Introduction to the IVF Process at Pacific NW Fertility

Welcome to Pacific NW Fertility At the amazing conclusion of a successful fertility journey is a human being—a baby. But we know how much people matter along the way, too. It shows in the individualized experience we provide each patient. In the highly trained staff that brings their talents to our state of-the-art fertility services. And in a collaborative process that delivers some of the nation’s highest success rates.

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Introduction to the IVF Process at Pacific NW Fertility

1101 Madison St. • Suite 1050 • Seattle,WA 98104P: 206.515.0000 • F: 206.515.0001

www.pnwfertility.com

WELCOME TO PACIFIC NW FERTILITY

IN VITRO FERTILIZATION

“HURDLES” FOR ASSISTED REPRODUCTIVE TECHONOLIGIES

COMPLICATIONS OF A MULTIPLE PREGNANCY

PHARMACY LIST

IN VITRO PROGRAM STAFF CONTACTS

Thank you for inquiring about In Vitro Fertilization (IVF) at

Pacific NW Fertility and IVF Specialists.This information

sheet is intended to give you an idea of what to expect

when you enter into In Vitro Fertilization. Additional verbal

and written instructions will be given at each step of your

cycle to clarify and simplify the process.You may also access

much of this information via our website at

http://www.pnwfertility.com

WHAT SETS US APART?An important aspect of our service at Pacific NW Fertilityis our team approach to patient care. Our physicians andstaff work together to ensure your IVF cycle is as successfulas possible. In addition, our physicians are committed tokeeping the cost of your IVF cycle at a minimum, whileassuring all is done to give you the best possibility of pregnancy.

Our patients find that they develop rewarding relationshipsduring their treatment with our care providers, whichinclude doctors, nurses, medical assistants, embryologists,and patient care coordinators.We focus on making you feelwelcome, confident, and most importantly, cared for.

Call 206-515-0000 to schedule an Assisted ReproductiveTechnology screen or “ART Screen”.The ART screen isrequired prior to beginning the in vitro process and consistsof two appointments. One of the appointments will be with the IVF coordinator and the other is with one of our physicians, Lee Hickok, MD, Lorna Marshall, MD, LoraShahine, MD, or Julie Lamb, MD.The entire ART screenappointment may take up to two hours.Your IVFCoordinator will provide you with the next steps. Beforeou leave the office, you will meet with a financial counselor to discuss costs and answer your questions.

IN VITRO FERTILIZATION PROGRAMIn Vitro Fertilization, or IVF, is a therapy for patients who are unable to conceive on their own, and this therapy canovercome many reproductive problems. The process iscomplex, carries some risks, and with all assisted reproductivetechnologies, pregnancy cannot be guaranteed. However,it is our goal at Pacific NW Fertility to make this process aseasy and successful as possible. We want you to be aninformed partner in your care and will continue to provideinformation in writing and through discussion. The followinginformation is an overview of this process.




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SCREENING OF PATIENT AND PARTNER You will be scheduled for a screening appointment withone of our physicians to discuss the IVF option in detail.You will also speak with one of our IVF coordinatorsand a financial coordinator. Before you begin a cycle,you will have many laboratory tests performed, including but not limited to: Blood type and Rh, Rubella titer,Varicella titer, RPR (test for syphilis), HBsAg (Hepatitis B surface antigen), HCAb (Hepatitis C antibody), HIV(Human Immunodeficient Virus,). You may also have asaline infusion sonogram or hysterosalpingogram to checkyour fallopian tubes, ovaries and uterus. Your partner willhave most of these screening blood tests and a semenanalysis as well. If you have had any of the above mentionedtests performed, please bring copies of the results alongwith you to your IVF screening appointment.

IVF CYCLES You will usually be placed on birth control pills and aninjectable medication called Lupron. This will regulate andcontrol your menstrual cycle so we can optimize stimulationof the ovaries to produce multiple eggs. Other medicationregimens may be recommended depending on your ownhistory and evaluation. Hormone blood tests (such asestradiol) and vaginal ultrasounds will be performed tocheck your ovaries and uterine lining and your response tothe medications. Eggs are too small to see on ultrasound,but they are surrounded by fluid filled sacks called follicles,which are visible on ultrasound. The follicles grow larger as

the eggs mature. When ultrasound and blood estradiollevels indicate the timing is right, you will give an injection at a specified time in the evening. The egg retrieval will beperformed 35 hours after this trigger injection is given.Theeggs will be recovered by sonographic egg retrieval underanesthesia in the clinic procedure area. If partner’s sperm isbeing used, he will be scheduled for a semen collection thesame time as the retrieval. After egg retrieval, you will beplaced on estrogen patches and injectable progesterone tosupport your uterine lining and prepare it to accept theembryos at transfer.

