Intramuscular (IM) Progesterone injections
You will need for each injection:
1. 1-sterile 3-cc. syringe with an attached 22-gauge 1.5" needle.
2. 1-18 gauge 1.5" needle (this may be used to draw up progesterone)
3. Alcohol wipes or alcohol bottle and cotton
4. Progesterone vial

The progesterone is compounded in sesame oil and will be mailed to you from a compounding pharmacy.
I. Drawing up the medication
1. Calculate the correct amount of medication. There are two dilutions of Progesterone. The dilution is either 50 mg/cc or 100 mg/cc. Therefore the volume given depends on the dilution used. Check your bottle label. Do not draw up or inject more than 2 cc in an injection site.
2. While in the wrapper, twist off the needle and take out the syringe, leaving the needle in the sterile wrapper.
3. Place an 18-gauge needle on the syringe. The larger needle will make it easier to draw the thick medicine out of the vial. 4. Scrub the rubber cap of the vial with an alcohol wipe.
Gently roll the vial between your hands to warm it.
5. Pull back the plunger of the syringe to draw an amount of air into the syringe equal to the amount of medication to be given. Remove the needle cover and carefully inject air into the air portion of the vial (this prevents bubbles).
6. Withdraw the correct amount of the medication - this may be difficult because of the thickness of the solution. Flick the syringe with your finger to remove air bubbles.
7. Remove the needle from the vial and replace the needle cover.
8. Remove the 18-gauge needle and replace the 22-gauge needle.

II. Select the site for injection
The dorsogluteal sites are used for the progesterone injection because the buttock muscles are thick and permit injections of larger quantities of medicine.
1. The site may be located by dividing the buttock into quadrants.
2. The injection is given in the outer aspect of the upper outer quadrant of the button 2-3 inches below the crest of the ileum.
3. For an intramuscular injection, the patient may stand, lie face down, or on her side. In all cases the muscle should be relaxed (no weight bearing when standing). If lying down, toes should be pointed inward; if on side, leg should be bent.
4. The muscle is palpitated and the skin is wiped with an alcohol wipe. Let the alcohol dry.
5. The skin is held taut by pulling it to one side. The needle is inserted at a 90-degree angle in a quick dart-like motion. When the needle is inserted smoothly and firmly, this is a relatively painless procedure.
6. The hand holding the skin is then moved to hold the syringe firmly. Pull the plunger back in order to make certain the needle has not entered a blood vessel. If small bubbles appear in the syringe, continue on; if blood appears, remove the syringe, change needles and start over.
7. Holding the syringe steady, inject the medicine slowly (60-90 seconds for 1 cc and 90-120 seconds for 2 cc). The slower the medicine is injected, the lesser the localized reaction. The medicine may be difficult to inject because of its thickness. Continue slowly. If difficulty is encountered, the needle may be drawn back 1/4" to 1/2". The rest of the medicine may then be injected.
8. The needle is then removed quickly and the area can be massaged gently with a cotton ball to help absorption of the medication. Recap the used needle. Discard all needles and syringes carefully, by replacing the cap and putting needles into a box. If you wish, you may bring used syringes back to the clinic in a box for disposal.
9. Massaging the injection site can help disperse the medication and decrease discomfort. If discomfort occurs, a warm compress or soaks in the tub can help it feel better. Never inject into swollen reddened or bruised areas. Never inject more than 2 cc's into an injection site.

Tips:
·If you are allergic to sesame oil, other oils can be requested.
·Progesterone does not need to be refrigerated.
·It is preferable to have a family member or friend give you the injection (rather than trying to give it to yourself).
·If you feel you need to practice before giving your first injection, you can request an extra needle and practice on an orange.
·You may want to roll the vial in your hands before drawing up the medication to gently warm the medicine so that it has an even consistency.
·If you feel anxious or light headed during injections, lying down may make the injection easier.
·Make sure you have eaten something before the injection.
·Tense muscles will result in more discomfort, so try to relax your muscles during the injection.
·If giving multiple injections over several days, be sure to alternate injections sites and massage the site after the injection to reduce discomfort.
·Side effects may include soreness at the injection site, backaches, sleepiness, or flu-like symptoms for 24-48 hours. If redness or discomfort persists for more than 3 days, call the nurses.

Call the nurses if you have any questions.

Vaginal Progesterone
Vaginal Progesterone suppositories are made at a compounding pharmacy. You insert them at night before going to bed to allow them plenty of time to be absorbed.
If you forget, you may insert it the next morning; however, it is recommended that you lie down for an hour afterward to give your body time to absorb it. Night time is the best time to use the suppositories.
You may find it more comfortable to wear panty liners while using the vaginal suppositories. If you are uncertain how to chart the discharge you are seeing, contact your FertilityCare Practitioner.

HCG subcutaneous injections
HCG subcutaneous injections are given in the abdomen with a small needle that reaches into the subcutaneous layer of skin. You will receive the HCG as a powder that you mix with sterile water (find your dosage on your medication). Once the solution is mixed it should be refrigerated until needed. You may warm it by rolling the vial in your hand before using.

Labs
In evaluating fertility, it is important to understand the fluctuations in hormone levels as ovulation approaches, as the Peak Day occurs and afterward as the lining of the uterus is prepared for pregnancy. In order to do this, we monitor hormone levels in relation to your Peak day. To learn more about peri-ovulatory hormones, blood tests are drawn every other day beginning about 4 days before the anticipated Peak day. For a post-ovulatory hormone profile, you will need as many as 5 blood draws, beginning on Peak +3 and every other day until Peak +11. Your lab work will depend on your circumstances. You do not need to do anything to prepare for the labs.
The samples can be drawn at our office, or at another lab working in cooperation with us.

List of labs in various cities - coming soon

If you are using a lab other than the Woman's Clinic, you will take your order to the lab to have blood drawn. You will keep the labs at home in your freezer until the series is complete, then send the labs to the Woman's Clinic through Fed Ex or UPS.

Ultrasound Series
An ultrasound series is the best technique currently available to determine if a woman is ovulating normally. With daily ultrasound exams, the developing follicle can be followed until ovulation occurs. When the follicle ruptures, ultrasound will detect its collapse; evidence that ovulation has occurred. A baseline pelvic ultrasound is generally done on Day 5-8 of your cycle. Then, starting on approximately Day 10-12 of your cycle, daily scans will be done until the follicle has ruptured, indicating that ovulation has occurred. This usually requires 4-5 scans, but may vary depending on your individual circumstances. Please bring your chart to your ultrasound appointment every day. If you do not have regular cycles, a serial ultrasound evaluation cannot be done. Instead, a single pelvic ultrasound will be done, and a series might be done on medication later on.
These ultrasounds do not require any preparation, and you may come in with an empty bladder.