Things are progressing. You’ve had your new patient consultation, and met with your doctor and your nurse. You’ve had a chance to discuss insurance, benefits and/or payment issues with your financial counselor. Any needed pre-testing (bloodwork, HSG or semen analysis) has been obtained and reviewed by your clinical team. Your doctor has recommended a treatment plan, and you are almost ready to start a new phase of your fertility journey!
Before you proceed with your treatment cycle, you will need some final education. Your nurse or clinical assistant will share and review a written ‘protocol’ of your proposed treatment. This written protocol sheet serves as a combination of calendar and instructions for your upcoming treatment cycle. It provides instructions on when to call the SG office, when to come into the office for ‘baseline testing’ (bloodwork and/or sonogram to confirm your ovaries and uterus are at a ‘baseline’ stance), and when to take any recommended medications.
You will make sure that if you are taking any injectable medicine, that you have signed up and completed an injection class. Your nurse or clinical assistant will remind you to read and return your signed treatment consent forms.
When it is time to start a ‘treatment cycle,’ usually you are instructed to place two phone calls. One call is to your office front desk, who will make your appointment to come in the first few days of your menstrual cycle. Additionally, you will be asked to contact your primary nurse, who will verify your cycle start instructions, as well as make sure your orders are in the computer. This will insure your care is streamlined when you arrive at the office.
Monitoring: What is it?
‘Monitoring’ is a general name for the morning activities of ultrasound and bloodwork testing, to evaluate how a woman is responding to her treatment. The results of the ultrasound and/or bloodwork are reviewed each day by the physician, and further instructions for continued treatment are shared by the patient’s nurse.
Whether you are having a ‘natural cycle’ (no medication) with timed intercourse, an IUI (Intrauterine Insemination) cycle, IVF (in vitro-fertilization) or donor egg treatment, monitoring is a part of each woman’s treatment plan.
- IUI: Either oral or injectable medication may be introduced to encourage follicle growth. With monitoring, ovulation timing is determined, and an office IUI is scheduled.
- IVF: Injectable medications are given, and monitoring appointments are necessary to observe the number and size of a woman’s follicles. Medication dosing is then adjusted, based on the monitoring results.
- Donor Egg: Donor patients are given injectable medication, to induce follicle growth, like the IVF patients. Recipient patients are given injectable medication to encourage uterine lining growth, for placement of an embryo at the appropriate time.
The Monitoring Team: Who You’ll Meet
Your morning monitoring team is a well-orchestrated group of professionals whose daily focus is to insure you have a safe, efficient and caring appointment. It begins at the front desk, where the PSR (Patient Services Rep) will check you in for your appointment.
The monitoring MAs (Medical Assistants) will draw any needed bloodwork, and take you to the ultrasound area. There, one of our registered sonographers and/or a Shady Grove physician will perform the ultrasound examination and provide feedback. Additionally, one of our SGF nurses is typically available to answer questions, offer clarity, provide additional prescriptions prescribed by the doctor, or other services as needed.
The office financial counselor is usually available in the mornings for any financial questions. And at checkout, our PSR can help make any additional appointments.
The First Step: Baseline or Premed Testing
A blood pregnancy test and an ultrasound are done in the early days of a woman’s menstrual cycle (typically days 2, 3, or 4). The purpose of this ‘baseline’ is to assure that the patient is not currently pregnant, her blood estrogen is low, and her uterine lining thin. This accompanies an ultrasound assessment to assure there are no significant ovarian cysts, and measure the resting antral follicle count (AFC). These measurement parameters signal the best time to begin a treatment cycle.
Once your physician has reviewed the results of your blood work and ultrasound, you will receive a phone call from your nurse, typically in the afternoon, to begin your medication protocol and to make an appointment for your first monitoring appointment.
No matter what treatment type you are embarking on (excluding donor recipients), monitoring will include two factors: blood estrogen level testing and ultrasound to view follicle growth and uterine lining.
Monitoring Blood Hormone Levels
The estradiol (blood estrogen) or ‘E2’ level is produced inside the developing follicle. The blood estrogen level helps correlate appropriate growth of the egg follicle and can alert the SG doctors and nurses to an increasing risk for hyperstimulation. We are not looking for a specific estrogen level, but rather a progressive growth.
The blood LH level indicates when a woman is about to ovulate. This helps with the timing of ‘timed intercourse’ and IUI treatment cycles. This LH level is drawn in some of our IUI patients’ cycles.
Monitoring Egg (Follicular) GrowthEither simply time or medication may be used in a treatment cycle to help promote egg (follicle) growth. ‘Ideal’ follicular development is based on treatment type. If a woman is not ovulating at all on her own, doctors may try to mimic Mother Nature and attempt to get a single egg to grow.
