Your IVF Manual

1. Your IVF Manual RMFC OHB Team One Healthy Baby!

2. What’s Inside • Step One – Realize you are on a journey, not a race • Step Two – You are an important member of your IVF Team • Step Three – IVF is a stressful process – learn some tricks to cope • Step Four – Positively, Absolutely, Must DO’s! • Step Five – IVF Consents • Step Six – IVF Financials • Step Seven – IVF Calendar • Step Eight – IVF Medications • Step Nine – Procedures, all of them • Step Ten – Egg Retrieval/ Oocyte Pick up • Step Eleven – Waiting and Schedule of Calls • Step Twelve – Day of Embryo Transfer • Step Thirteen – Worries, OHSS, and more • Resources

3. Step One – Realize you are on a journey, not a race • It has taken you both time and heartfelt concern about your fertility to get you to the point of accepting that IVF is your Treatment of Choice • Wonderful, now breath • You will be going though many different feelings and “invasions of privacy” as we test and determine the best course of treatment • Try to understand that our goal, like yours, is an OHB • One Healthy Baby … so yes, it is worth it • There WILL BE CHANGES as you go along • We Personalize your care… no cookie cutter, so your biology will dictate the treatments • Be Flexible • We do NOT expect you to be an expert! Ever! • So call us, ask questions, do not leave until you understand the steps, BUT, do the steps, do NOT try to “game” how we do things • This will INTERFERE with you work, your play, your family, your friends, your free time, your plans • John Lennon quips, “Life is what happens between plans…” embrace the chaos!

4. Step Two – You are an important member of your IVF Team • You are the KEY member of the IVF Team • You must READ everything we give you • You must understand and ask questions if you do not • You must Follow the Plan…even as it varies • You must set alarms to take your meds, visits • You recommend at least two or three alarms per event • Timing is Everything • You must understand the consents, BEFORE you sign them • You must track your medications • Do you have enough? • Do you need more? • How many more days do you need your meds? • Is it the weekend…do you have refills? • Call with your period, first day! • Why? • The call helps us coordinate your testing, your care plan, your treatments, lets us check to ensure that you are in-sync! • Your PARTNER has tasks and duties too! • If male, need sperm and bloodwork • If female, need bloodwork • Either male or female MUST SIGN CONSENTS

5. Step Three – IVF is a stressful process – learn some tricks to cope • They have called the IVF process an “emotional rollercoaster” • It definitely is for two reasons • You are “out of control” or at least that is what it feels like • You are in an hormonal soup! • Estrogen keeps women able to cope with stress by crying • Crying cleans the tear ducts… we have plenty of Kleenex • Walks, simply walking outside for 20 min each day can and will relieve stress • Yes you can make the time • Acupuncture or TCM • We have done many years of study that demonstrate the TCM in the form of acupuncture can increase your odds of an OHB (One Healthy Baby) but it has been demonstrated repeatedly that it can reduce stress • Talk and talk and talk to your friends, family, partner and us… it is OK… we know it is different and strange, just remember we have been doing this for years and we probably heard you concerns a hundred times… we can help… ask.

6. Step Four – Positively, Absolutely, Must DO’s! • Call with your period EACH and EVERY month until you are pregnant! Really • This keeps us all in the know! • Mark your calendar four weeks after your first day of bleeding with your menses, then the next four, etc. • Critical for Testing • Critical for Treatments • Critical for keeping you progressing to your OHB • Critical for us to monitor the risks for Ectopic pregnancies • Critical for our PCOS patients, CALL WHEN you THINK you should have your period… every 28 SDAYS… mark your calendar • CONSENTS • Must be complete and YOU must confirm receipt by a member of my team • SPERM • We must have fresh or frozen ON SITE… it doesn’t help if the sperm are in another state and your eggs are in Colorado Springs! • PAYMENTS • Your payments allow us to get the supplies we need, the equipment kept at optimal functioning, the staff happy and our lights on… please put on your calendar when your payments are due… we will try to remind you, but honestly, it is your responsibility to keep track of all required dates for treatments and payments. • TELL US if you missed, or did a medication mistake, or will be out of town, or are running out of medications, or can’t make appointments, or having issues with your drugs, timing, cash flow, injections, or simply are confused… • We have a 24 hour phone line, and Dr. Mag’s cell phone is 719-331-6392…call it if something urgent comes up… he is happy to help • MUST take the meds how we prescribe it… do not vary in our protocols and even if you do or did, TELL US