Not all follicles are expected to yield an egg. Once theeggs and sperm are in the laboratory, an embryologist willcomplete fertilization. Not all eggs will be expected to fertilize. We will contact you the day after egg retrievalwith a preliminary report on fertilization and instructionsfor the embryo transfer. Embryos will remain in culture inthe laboratory for 3 or 5 days, and you will be scheduledfor embryo transfer on one of those days.

You will be given medication to reduce cramping during theembryo transfer procedure, so someone will need to driveyou to and from the transfer. Prior to the transfer, anembryologist will give you a detailed report about yourembryos. A very fine catheter will be placed through thecervix into the uterus and the embryo or embryos will betransferred into the uterine cavity with ultrasound visualization.After the embryo transfer you will remain in the transfer



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room for about 15 minutes. Any additional normally developing embryos can be cryopreserved (frozen)for future use. Not all patients will have extra embryos to freeze.

You will be scheduled for a quantitative blood pregnancytest about 15 days after egg retrieval. If you are not pregnantan appointment with your physician will be scheduled todiscuss the cycle. If you conceive, you will remain on yoursupportive medications until approximately 10 weeks ofpregnancy. Early obstetrical monitoring with ultrasoundswill be done at PNWF until your obstetrical team takeover around 10 weeks.

CONGENITAL ANOMALIES ANDMISCARRIAGE Birth defects and miscarriage can be caused by too manyor too few chromosomes. Congenital anomalies occur in3-5% of infants born. Risks of these anomalies increaseswith age, and diagnostic procedures such as amniocentesisor chorionic villi sampling may be recommended for pregnantwomen 35 years of age and over. Miscarriage can occur for many reasons, and is still a risk even with the supportivemedications you will be given. There is no way to completelyrule out or prevent birth defects or miscarriage. Somestudies have indicated an association with increased risk ofmiscarriage and birth defects with IVF and ICSI, but otherstudies have not shown such an increase. Please reviewthe enclosed information in Genetic Screening and Planningfor Pregnancy.

FINANCIAL Few insurances cover these procedures. We will have youmeet with one of our financial counselors to discuss costsand payments in detail. For IVF you will have to pay themajority of the costs prior to starting the cycle.

EMOTIONAL SUPPORTThe procedures and requirements for IVF can be stressfuland emotionally draining. During an IVF cycle, you may beinstructed to avoid vigorous exercise while your ovaries arebeing stimulated. We strongly encourage any activitieswhich may take your mind off the normal preoccupationwith your IVF cycle. An attempt to minimize stress duringyour IVF would also be beneficial. Some patients findacupuncture or yoga helpful in reducing stress. A referralcan be made to a counselor who has experience workingwith people going through this process. Other support canbe found through the national fertility support associationResolve, http://www.resolve.org. You may find ourMind/Body Class especially helpful throughout your treatment. Contact Carol Knoph at 206-604-6107 formore information on the Mind/Body Class.



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“HURDLES” FOR ASSISTED REPRODUCTIVE TECHNOLOGIES


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Although we expect that your IVF cycle will go smoothly, problems may occur. The following list will help increaseyour awareness of potential pitfalls.The "hurdles" are listed in the order they might occur.

1. Ovarian cyst At the suppression check ultrasound, we will be looking for ovaries at rest (no ovarian cysts), alow estradiol and a thin endometrium. If any of these parameters are not met, we may have to delay orcancel your cycle.

2. Inadequate stimulation Some patients do not respond adequately to ovulation induction medications(Repronex/Gonal F/Follistim). If there is inadequate follicular development, the cycle may be canceled.

3. Hyperstimulation A small percent of women are extremely sensitive to ovulation induction medications.Theymay develop too many follicles. If this occurs it may be necessary to cancel the cycle and allow the ovaries tonormalize.

4. Unexpected drop in estradiol level Estradiol levels are measured on a regular schedule.We expect the levelto continue to rise or plateau. If the estradiol level shows a significant decrease, the cycle may need to becanceled.

5. Premature LH surge/progesterone rise A few patients may experience a premature LH surge and/or a risein progesterone level prior to achieving adequate follicular growth. If this occurs, it may be necessary tocancel your cycle.

6. Low number of eggs at egg retrieval Usually the number of mature follicles at the final ultrasound is anindication of the number of eggs that will be retrieved. Occasionally, the number of eggs retrieved is less thanthe expected yield.

