When you think IVF, you think injections, right? Drugs, hormonal induced meltdowns and lots of jabs. It is one of the most daunting aspects of IVF, but is it really that bad? This article considers the key questions, surprises and issues that I experienced during my druggie phase of IVF. It explores whether the injections hurt (taken from the experience of a total wuss - me), what the different hormones do and what happens when you have a jab related disaster and spurt the contents onto the floor of a public loo.
Collecting and storing IVF drugs
Do IVF drugs require refridgeration?
Collecting my IVF drugs was much less dramatic then I was expecting. The anticipation of a good anecdote, based around a box of expensive hormones being delivered to work, required to be stored in the office fridge nestled in between bottles of milk with possessive initials scrawled on the lids and packed lunches, was totally misplaced. This happens to others and I would have dined out on that story (with embellishments) for weeks. But my drugs collection and storage was tame in comparison. I called the clinic to let them know that my period had begun and scheduled my first baseline scan to see what was happening with my innards. The IVF drugs were collected from the on-site clinic pharmacy following my baseline scan.
In preparation, all the greens had been cleared out of our home fridge ready for drugs storage. And by 'greens', I actually mean a tub mayonnaise, a carton of half eaten tomotoes and a tuppawear of cheese that both Joe and I were secretly hoping the other would throw out, or that would grow legs and walk off of its own accord. It turns out that all my drugs (listed below) could be stored at room temperature. Humph. So I moved the mayo back to the middle shelf to make it look more like the type of fridge that could have been stocked by sensible adults rather than one located in university accommodation. It wasn't fooling anyone.
What injections are used for IVF?
How difficult to use are IVF drugs?
Honestly, IVF drugs are tricky to get your head around the first time, but a doddle from then on. Demonstrations and a thorough walk through of how to undertake an injection had already occurred at our drugs appointment. I had grabbed some fat and plunged in a needle, so I was all good to go. But when you are at home, faced with the prospect of actually doing your first injection without a medical professional to check your steps, it can be daunting. What you should receive, but you don't because that would be far too simple, is a needle that is ready for injecting. Oh no, no way. The drugs come in separate parts, so you have two different types of needles, the syringe, sterile water, powder that becomes the hormone injection once mixed with the water (which you may need to mix multiple times) and a terrifying 'sharps tub' which is a thick plastic box with a 'go near this and you are going to die' skull and cross bones warning on the side. Comforting. The sharps box is to safely discard your sharp objects (syringes, needles etc) so that your husband or pets don't accidentally prick themselves and start growing boobs or having babies. Top tip, don't slide the lid of the sharps box to the fully closed position until it is full and you are done with it. You can't reopen that stubborn little death box.
It is different at every clinic, and different again if you are having private IVF and ordering your own drugs, but my clinic only provided the exact amount of drugs to get me through to the next appointment, where I would then pick up more to see me through to the next appointment, etc. At no point did I have all my IVF drugs at home at the same time. Still, my first 7 days worth of stimulation injections laid out on the table brought home the reality of IVF and induced a long and meaningful intake of breath. I felt like a drug lord surveying my stash. Luckily, the drugs came with detailed step by step written instructions from the clinic, for everyone like me who forgot everything they were ever told about how to do an injection. My instructions filled one and a half pages of A4. And the nurse had said it was super simple. Really? I followed them slowly and carefully like a diligent student. At first it does seem complex with multiple steps, but after a few injections you get into the swing of the process and it all comes together, like learning to tie your shoe laces, only sharper with the chance of accidentally drawing blood. Failing that (as with everything else in life you don't know how to do) there is always YouTube.
Mixing the hormones and preparing the syringe requires a sterile site. My sterile environment was my dining room table, wiped clean. It wasn't hospital standards of sterile, I'm not going to lie, but it was good enough. Probably. One thing I learnt early on was that maintaining a sterile environment whilst doing a morning injection was not possible with a hungry and inquisitive cat. I had to feed our cat Roger first as a distraction technique otherwise he would grab my hand with his paw and attempt to rub the needle against his chin, all the time purring and dribbling on to my 'sterile' table.
What are the IVF stimulation drugs and what do they do?
There a multiple brands of drugs that are used for the same purpose, so below only represents my drugs protocol. I was fortunate to only have to inject twice a day: Cetrotide in the morning and Menopur at night, enabling me to always be at home for my injections (with the exception of one injection on a hen do. More on that disaster below).