7. Step Five – IVF Consents • CONSENTS • For treatments • For medications • For procedures • For IVF • For Trial Transfers • For Embryo Transfers • For Selective Reduction of Embryos • For Surgery • For number of embryos to transfer • For use of Donor eggs if applicable • For use of Gestational Carrier if applicable • For saving Frozen Eggs, if applicable • For Efficiency Cycles, to use only 6 eggs from a Donor if applicable • For getting your OLD RECORDS • For allowing us to share your information with other doctors or your partner

8. Step Six – IVF Financials • Financials are simple and straight forward • Premier IVF at RMFC is $ 4,800 • Includes everything except medications • Medications run between $ 1500 to $ 3600 • Yes we will put in applications to help you pay for your meds • No promises, it is based on YOUR income • HQA-IVF with monitoring in your city • $ 4,800 for RMFC • Ultrasounds and Bloodwork at YOUR city vary between $ 800 to $ 2200 • We have NOT control of what your doctor charges but will help if we can to find alternatives • In Las Cruces, Mountain View will do the monitoring for $ 800 • In ABQ, UNMwill do the monitoring for $ 2200 • These are only examples • We charge $ 500 for Ultrasound and Blood work at RMFC • We do NOT charge for your Frozen Embryo Transfers any of the typical “technical” fees of $ 3000 to $ 5000 • This applies to a Failed Fresh cycle with Frozen embryos that are not used in the Fresh Cycle • If you want to add Comprehensive Chromosomal Screening (CCS) to an RMFC IVF Cycle, then the fee is $3,200 for 8 embryos, more if there are more embryos • So you can add this to one cycle, so $ 4,000 + $ 3,200 = $ 8,000 • If two Fresh cycle and one CCS = $ 7,800 + 3,200 = 11,000 • If three Fresh cycles and one CCS = $ 10,800 + n3,200 = $ 14,000 • Remember medications are in addition to these costs • Also, if you do not get pregnant with Fresh transfer, a Frozen transfer is only the RMFC cost of $ 500 for ultrasounds and bloodwork • All payments must be confirmed 4 weeks prior to your IVF cycle… no exceptions, sorry. • Deb is your contact 877-475-2229

9. Step Seven – IVF Calendar • Your IVF Calendar of Treatments • What it is: • A GUIDE to your care based on the “average’ response of an IVF patient to her medication • If is NOT an ABSOLUTE guide… it can and may vary based on your responses • What it is NOT: • An ABSOLUTE guide to dates and times of your visit… you can and may vary based on your biology… I already said that  • How to use it • Tell your employer that you need time off • Day of egg retrieval PLUS the next day • Day of Embryo transfer PLUS the next 4 days • Do not go OUT OF TOWN • For 10-15 days during your stimulation with fertility medications, you will need to be able to get an ultrasound, bloodwork, trial transfer, physical exam, emergency medications if you did NOT keep track, additional medications as Dr. Mag orders, follow up etc… • So Plan to be IN TOWN during your 30 days of care… please!

