IM injections
by Lisa

Why would you be doing an IM injection?

While most of the stimulant drugs are administered via sub-cue injection, some injections, including progesterone in oil (PIO) and some “trigger” shots (Human Chorionic Gonadotropin, or HCG) are given by intra-muscular (IM) injection.

What to expect

For those of us scared of needles (even despite administering hundreds, if not thousands, of sub-cue injections), the prospect of an IM injection can be utterly horrifying. The needle is 1 ½ inches long and often 22 or 25 gauge (remember that the lower the number, the thicker the needle so an 18 gauge is much thicker than a 25 gauge needle.) But take it from a recovering needle-phobe, these injections are actually much less painful than the size and gauge of the needle would indicate.

As with any injection, get everything ready beforehand: extra needles, gauze pads, and, for IM injections, plug in a heating pad for post-injection. I always iced the area for 5-10 minutes (sometimes 15 when I was particularly nervous!) beforehand. I know people who didn’t ice the area beforehand—they are much braver than I, but it just goes to show you that it is possible to do without icing. Do what makes you feel most comfortable.

Often, you will draw up the medication with a larger (18 or 22 gauge) needle, and will then switch to a smaller (22 or 25 gauge) needle for administration. Since it is extremely thick, PIO typically needs to be drawn up and administered with a thicker needle. You can administer it with the thinner (25 gauge) needle, but it will take a little longer to inject the oil and I personally never felt any difference between the 22 and 25 gauge needles, so if you want the needle out of you as fast as possible, go with the thicker (22 gauge) needle for administration.

A couple of things to remember: first of all, switch needles after drawing up the medication and before administering it, even if you are using the same size needle to draw and administer. The needle can get just a little bit dull after it is placed into the vial of medication, and you want as sharp a needle as possible for administration—dull needles hurt a lot more than extra sharp ones! Also, remember to tap all air bubbles to the top of the syringe and depress the plunger a small amount to get the bubbles out (I usually pushed the plunger until a tiny bead of the medication came out of the tip of the needle, which indicated to me that the air was out.)

Now, for the dreaded injection. IM injections must be done in the large muscle of the buttock. To locate the correct area, imagine the buttock is divided into four areas (like an x/y axis). The injection should be given in the upper, outer portions. Another easy way of locating the correct area was demonstrated by my nurse: place your hands on your hipbone, with your thumb pointing toward your butt crack and your other fingers on the front of your hip, with the area in between the thumb and forefinger flat against your hip bone (like you’re putting your hands on your hips). The injection can be given below the thumb, but not past the tip of the thumb—that area gets close to your sciatica nerve and you want to avoid that area.

The easiest way to administer the injection is to have someone do it for you. However, it is possible to do it by yourself—I traveled on business during the 2ww and had to do it myself two nights in a row unless I wanted to as a business associate to help me (granted, she is also a good friend and knew about our IF treatments, so she even volunteered to help if necessary but I just couldn’t bring myself to have her injecting me in the butt.)

If you have someone to do it for you, the easiest position is to lean against a counter and put all of your weight on the leg opposite the side of the injection (you should alternate sides each night from left to right to avoid over-irritating one side). Don’t look back. The person administering the injection should hold the skin taut with his/her thumb and forefinger of the hand not holding the syringe, and should be holding the syringe in the other hand like a dart. Have the other person count to three if you’d like, and then go in at a 90 degree angle as quickly as possible­— you will feel a slow injection more than a quick one, so make sure they go quickly.

If you are doing the injection yourself, find a comfortable position where you can hold the needle steady and still keep all weight off of the side you are injecting. I leaned against the counter similar to when my husband did the injection, but you can also try sitting in a chair and leaning to one side. Twist yourself around so that the hand not holding the needle holds the skin taut between your forefinger and thumb. With the other hand holding the syringe like a dart, inject as quickly as possible at a 90 degree angle.

Once the needle is in (make sure all 1 ½ inches are in the skin/muscle), pull back the plunger just a small amount to make sure there is no blood, which would mean the needle is in the incorrect position. IF you see blood, DO NOT PANIC. Simply pull the needle out slowly, attach a new needle, and inject again in a different location. You do not need to discard the medication because of the blood. The blood is your own and can be re-injected (with a clean needle) along with the medication. I have a friend who wasted a lot of PIO because she thought she had to throw it away if she drew blood.

If there is no blood in the syringe, slowly depress the plunger to inject the medication. When done, quickly pull the needle out in a straight line. Do not panic if you have a little (or even a lot) of blood coming out of the injection site—just put pressure on with a gauze pad for a minute or so and the bleeding will stop. You can put a band-aid on the area if necessary.