Menopur - (75 IU and 150 IU alternating each day)
A stimulating injection which is made up of follicle-stimulating hormone (FSH) used to stimulate the ovaries to grow follicles and eggs.
Unlike Cetrotide and the trigger injection, Menopur can be taken within a 1-2 hour window and is not required to be taken at exactly the same time every day, as I found out when I injected it onto a bathroom floor in a bar in Soho.
It mixes easily, with the powder dissolving almost instantly. The consistency is like water which allows the air bubbles to be easily removed with flicks of the syringe.
You may have to mix in more than one powder of Menopur per injection, depending on your dose.
One thing to note is that it takes longer than you'd think to inject liquid into fat. This surprised me, but there is no rush with the injections so I just went at the pace that felt right, for me and for my fat.
Cetrotide - (250 mcg)
Cetrotide is used to prevent premature ovulation. It works by blocking the effects of gonadotropin-releasing hormone (GnRH) which controls the secretion of luteinizing hormone (LH).
Cetrotide should be taken at the same time every day in order to ensure that it is most effective. I wasn't fully aware of the importance of this until my Menopur disaster later in the cycle, but luckily I had been taking it at 7am on the dot every morning.
It is tricky to mix, with the powder dissolving slowly and the thick gel like nature of the liquid resulting in air bubbles being difficult to remove. One tip is when injecting the liquid into the powder, circle it around the edge of the glass vial so that none of the powder remains on the sides of the glass. Otherwise, you have to give it a bit of a gentle swirl in order to ensure all the powder is captured and dissolved, which then increases the number of air bubbles.
It induced bleeding at the injection site on a couple of occasions. During my first time with Cetrotide, once the needle had gone into my tummy fat, a tiny amount of blood visibly drew up into the needle. I carried on with the injection (like a trooper, right) only to read the final step in the accompanying instructions was not to continue with the injection if blood is drawn up into the needle, but to discard that needle and start over. Bugger. A quick call to the nurses helpline at the IVF clinic and I was reassured. The nurse asked me if I had injected all of the Cetrotide. 'Yes, all of the Cetrotide' I replied, 'along with a bit of blood and quite a lot of air.' The nurse gave a telephone equivalent of a shoulder shrug and informed me that as the injections are going into fat and not straight into a vein, air bubbles (although not desirable) are sometimes unavoidable and nothing to panic about. Oh, and a bit of blood never hurt anyone. That was reassuring. It was my own blood after all.
Do IVF injections hurt?
It varies so considerably person to person that I'm hesitant to make false promises, but for me the IVF injections were less of an ordeal than I had imagined. A walk in the park, of sorts. IVF was more emotionally challenging than physically.
When I first saw the needle my heart skipped a beat. Honestly, it looked like a needle you'd use to tranquillise an elephant and not something that I would allow anywhere near my tender little tummy. Luckily, I was gasping at the mixing/drawing up needle, which is much thicker than the teeny tiny needles used for the injections. They are smaller than a sewing needle, super sharp and pretty painless.
For the first injection we decided that Joey would be the mixologist and I would be the patient. I loudly and clearly read out the instructions in my best BBC newsreader voice as he followed the steps to the letter. It ended in a blood bath. A Joey blood bath. In pulling the protective cap off the drawing up needle (those caps can be really tightly wedged on) he managed to pierce his finger to the bone, drawing up not my hormones as planned, but quite a lot of his own blood. So now I had to console Joey, wrap his finger in kitchen roll to prevent him from bleeding on to our cat, replace the now contaminated needle with a fresh one and continue alone with the chemistry class of mixing the hormones. Later in the week I also stabbed my finger with the drawing up needle and it was the most painful experience of the whole IVF injections. Be warned! Those needle caps are hard to pull off.
Cetrotide has a bad reputation. If often creates an itchy red rash on the skin at the site of the injection, which is apparently ‘normal’. Well, as normal as a red rash can be. I had read horror stories of bad bruising, intense stinging and drawing blood. But Cetrotide was pain free for me. The thick gel like substance injected like a dream and I only experienced one small red rash, which I proudly wore like a warrior battle scar, until much to my disgust it disappeared about 30 minutes later.
Menopur, on the other hand, is a stingy little bitch. On some occasions it induced no sensation whatsoever and on others it felt like half the level of sting you get when you put lemon juice on a paper cut. It was no where near as bad as a bee sting, let's not get carried away, and not once did it bruise or draw blood. If the injections do hurt, then a bruise pad which can be frozen or heated may help to numb the soreness.
