You should take folic acid 400 micrograms daily from 3 months before the scheduled treatment cycle. This is a Department of Health advice for all women wishing to conceive and not just for assisted conception treatment. This vitamin has been shown to reduce the chance of spina bifida and is available from chemists. You should continue with it for as long as you are trying to conceive and for the first three months of pregnancy. Also it is good advice to eat a balanced diet with plenty of vegetables and raw fruit. We would recommend taking folic acid combined in with a multivitamin product specific to pregnancy.
Smoking can be dangerous during pregnancy and can also decrease your chance of conceiving. Therefore it is imperative that neither of you smoke.
HFEA consent to treatment by husband/partner insemination form must be signed by both partners prior to commencing treatment.
HFEA consent to legal parenthood by partner insemination form must be signed by both partners prior to commencing treatment.
It is very important to have PROTECTED (use a condom) intercourse from day 1 of the cycle on which you are starting treatment.
Please telephone the clinic when Day 1 -2 of your period commences. Start Buserelin injections or if prescribed Nafarelin nasal spray on Day 2 of your period. IF your period commences over the weekend – start injections or nasal spray ring ACU unit first thing Monday morning. We will arrange for you to come in for a baseline scan (usually between Day 2 – 4 of your period) following which one of the nurse specialists will explain about your treatment and you will collect your drugs from pharmacy. Another scan appointment will be booked for you before you leave the clinic. Buserelin injection or nasal spray will continue until the day that the trigger injection is indicated by the nurse. Injections may be daily or alternate days dependent on which protocol is most suitable for you. This will be discussed after the first scan. It is important that all your screening results are available and in date (within the last year) so please ensure you bring any that are outstanding to this appointment.
BASELINE ULTRASOUND SCAN
Attend for your baseline ultrasound scan as instructed by the nurse. The scans are performed with a vaginal probe and therefore a full bladder is not required. This scan will be performed even if your are bleeding. If your scan shows any persisting cysts or follicles in the ovaries your cycle may need to be delayed.
FSH HORMONE INJECTIONS
Start the follicle-stimulating hormone (FSH) injections on the planned day following the baseline scan. The dose of the drug may alter depending on previous baseline hormone results and responses to previous stimulated cycles. FSH may be prescribed as Menopur or Gonal-F.
Make sure you know the dose you are to start on.
After your baseline scan your dosage of FSH will be confirmed and you will be given a medication chart. The injections should be given in the evening unless specifically instructed otherwise and prior to 8pm
You will be taught how to do your injections by the nurse at treatment planning. If you do not wish to self-inject please discuss this with the nurse.
HORMONE BLOOD TEST
On some days you may need to have blood taken for hormone assessment. This is usually done if there is not enough ovarian response (too few follicles) or if there is over response. We also perform a hormone assessment assay preceding the IUI. CONTINUED FOLLICLE MONITORING - (Progress Scans) In order to monitor the response to FSH injections you will need to attend for further scans on certain days. Some of these appointments for scans are possible to predict in advance but please do be prepared to have to alter the days of scheduled attendance if the response to the injections is not as we had predicted.
We will use the results of the scans (and possibly blood tests) to adjust the dose of FSH injections and to determine the date and time of the trigger injection. This injection of hCG matures the eggs within the follicles and stimulates ovulation.
Please do keep in contact with the unit throughout this phase. There will be further instructions as you go along. In order to assist staff please bring the medicine chart with you whenever you attend, and check your supply of needles and syringes so you can collect more if needed.
Your insemination will probably be on or about the day that we have planned for, but the precise day may vary according as to how the ovaries respond to the FSH injections. Occasionally the eggs take longer to develop in which case the procedure may be deferred until the following week. The final decision will be taken at least two days before the insemination based on the scan findings and blood hormone assessment.
The male partner will need to produce a semen sample on the day of the insemination, one to two hours before the procedure. The man should have abstained from ejaculation for 2 to 3 days before. On the day of your final scan the nurse will inform you of the times for the procedure. Insemination will occur in the Victoria Wing, is usually a simple painless procedure lasting 5 to 10 minutes and does not require a general anaesthetic. The procedure is performed on an out patient basis. You will be asked to tell us your full name and date of birth. Two people check each stage of the sperm preparation and you will be shown the details of your names and dates of birth on the ampoule, which contains your partner’s sperm. Either a Nurse or a Consultant will carry out this procedure. In some circumstances there is insufficient response and the cycle is abandoned. Other times it is possible to have over-stimulation of the ovaries; it is not possible to perform IUI when there is over-stimulation because of the risks of multiple pregnancy and in these circumstances it imperative that you do not have intercourse as spontaneous ovulation can occur even when the Pregnyl injection has been withheld. All these options will be discussed with you if appropriate HORMONE SUPPORT (after IUI) Hormone support will be given in the form of hCG (Pregnyl 1,500IU) two and five days after the insemination.