Massage the injection area to help spread the medication (especially PIO) around. I always put a heating pad on the injection area for 10-15 minutes after the injection, especially with PIO because the heat can dissipate the oil so that it does not harden in an uncomfortable lump. I also made sure to walk around a bit to avoid any muscle soreness and, for PIO, to further spread the oil around. The few times I did not use a heating pad and/or walk around after the injection, I felt more soreness the next day.

Some problems that might arise (and ways to troubleshoot)

As mentioned above, there is always the chance that you will hit a blood vessel and draw blood when you draw back the syringe. Do not panic—just withdraw the needle, make sure to change the needle, and re-inject in a different spot.

You may also experience soreness—some people experience more soreness than others. The best ways I found to eliminate, or at least reduce, soreness was to consistently use a heating pad after the injection, massage the injection area, and walk around a bit. Soreness is more likely with PIO because the oil has a tendency to coagulate in the muscle and cause an uncomfortable lump. Massage, heat, and moving around can help the oil spread out and prevent these lumps.

Finally, there is a chance that you could hit a nerve when administering the injection. If you are careful, this will not happen (it never happened to me). To avoid this possibility, make sure you are giving the injection closer to the hip than to the middle of the buttocks. Remember the “thumb” rule mentioned above—put your hands on your hips with your thumbs pointed towards the back, and do the injection below the thumb and not past the tip.

My personal tips

I covered my personal tips above, but one additional tip would be to have a nurse do your first IM in
jection, if possible, with your significant other (or whoever will be administering your injections) present. We did this for our first IM injection and we both felt better knowing that a professional had gone over the procedure before we tried it ourselves. Remember, I was needle-phobic before this whole IF journey, and I found the IM injections very easy. I almost preferred them to the sub-cue injections because they were actually less painful (stung less than the stim drugs). So take a deep breath and just do it. You’ll realize that it isn’t as bad as you are probably imagining!

Ovarian Hyperstimulation Syndrome (OHSS)
by Bronwyn

Why would you be dealing with Ovarian Hyperstimulation Syndrome (OHSS)?

Because you have undergone controlled ovarian hyperstimulation – either for IVF or IUI. Every time you undergo controlled ovarian hyperstimulation there is a small degree of risk. However, your symptoms are likely to be very mild, involving only a minor degree of swelling or discomfort. OHSS usually starts a couple of days after an egg retrieval – although, like everything, this can vary and your symptoms may start earlier or later.

Factors Which Increase Your Risk

1. Lots of follicles and high estrogen levels. This is the biggest risk factor, and one of the reasons why more isn’t necessarily better. You may be “coasted” to reduce the number of follicles/estrogen levels.
2. hCG seems to trigger, prolong, and increase the severity of OHSS. If you are at very high risk, your retrieval may be cancelled because the hCG trigger injection will be deemed too dangerous. If you are at slightly lower risk, you will be asked to trigger and undergo retrieval, but your transfer will be cancelled to avoid pregnancy in that cycle and the embryos frozen for later use.
3. Low body mass index. For some reason skinny women are slightly more at risk. No-one knows why.

What You Can Expect

Symptoms: Pain or swelling of the belly. Decreased urine output and pain when urinating. Nausea and vomiting. Thirst. Shortness of breath. Sudden increases in weight.

The average case lasts seven to ten days. Unfortunately, there is no way to make the OHSS go away. Instead, you need to support your body until the hormones settle down. Most of the time, adequate monitoring and treatment can be given at home – this is discussed in more detail under “troubleshooting”. If your symptoms become too severe for at-home treatment, you will be admitted to the hospital. Although the principles of supportive care and monitoring remain the same, both will be more aggressive for in-hospital patients.

Treating OHSS

1. Keep up the fluids. You will be losing fluids into your abdominal cavity. If you can’t keep up with this loss by drinking fluids, you will be put on an IV drip.
2. Keep up the proteins. You will also be losing proteins into your abdominal cavity. If eating protein-rich foods and drinking protein shakes isn’t enough, you can be given albumin via a drip. 3. Control pain. The type of painkiller you need will depend on your level of pain.
4. Control nausea. Anti-nausea medications may be used.
5. Control shortness of breath. Mild shortness of breath can be treated with rest. In more severe cases, intranasal oxygen may be used.
6. Maintain organ function and treat specific complications. If the pressure in your abdomen is too great, an in-dwelling tube can be placed under local anaesthetic to drain some of the fluid away. As the proteins in this fluid are lost to the body forever, and cannot be resorbed, this will only be done if the benefits are thought to outweigh the risks. If you are having trouble emptying your bladder due to the enormous swelling of your ovaries, you may need an in-dwelling urinary catheter placed. Other specific complications are treated as they arise.
7. Maintain circulation. You may find that fluid collects around your lower body. Flight socks can be used to prevent swelling around the calves. Heparin injections and aspirin may be prescribed to lower the risk of clotting and thromboembolism.