7. No eggs at egg retrieval This is extremely rare.

8. Poor fertilization of eggs Normal IVF fertilization rate is about 70 - 80%. In some cases, the percentage ismuch lower. Poor egg quality, poor sperm quality and/or other factors may contribute to this occurrence.

9. No fertilization Although this is extremely rare for IVF, it can occur.

10. Illness during cycle Significant illness or high fever, with either partner, may affect the success of the cycle.


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The goal of infertility treatment is the birth of a healthy baby. However, many therapies carry the increased risk ofmultiple pregnancy or multiple gestation.There are risks to both the mother and the babies. Patients should beaware of and understand these risks before proceeding with therapy. With IVF procedures, the risk can bereduced by transferring fewer embryos.The number of embryos that will maximize your chance of pregnancywhile minimizing risk of a multiple pregnancy should be discussed in detail with your physician prior to treatment.

COMPLICATIONS FOR THE FETUS AND NEWBORN IN A MULTIPLE PREGNANCY

Intrauterine growth restriction, congenital anomalies, miscarriage of one or more of the fetuses and death aremore common.

Preterm birth occurs in 50% of twin pregnancies, 90% of triplet pregnancies, and virtually all quadruplet (and more) pregnancies.

Prematurity is associated with an increased risk of low birth weight, intra-cranial hemorrhage, cerebral palsy,blindness, neonatal death, and respiratory distress syndrome (RDS). RDS accounts for 50% of all neonatal deathsassociated with premature birth.

Lifelong disability is over 25% for babies weighing less than 1,000 grams (2 lbs 3 oz.).

MATERNAL COMPLICATIONS

An increase in adverse pregnancy symptoms such as nausea, vomiting, fatigue, weight gain, heartburn, and insomnia. Additional risks include financial burden, depression, and marital discord.

More frequent occurrence of medical complications such as anemia, preeclampsia (also called pregnancy inducedhypertension), placental abnormalities associated with severe bleeding, polyhydramnios (excess amniotic fluid),and gestational diabetes. Some of these can be life threatening.

Premature labor requiring prolonged bed rest or hospitalization are more common.

Caesarean section is frequently needed for multiple pregnancy.

If you have a multiple pregnancy, multifetal reduction to lower the number of viable fetuses may be recommended.However, this procedure carries risks for the entire pregnancy. Patients contemplating this procedure should becounseled by a qualified perinatologist to understand their individual risks and benefits.

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Specialty Pharmacies

Avella Specialty Pharmacy Phone: 877-546-57791606 W.Whispering Wind Drive, 2nd Floor Fax: 877-645-5780Phoenix, AZ 85085 www.avella.com

Ascend Specialty Pharmacy Solutions Phone: 800-850-9122Portland Professional Pharmacy Fax: 800-218-322153 Darling Avenue www.portlandpharmacy.comS. Portland, ME 04106

Freedom Fertility Pharmacy Phone: 800-660-428312 Kent Way Fax: 800-660-4283Byfield, MA 01922 www.freedomfertility.com

MDR Encino Pharmacy Phone: 800-515-DRUG (3784)16500 Ventura Boulevard Fax: 888-939-2020Encino, CA 91436 www.mdrusa.com

Rox San Pharmacy Phone: 888-371-9919465 North Roxbury Drive Fax: 310-276-4152Beverly Hills, CA 90210 www.RoxSan.com

Strohecker’s Pharmacy Phone: 503-222-48222855-A S.W. Patton Road Fax: 503-222-4868Portland OR, 97201 www.stroheckersrx.com

Walgreen’s Specialty Pharmacy Phone: 800-424-90027164 Technology Drive Fax: 800-874-9179Frisco,TX 75034 www.walgreenshealth.com

Local Pharmacies

Walgreen’s Pharmacy Phone: 206-204-1982566 Denny Way (Corner of Denny & 6th Street) Fax: 206-204-1988Seattle,WA 98109

Custom Prescriptions, LLC (for compounded medications) Phone: 425-289-03471200 112th Avenue NE, #A102 Fax: 425-289-0891Bellevue,WA 98004

Walgreen’s (open 24 hours) Phone: 425-603-1438647 140th Avenue NE Fax: 425-603-9244Bellevue,WA 98005

QFC Northtown Phone: 425-576-92222636 Bellevue Way NE (corner of NE 24th) Fax: 425-576-9199Bellevue,WA 98004





Abigail Endicott, RNIVF [email protected]

Nina Kuhlman, RNIVF [email protected]

Melinda Lloyd, RNIVF [email protected]

Elaine WhiteFinancial [email protected]

Renee LanzollaIVF [email protected]

Kallie Fleharty, RNIVF [email protected]

Documents

Introduction to the IVF Process at Pacific NW Fertility