We advise that every woman has a pregnancy test checked 16 to 18 days after IUI. During this time you may experience increased discharge from the vagina and some low abdominal pain. If you notice vaginal bleeding please contact the unit. Please ensure that you inform the ACS unit of the outcome of your treatment, whether it is negative or positive. If the pregnancy test is positive you will be offered a scan to check the pregnancy. Unfortunately about 10% of pregnancies will miscarry with a small chance of an ectopic pregnancy.
If the test is negative, an internal review will be carried out by the nurses, embryologists and your consultant to review what should happen with your next cycle. This will then be relayed back to you by telephone or letter. On some occasions we may recommend a review for you with your consultant.
The fertility unit is staffed Monday to Friday from 07.30 to 17.30 hr. Outside these hours an answer phone is used. If you leave a message please tell us the date and time it was left. If there is an emergency a member of the team is always on call and can be contacted via the unit mobile (077404 22717), or via the main hospital switchboard (01483 227800).
SIDE EFFECTS OF DRUGS Nafarelin and Buserelin work by suppressing the production of hormones from the pituitary gland in the brain, which stimulate the ovaries to develop follicles. After approximately 14 days administration of Nafarelin / Buserelin the normal function of the ovaries will be 'switched off'. This allows for more control over the development of the follicles, in response to the administered fertility injections and prevents spontaneous ovulation. However, once the ovaries are 'switched off' and the oestrogen levels in the blood are low, some women experience symptoms. These include hot flushes, feelings of depression, irritability and headaches (it is all right to take Paracetamol). Whilst taking Nafarelin / Buserelin the period may be different (sometimes lighter, but also may be heavier). These symptoms usually stop when the FSH injections start. The FSH injections stimulate the production of follicles and hormones within the ovary. Whilst receiving these injections some women experience abdominal bloating, breast tenderness, increase in vaginal secretions and if their ovaries over respond, large number of follicles with abdominal distention. The majority of women do not experience any side effects, but if they do they are usually short lived and will cease when the treatment is finished. Some patients will over respond to the FSH injections and produce too many follicles. If this happens and treatment continued there is a risk of developing the Ovarian Hyper Stimulation Syndrome (OHSS). Patients at risk of developing the OHSS maybe advised not to have the trigger injection, must not have unprotected intercourse (use a condom), their cycle will be cancelled and they must continue on the Nafarelin nasal spray until all the follicles have disappeared. Once this has happened treatment with a lower dose of FSH injections can be restarted. Some patients could still develop OHSS in the two weeks after insemination. The majority will develop a minor or moderate form of the condition; their ovaries become enlarged with multiple cysts and ascites (fluid in the abdominal cavity), causing abdominal discomfort. The most severe form of OHSS only occurs in 1-1.5% of patients receiving fertility injections. It is characterized by nausea, vomiting, ovarian enlargement and ascites, causing marked abdominal pain and distention. The abdominal distention may prevent the proper movement of the diaphragm (the muscle between the chest and abdomen) so that the woman may feel extremely breathless.
She may also feel weak and faint due to a reduction in her circulating blood volume (hypovolaemia). In the most extreme situations there is a reduction in the blood flow through the kidneys, resulting in a reduction in urine output. If this occurs it may lead to renal failure requiring treatment with renal dialysis. Those women who develop severe OHSS require hospital admission, usually for a few days, occasionally for a few weeks, to relieve their symptoms and to monitor their progress. Management of severe OHSS may include aspiration of some of the ascitic fluid from the abdominal cavity. It will include maintaining the circulating blood volume by administering intra venous fluids, which will also substitute the fluids lost by vomiting.
The majority of patients (75%) with severe OHSS are pregnant. Symptoms do not persist after the first three months when the hormone production supporting the pregnancy shifts from the ovaries to the placenta (afterbirth). In the majority of cases the symptoms disappear within a few weeks. Those patients who are not pregnant recover much quicker, usually by the time they have their next period.