10. Step Eight – IVF Medications • What they Are • Lupron– keeps you from losing the wonderful eggs your growing in your follicles • This medication (some will be on Ganirelix, see below) is THE most critical medication • You miss your dose… YOU LOSE your eggs, simple. • Do NOT miss any doses, call us if you are unsure at all • Ganirelix– keeps you form losing the eggs you are growing in your follicles, like Lupron, see above • Do not worry about which medication, Lupron or Ganirelix, that you are on • For some of you : YOU MAY BE ON BOTH!! • Follistim Gonal F, Bravelle – this are your follicle stimulation medications, they help you grow the follicles that will give us our eggs • Your doses and timing are IMPORTANT • Write down what you take each and every day • See next page for Log sheet • Calculate your doses and calculate how many days worth of medications you have and TELL us at each visit what you have left • Especially if the weekend or holidays are coming up • We do have an emergency supply but DO NOT count on it • Menopure • Dr. Magarelli sometimes uses a “missed protocol” that means he has you take Menopure for your evening dose instead of the F, GF or B above • This are usually and almost ALWAYS Intramuscular with a 1.5 inch needle • Be sure you know which needles go with which medications • Ask • We also can direct you to websites for instructions • www.FertilityJourney.com ???? • Miscellaneous medications • Doxycycline (if NOT allergic) for both partners starting usually at Stim Start • Medrol and anti-inflammatory medication usually started • Pre natal vitamins, extra folic acid, baby aspirin • Men, Mega Man Vitamins • Anti-nausea medications on day of egg retrieval • Pain medications on day of retrieval and thereafter as needed, no worries if you need more… rare, but do not hesitate to ask

11. Your Diary

12. Step Nine – Procedures Vaginal Ultrasound Egg Retrieval Vaginal Ultrasound Embryo Transfer

13. Step Nine – Procedures continued

14. Step Ten – Egg Retrieval/ Oocyte Pick up (OPU) • The Egg Retrieval is usually scheduled after 11 days of fertility medications • On Day 11 of fertility medications or there abouts, you will be told EXACTLY what time to take your “trigger shot” or HCG • This shot is usually in the very late evening, and/or early morning hours 1am or so • Set THREE alarms… timing is CRITICAL • The dose is usually 5000 to 10,000IU and is given either intramuscularly or sub cutaneous • You WILL be told… ASK if uncertain, then ASK again • 34 to 36 hours later, usually 35 hours later, we will take the eggs out via a vaginal procedure… see Step Nine • You will be asleep with a CRNA at your side giving anesthesia medications… do NOT eat after midnight on the day before your egg retrieval • That day and the next day you REST • We will tell you the Number of Eggs retrieved • WE will then fertilize the eggs using a procedure called ICSI • See Step Nine – Procedures continued • Must have someone drive you, NOT A TAXI!

15. Step Eleven – Waiting and Schedule of Calls • Waiting and Scheduling of Calls • We KNOW you are nervous about your eggs, embryos and future babies… we KNOW • We will call you at the end of each day, usually between 4 and 6pm • If no call… call us 19-440-3884 or if the nurse does not get back to you within 2 hours, then call Dr. Mag 719-331-6392 • My staff MUST get approval for prescriptions, etc. and we will have them usually within 24 hours of your call, not before… so please plan ahead! (not the same day… sorry) • If Dr. Mag calls, usually it means that there is a medical decision to be made… do NOT panic… he is doing his job! • Your Ultrasounds and Clinic Appointments • Ultrasounds at RMFC are usually done between the hours of 7am and 10 am • Be sure to be there 5 min before, it will get busy • Be sure you know when your NEXT appointment is • Do NOT leave the clinic until you know…this is Critical for your stimulation and other procedures • If unsure ASK, then ASK again • Labs and Embryo Reports can take us late into the afternoon and early evening to report • Do NOT worry, see above • If you are being monitored in a clinic other than RMFC, we are at the mercy of that team… so PLEASE reinforce to your care provider how important it is to SEND the results to RMFC 719-475-2227 is fax, info@RMFCfertility.com and DrMag@RMFCfertility.com • Do NOT worry, Dr. Mag has been doing this for many years and can help mitigate late results, one day matters, but we are able to offset lack of data with clinical experience • However, please, again, tell you providers to send the info… it is that important!