Monitoring OHSS

1. Daily weight checks.
2. Measurement of urine output and fluid intake.
3. Daily blood tests for in-hospital patients.
4. Monitoring vital signs for in-hospital patients (heart rate, respiratory rate, oxygenation, temperature).
5. X-rays and ultrasounds may be used for some in-hospital patients, depending on symptoms.

After OHSS

Most clinics advise taking a cycle off to allow your reproductive system to get back to normal. Opinions do vary, though – some specialists are willing to do an FET the very next cycle, and others advise a longer wait of several cycles. Most patients find their next cycle is longer than usual. It’s common to be anything from two to four weeks late in the cycle following OHSS. The cycle after that may also be prolonged.

Ways to Troubleshoot

You should report any and all symptoms to your specialist. This is important! Simple treatment for mild cases: 1. Drink plenty of fluids. Electrolye drinks (sports drinks) and protein shakes (eg sustagen) are especially good. This is because your body is losing fluid, electrolytes and proteins into your abdominal cavity. High-protein foods, such as chicken, are also recommended. 2. Take pain killers. Doctors usually prescribe paracetamol/acetominophen plus or minus codeine for mild pain. If these don’t work, consult your specialist. 3. Rest up. I promise this will make you feel better. 4. Monitor your symptoms. Check your weight on the bathroom scales each morning. Report any sudden increases in weight. Measure your waistline. If you are putting on inches each day, talk to your clinic. Take note of your urine volume. If it’s decreasing, or if you find you are going to the toilet very frequently without passing much each time, contact your clinic. If any other symptoms arise – nausea, vomiting, shortness of breath etc – contact your clinic.

Personal Tips

1. Don’t be afraid to talk to your clinic about your symptoms. If your symptoms are changing and progressing – talk to them again. Better safe than sorry.
2. OHSS is tough mentally and emotionally. There are an awful lot of hormones involved, and you are genuinely sick, which is frightening. The fact no-one can tell you how long it will last is frustrating – will it be a few days or will you be that rare patient whose symptoms go on for over a month? Supportive treatments, especially IV albumin, can make you feel better temporarily and lead you to think it’s all over – until they wear off. This is very different from illnessess or injuries you may have had in the past, where each day you can feel yourself getting a little bit better. With OHSS, you may be getting worse each day, or feeling up and then down again, with no clear ending in sight. Please remember almost everyone gets better in seven to ten days. During my ten days in the hospital, a couple of things were said to me which I clung to. A nurse said, “You will get through this – hour by hour, day by day, moment by moment.” And another said, “You’ll never stop putting yourself through these things for your kids.”

Saline Sonohysterogram (SSH, saline sono, hysterosonogram, saline infusion sonogram)
by Kelly (she’s gaining on you, Carolyn! 🙂

Why would you be having a SSH?

This procedure is used to determine if there are any abnormalities (such as polyps or fibroids) of the uterine cavity that could interfere with pregnancy.

What you can expect

The physician will place a small catheter into the uterus and sterile saline will slowly be injected into the uterine cavity. This will slightly inflate the uterus so that most abnormalities (polyps or fibroids) can be visualized with ultrasound. After the procedure, the saline will slowly drain out of the uterus, so you will need to wear a pad to protect your clothing. You may experience some light spotting (bleeding) after the procedure also.

My personal tips/experiences

This procedure was worse for me than the HSG because my cervix is tilted. It was performed by the nurse who couldn’t seem to get the dye to go to the right place so they were never able to determine whether I had a polyp.

The worst part of this was that when I left I had the most horrible cramps that I have ever had – I think because she had injected so much dye (because she kept trying over and over again to no avail). I drove myself home from the appointment which was a big mistake – I would definitely suggest having someone come with you just in case yours goes anything like mine did. I almost had to pull over because the pain was making me nauseous (I only live about 10/15 minutes from my doctor’s office, but the ride felt like an eternity).

I came home from the appointment and lay down because my cramps were so bad. I think the best thing though is to walk around and let the saline drain out of you. Once it started to drain out, the cramps started to subside.

I would also suggest taking motrin or advil prior to going. They suggested this for the HSG for me but not for this procedure so I wasn’t prepared for the cramping.

Also, wearing a pad is a good idea because once the saline started to gush out (yes, mine did not slowly drain) I felt like I had peed myself (lovely picture, right?).

I did not have spotting immediately following the procedure but I did have it start a couple of days later. It was relatively heavy and lasted a good 4 days or so.

Honestly though, I think that this procedure goes pretty smoothly for the majority of women. Most women that I have heard from say that this procedure was much easier for them than the HSG so I definitely believe that experiences will vary greatly among people.