EMERGENCY CONTACT NUMBER 077404 22717
The symptoms you should be concerned about are as follows:
Abdominal bloating and discomfort
Heart burn or indigestion
Reduced frequency of passing urine (we advise drinking 2 litres of water daily)
General feeling of lethargy
Difficulty in breathing
If you feel you have any of these symptoms please do not hesitate to contact a member of the Victoria Wing nursing team.
If admitted to hospital – give the OHSS card immediately to the nursing staff. RISKS OF MULTIPLE PREGNANCY. A multiple pregnancy is where 2 or more foetuses develop in the uterus at the same time.
Twins and triplets can undoubtedly bring many joys; both parents need to be realistically prepared for the possibility and potential problems.
A multiple pregnancy will place a much greater strain on the mother and carries a higher risk of miscarriage. Complications (such as high blood pressure or bleeding) are more likely to occur and can arise earlier in the pregnancy.
Most multiple pregnancies are delivered early (before 40 weeks). The average length of pregnancy is 37 weeks for twins and 34 weeks for triplets. There is a high rate of caesarean section for twin pregnancies and the majority of triplets are delivered in this way.
The birth weight of twins and triplets is generally lower than that of singletons. Any pre – term baby is more likely to die than one who is born at full term, so twins and triplets are at much greater risk than singletons. Babies who are born very prematurely are also more likely to have complications which can lead to long term problems in the functioning of their lungs or heart and, in particular their brain.
The problems of caring for more than one baby can be considerable and include emotional as well as financial aspects. There are no additional state benefits for multiple births in the UK, yet the every day costs of bringing up twins, even more so triplets are much greater. The cost of nursery equipment, clothes, food and childcare is inevitably substantial and many mothers who hoped to return to work after the birth have found the cost of childcare makes this financially nonviable.
Many parents own physical and mental health suffers as a result of caring for twins or more. Depression is more likely and this, like other problems, can affect their relationships with each other, the wider family or friends.
Your consultant and nurse counsellor will discuss these issues with you further but if you have any questions please do not hesitate to ask.
You can also contact the Multiple Births Foundation www.multiplebirths.org.uk 02083833519
For detailed outcome results please see statistics sheet
Our team at the Nuffield Health Woking Hospital, Victoria Wing will give support, before, during and after treatment, providing information and implications counselling and guidance to explore relevant issues.
Undertaking treatments can be an emotionally stressful time for you and your partner and it can help to talk things over with someone else. We do have access to independent counsellors and this consultation is strictly confidential. We strongly advise couples to seek independent counselling prior to treatment. Treatment where donor sperm is being used will require a mandatory session with our counsellor before any treatment can commence. This is to ensure all legal aspects of donor gametes is fully understood by all parties involved in treatment.
If at anytime during your treatment you are not happy with the standard of care will you please tell the nurse coordinator. If you feel you wish to complain will you please write to the named complaints officer: Ms Monnik Vleugels, Hospital Director,
Nuffield Health Woking Hospital,
Surrey GU21 4BY. We are constantly striving to achieve excellence within the department; however we appreciate that you may feel there are areas which do not come up to your expectations. We would like to know about this. We want your treatment to progress smoothly for you.
WHAT YOU NEED TO KNOW BEFORE TREATMENT BEGINS
Before commencing with the proposed treatment, please ensure you have been given the following information. 1 The limitation and possible outcomes of the proposed treatment
5 The costs involved and costs of alternative treatment
6 The availability of counselling facilities
7 The possible disruption to your normal life Your general practitioner is not obliged to prescribe the medication you may require for your treatment.
IUI (excluding cost of drugs) See fee structure The IUI fee includes all scans, blood Oestradiol level, nursing services, sperm preparation, insemination, and doctor's fees. It also includes one pregnancy test + pregnancy viability scan if positive result. It does not include: * Drugs
* Any investigation required before treatment
WHEN TO PAY?
Payment must be made in full prior to the treatment cycle commencing. Cheques should be made payable to the Nuffield Health, and all major credit cards are accepted.
We also offer you the facility for 'Banker's Automated Clearing Services' (BACS) which is a simple and cost effective way to make payments directly from your bank account to another bank account. For further information please discuss with our Accounts administrator.
The hospital will require details of a credit card before treatment starts, please discuss this with the ACS financial administrator if this is difficult for you.