During monitoring, the clinical team will be looking for the normal, progressive growth of a single follicle. If a patient is being monitored for an IUI cycle, the focus will be on a low number of follicles (egg sacs) exhibiting normal growth progression. In an IUI situation, we try to limit the number of follicles so that a multiple pregnancy is avoided. The exact number is dependant on the woman’s age, the egg quality and diagnosis. For example, a younger woman might be looking at 1-2 follicles, whereas in a 38-year old patient, the ideal number may be 3-4 eggs.
Egg (follicular) growth ‘monitoring’ is obtained through the use of a transvaginal sonogram. This relatively painless office procedure is performed by one of our registered ultrasound technicians and/or one of the SG physicians. This view provides immediate visualization of how the ovaries are responding to time and/or medication.
Uterine Lining Growth: Important for Embryo Implantation
Around days 6 or 8 of a cycle, the uterine lining (endometrium) begins to ‘thicken up.’ This is visualized as an increased area seen on the patient’s ultrasound. Lining growth is dependant on the estrogen levels, and how advanced the follicle growth is occurring. This is an important parameter that is watched during monitoring, to insure an optimal environment for embryo implantation.
It is not uncommon to have slower development of this uterine lining. This simply means a patient’s treatment cycle may take a bit longer. Again, this is not uncommon in women who have had historically longer cycles, those patients with PCOS, or those with hypothalamic amenorrhea.
Sometimes our patients respond to medications in differing ways. Occassionally we find that a woman’s uterine lining is too ‘thin.’ That may be related to medication. For example, while Clomid is a medication that assists ovulation, it also has some anti-estrogenic effects, making the endometrium thinner. This issue may be overcome with an estrogen replacement medication.
Physician Results Review and Cycle Instructions
The patient’s monitoring results from ultrasound and bloodwork are reported in the computer, where they are available for your primary doctor to see. Each day, Shady Grove Fertility has a results review, where the ‘Results Doctor’ and your primary doctor review your results and make dosing decisions.
You can expect to receive a call with your instructions between 4:00 – 6:00 pm. In addition to your primary doctor, you may have several other specialist physicians reviewing your cycle progress. This is a wonderful value of having a larger fertility practice: more expert eyes are involved in each case.
Convenient Monitoring Locations for Patients
Electronic medical records (EMRs) make it very easy for our patients to be followed by your primary clinical team, no matter where you decide to do your cycle monitoring. Our patients may schedule their monitoring appointments starting at 7:00 am in any of our 13 full-service locations Monday-Fridays, and on the weekends there are four locations open for monitoring (Annandale, Annapolis,Baltimore and Rockville). We know that your time is valuable, so our staff makes every effort to make sure your monitoring appointment goes smoothly and efficiently.
The decision to ‘trigger’ or induce ovulation is based on a combination of factors-the length of stimulation, the number of mature follicles, the blood estrogen levels, the type of treatment, and the patient’s personal history, among others. Follicles are considered ‘mature’ when they measure between 18-20mm.
When the timing is right, the patient will be instructed to take a trigger shot to mimic the LH surge in the natural cycle. Luteinizing hormone (LH) prepares the eggs for the final stage of maturation and ovulation. Patients doing timed intercourse or intrauterine insemination cycles will be instructed to take an injection of HCG. Our IVF patients will be instructed to give themselves an injection of HCG or Lupron. Lupron is given when monitoring has indicated patients are at a higher risk of hyperstimulation.
Sometimes Things Change – Being Flexible
While we try to share plans and expectations in a timely manner, there are times when situations change. It may come in the guise of needing additional medication, a different appointment time, or responding to the protocol in unexpected ways.
Please know all the SGF staff is here to assist you on your treatment course. Your flexibility will be a useful tool if you need to navigate the roads of unplanned medications, differing appointment times, or unexpected treatment response.
Some of our patients may require additional medications than originally planned, to obtain an optimal treatment response. This may cause distress in not only obtaining the medication, but also with costs. We wish your cycle to proceed optimally, and we have your best interest at heart. We will work with you to address any such changes in your treatment protocol.
Support for the Journey
Monitoring is something that nearly every patient experiences. To help you navigate the journey, Shady Grove Fertility offers many support services to assist our patients including:
- Psychological Support Services, including groups and focused discussions
- Our SGF Facebook page is an online community of active patient support
- Complementary and alternative medicine provides services as acupuncture and massage
- Blogs and our SGF website
Depending on the patient and her treatment regime, ‘morning monitoring’ may be 2, 3, 5, or 6 morning appointments to assess your status. This is an important time in evaluating your response to prescribed treatment, and making adjustments along the way. SG’s goal is to optimize your response to make this the most successful treatment for you.