16. Step Twelve – Day of Embryo Transfer • Embryo Transfer Day – Wow – what a trip! • Our goal is to safely transfer your future baby or babies • Our goal is OHB, One Healthy Baby, really, one is what you want • We know Twins are cute, but they do have issues with survival and safety and future growth, so please have as your goal an OHB • Likely you will receive one (1) embryo and possibly two (2) during the transfer… yes we check your name multiple times to ensure it is YOU and YOUR embryo! • We use an abdominal ultrasound to monitor the progress of the embryo transfer • HAVE a FULL and slightly UNCOMFORTABLE bladder! • It really helps • Even if requested by accident by a new MA, please do NOT pee when you get to RMFC… FULL BLADDER is what we need unless you are told otherwise • Your Partner and Mom or best friend CAN be in the room for the embryo transfer… we love it! • You CAN NOT drive after the transfer… we will be giving you valium… so no impaired driving… • Bring Water for both pre/post transfer to drink • Be sure to schedule your Pre/Post Acupuncture treatments… we really recommend it!

17. Lab & Other Stuff • Our Laboratory team is dedicated to managing your sperm, your serum for hormones, your eggs, your embryos • The INSIST on accuracy, precision and RIGHT person, RIGHT test, RIGHT time • So, be sure you and YOUR PARTNER have a valid ID • Drivers license • PLUS insurance cards • You MUST have a photo taken of you and your partner which is placed in our Electronic Medical Record • Why? You want your sperm, your eggs, your embryos • We are certified by CAP, CDC, FDA, AAS organizations to ensure safe and accurate laboratory measurements and techniques

18. Step Thirteen – Worries, OHSS, and more • Worries • What if I do not respond to the medications? • We will adjust the dose, but if you truly are NOT responding you will have a discussion with Dr. Mag • What if we miss taking our Lupron? • NOT a good idea, so CALL immediately, we may be able to rescue your cycle • What if things are going TOO WELL, i.e., Ovarian Hyper stimulation (OHSS) is starting? • We will ask you to start consuming VAST amounts of protein, over 150 grams additional per day • We will ask you to contact an Acupuncturist , ABORM certified, to help manage your OHSS…real important • We will INSIST that you measure your weight each and every day • We will INSIST that you contact us if you notice more than 1 pound of weight gain • We will INSIST that you TRACK all your protein consumption • We will INSIST you take frequent breaks from standing and recline • We will INSIST that you consume lots of fluids, especially some with electrolytes like bouillon, Gatorade, Recharge, etc. • What if our embryos do NOT grow? • This rarely happens, usually it is because the embryo, in nature’s wisdom, is not growing normally… Dr. Mag will discuss this with you, but likely no embryo transfer • What if we run out of medications? • This really should NOT happen, see Step Two, but if you do, be SURE to tell us… we usually have a stash of meds… • What if we do not get a call back? • If you have waited until 6pm or so and no call back… CALL Us 719-440-3884 or if urgent Dr. mag 719-331-6392 • Worse case, take the same amount of Lupron or Ganirelix and your stimulation medications like Gonal F, Follistim, or Bravelle or Menopure

19. Resources • Injection Teaching • http://www.freedommedteach.com/eng/ • Techniques • http://www.fertilityjourney.in/therapyOptions/AssistedReproduction/ARTreview/index.asp • Medication Info • http://www.emdserono.com/en/therapies/fertility/fertility.html • Support • http://www.resolve.org/ • http://www.theafa.org/ • Good Fertility Information • http://www.reproductivefacts.org/ Our Contact Info: During Day: Phone: 877-475-2229 or 719-475-2229 Fax: 719-475-2227 On Call Team 719-440-3884 Urgent/Dr. Mag 719-331-6392 Location 265 Parkside Drive, Ste 200, Colorado Springs, CO 80910

20. High Quality Affordable Fertility Care & IVF Members of our team: Reproductive Medicine & Fertility Centers, LLC University of New Mexico, UNM IVF Program Mountain View Wellness & Reproductive Medicine Centers You Our Contact Info: During Day: Phone: 877-475-2229 or 719-475-2229 Fax: 719-475-2227 On Call Team 719-440-3884 Urgent/Dr. Mag 719-331-6392 Location 265 Parkside Drive, Ste 200, Colorado Springs, CO 80910