Diagnosis: Infertility Caused by PID Scar Tissue
By: Carolyn

What PID Scarring Means and Its Impact on Fertility

Many women who have suffered an attack of pelvic inflammatory disease (PID) also suffer from infertility caused by the infection. PID can be caused either by a sexually transmitted disease or bacterial vaginosis. An infection can cause scarring in the fallopian tubes or in the abdomen. Blocked fallopian tubes hinder an egg’s ability to travel into the uterus to be fertilized, and scarring in the abdomen can effectively cement the fallopian tubes in place (making it nearly impossible for them to “catch” an egg) and completely separate them from the ovaries.

PID is frequently misdiagnosed, especially if the patient does not test positive for a sexually transmitted disease. A bad attack causes severe stomach/abdominal pain and an infection that must be treated with antibiotics. If you suspect you have had PID, inform your OB/GYN or RE so they can complete further testing.

It’s important to note that any kind of abdominal infection or abdominal surgery can cause scarring that may lead to infertility. You should inform your physician if you have any cause to suspect that you may have scar tissue.

Diagnostic Process

Unfortunately, the only way to definitively diagnose infertility caused by PID scarring is through a laparoscopy. Your doctor may decide a lap is indicated if an HSG shows that your tubes are blocked, if you have a known history of PID or abdominal infection/surgery, or if an HSG shows that your uterus and/or tubes seem to be pulled into an awkward position. If scarring is found during a lap, your doctor will remove all that (s)he can.

Treatment Options

Since many women who suffer from infertility caused by PID scarring (or scar tissue in general) have blocked tubes, unblocking them is frequently the first step. This is typically done during a laparoscopy. The best treatment for scar tissue is to remove it, however, because the nature of scar tissue is to grow back, removal may only result in a short window (usually 6 months to 1 year) of fertility. Aggressive scar tissue can grow back even more quickly.

IUI may not be recommended for a woman who suffers from PID scarring if she has blocked fallopian tubes or tubes that cannot retrieve an egg once ovulation has occurred. In those cases, or in the case of a woman whose scar tissue has grown back aggressively after removal, IVF is the only option.

Personal Experience

I suffered from a bad attack of PID three years before my diagnosis. The initial infection was misdiagnosed by no fewer than three doctors, all of whom assumed that I had a burst ovarian cyst. My HSG was perfectly normal, though a later review of the films showed that one of my tubes was pulled in a suspicious direction. After 15 months of infertility, a new OB/GYN recommended an exploratory laparoscopy just to rule out any problems that could have been caused by the infection. Lo and behold, I had scar tissue everywhere. My fallopian tubes were thankfully clear, but my tubes and ovaries were completely cut off from one another, and my tubes were tied down by scar tissue.

Not every doctor thinks to perform a lap before labeling an infertile patient “unexplained.” I will forever be grateful that mine decided to take that step before we wasted time and money on IUIs that would not have worked. As grateful as I am to my doctor, however, I never would have found him if I hadn’t been determined to find a diagnosis for my infertility. In my case, getting aggressive was likely the only way for me to find a cause and to determine which treatment options were best for us.

Postcoital Exam
by Melissa

Why would you be doing a postcoital exam?

It seems like doctors don’t use them very much anymore, but we had a postcoital exam to determine whether IUI was a good option or whether we should jump to IVF. A postcoital exam evaluates the cervical mucous and determines whether it is a good conductor for the sperm.

Thalia wrote in the comments (and I’ve added it here): There’s a reason why doctors don’t do these any more. The doctor I saw recently said, imagine a picture of a station after the train has just left. The postcoital test is like using that picture to estimate how many people got on the train. Enough said, in my opinion. If your doctor suggests one, ask why. If they insist, look for another doctor who has better kept up to speed with developments in fertility treatments [unless the test is being used to test the quality of the cervical mucous close to ovulation].

What to expect

Postcoital exams are conducted close to ovulation, when optimal cervical mucous is being produced. Simply put, the couple has sex (at home!) and comes to the clinic within a set period of time. A swab is inserted near the cervix to collect a sample of mucous. The mucous is analyzed and the couple is given a report on the quality of the cervical mucous. For the most part, the RE is looking to see how many sperm are still alive and moving in the mucous. And also the quality of the mucous (as well as quantity).

Problems that may arise and ways to troubleshoot

Except that you may not get to the RE’s office in time? There really aren’t many things that could go wrong with a postcoital exam. It’s a simple, painless test.

Personal tips

The worst part of the postcoital is that it’s embarrassing. In reality, all fertility tests and treatments are embarrassing, but this one is particularly blush-enducing since you just had sex prior to arriving at the RE’s office. Some women drink green tea daily from CD 1 until ovulation in order to produce larger quantities of cervical mucous. I’m not sure if this is even a proven result of drinking green tea, but it can’t hurt to down a cup or two a day in the days leading up to the test.