventing a Premature LH

Surge during Controlled Ovarian Stimulation with Human Menopausal Gonadotropins. Manual of Ovulation Induction & Ovarian Stimulation Protocols. 2016:260.

• Ferraretti AP, Gianaroli L, Magli MC, Devroey P. Mild ovarian stimulation with clomiphene citrate launch is a realistic option for in vitro fertilization. Fertility and sterility. 2015;104(2):333‐338.

• Gerris J. Minimizing Multiple Pregnancy After Assisted Reproductive Technology. Complications and Outcomes of Assisted Reproduction. 2017:33.

28

References Medications

• Fertility medication information: CLOMIPHENE CITRATE. DailyMed Web site. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=be399623‐6400‐475d‐93d3‐1dedd4d43017. Updated March 2013. Accessed January 19, 2017.

• Fertility medication information: CRINONE®8%. DailyMed Web site. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=7def92fe‐d521‐41c0‐b419‐48e028f59f15 . Updated August 2014. Accessed January 19, 2017.

• Fertility medication information: ENDOMETRIN®. DailyMed Web site. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=2ba50fa9‐b349‐40cb‐9a4b‐1af8faa4ec09#section‐1 . Updated September 2016. Accessed January 19, 2017.

• Fertility medication information: FEMARA®. DailyMed Web site. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=82b77d74‐085f‐45ac‐a7dd‐1f5c038bf406. Updated January 2014. Accessed January 19, 2017.

• Fertility medication information: FOLLISTIM® AQ Cartridge. DailyMed Web site. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=96f11b5d‐cc7b‐48aa‐830a‐a28e1962d871. Updated December 2014. Accessed January 16, 2017.

• Fertility medication information: GANIRELIX ACETATE Injection. DailyMed Web site. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=96118395‐557e‐4998‐842d‐424a59d574b6. Updated March 2016. Accessed January 19, 2017.

References Medications

• Fertility medication information: GONAL‐f®Multi‐Dose. DailyMed Web site. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ae85b9c3‐e7eb‐4981‐a5d9‐346050e8f189. Updated April 2013. Accessed January 19, 2017.

• Fertility medication information: GONAL‐f RFF®Redi‐ject. DailyMed Web site. http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=b6d11c45‐b502‐478e‐bb28‐2ff596ea259c. Accessed January 19, 2017.

• Fertility medication information: LETROZOLE. DailyMed Web site. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=4818abc4‐2797‐4248‐b7d7‐5cb4b5cdcf6a#section‐1 . Updated October 2014. Accessed January 19, 2017.

• Fertility medication information: LEUPROLIDE ACETATE. DailyMed Web site. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=8bd72c1e‐2751‐4498‐a346‐bc5e3acbba0b. Updated January 18, 2017. Accessed February 10, 2017.

• Fertility medication information: NOVAREL®. DailyMed Web site. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ac6918ff‐9dc3‐40d9‐8619‐54b26e4bdfc8 . Updated September 2016. Accessed January 19, 2017.

• Fertility medication information: PREGNYL® (chorionic gonadotropin for injection USP) https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=3e26b843‐9c7a‐4517‐a1b6‐9362aab0b86c. Merck Sharp & Dohme B.V., a subsidiary of Merck & Co., Inc. Updated January 2015. Accessed January 19, 2017.

faculty - proces3.proce.com/res/pdf/fertility/fert3.pdf · controlled ovarian stimulation (cos) 7...

Documents