Those unfortunately souls who have down regulation injections in addition to stimulation jabs can be injecting themselves for for twice as long. They undoubtedly get sore flesh around the tummy area. I tried to be strategic and work consistently out from the belly button, doing Menopur injections on the right and Cetrotide on the left, or was it the other way around? This system quickly broke down as I consistently forgot where I was, which side I was going on, and generally what was happening. So I just grabbed flesh that didn't feel tender and would use that as the target site. Strategic injecting may become more necessary for those injecting for longer than my measly 10 days.
What happens when it all goes wrong? IVF drugs disaster - My menopur-meltdown
Make sure the needle is attached to the syringe securely and push it until you hear a click. Just a little tip from me. How I discovered this advice went like this:
All my injections were done at home. All bar one. You know where this is headed already. Like badly written fiction, or just plain old Sod's law, the one injection that went tits up was the one where I was an hour away from home and with my last 150 IU dose of Menopur. I was on a hen do for my best friend and was shooting up in a toilet of a bar in Soho, London. A public loo is about as far from a sterile environment as one can get, so I was being obsessive about the needle and all the component parts not touching anything. Yuck, gross. It all appeared to be going swimmingly, I have photographic proof of what appears to the naked eye to be a satisfactorily constructed IVF jab. But oh no, no no. Eliminate air bubble, check. Insert into tummy fat, check, Plunge the syringe.... why won't it plunge? This feels really tough, it won't budge, oh shit! The Menopur squirted out of the back of the syringe all over the toilet floor. It must have been the build up of pressure due to me not fastening the needle on properly that caused the syringe to burst. All my fears about sterile environment disappeared as I knelt next to my hormone puddle and wondered whether I could somehow scrape it off the floor back into the syringe and try again. Would a drop of some else's urine and a bit of dirt from other people's shoes injected into my flesh be acceptable? Probably not. Best to leave it.
Our clinic ran a 24 hour nurses helpline (staffed by angels) that patients could call in an IVF emergency. I got straight on the blower, holding back the tears, to explain that I had been an accidental idiot and squirted my drugs onto the floor of a loo. The nurse wanted to know how much I actually managed to inject. Nearly all of it? None of it was the disappointing answer. It was all on the bathroom floor creating a slip hazard as we spoke. I was keen to know if I had I messed up the whole IVF cycle. Was this a disaster? The nurse reassured me that Menopur could be taken within a window of an hour or two, it didn't have to be exactly the same time each day (unlike Cetrotide - which was the first I'd heard of that). We agreed that I would dash home which would take me 1 hour, ditching the hen (sorry Laura!) to take my final lesser dose of Menopur. I would then attend the clinic the following morning to collect a replacement Menopur for the one I just spilt on the floor. Despite reassurance that this shouldn't impact my IVF cycle, I was an emotional wreck. It was my one and only IVF meltdown, and it was a biggy.
What are the side effects of IVF injections?
Are the IVF drugs working? Why am I not bloated?
I was promised bloating. You will look 4 months pregnant, they said. It'll be hard to do up your trousers, they said. But after 6 days of injections I felt, well.... nothing, other than mild trepidation that IVF drugs don't work on me and the first progress scan at day 7 was about to show some very empty ovaries. Don't panic about bloating. Everyone reacts differently to the drugs and despite the lack of any outward signs of success, my ovaries were growing a fair flock of 19 follicles at the first scan. You really cannot tell what is happening in there, so try not to worry.
My sonographer was a believer in audience participation and handed me a post it note and pencil during my first progress scan. 'I'll call out the follicle sizes' she said 'and you write them down for me.' Fabulous, I love a good task. The result was that I had a pack of 9 follicles in the elite growers group and 10 in the peleton lagging behind. My right polycystic ovary was working like a trooper with 12 good follicles, whist my left 'normal' ovary was not pulling it's weight. During the progress scans they will also check the depth of the lining of the womb to see whether it is padded enough for an embryo to implant. Luckily mine was nice and thick, good stuff.
For my second progress scan 2 days later, Joey accompanied me and took on the mantle of writing the follicle sizes on a pad of paper for the nurse. I had dutifully forgotten to tell him this occurred or what the numbers meant. He had no clue and thought he was recording the number of follicles. He recalled his confusion to me afterwards: 'On the right ovary, 18... (18! That's excellent!)....another 18..... (another 18? So 36, from the same ovary?)....16.....(how has the number gone down? Did she miss count the first time?)....17....(Oh, OK, so I don't actually know what is happening here)..... and so it went on. Poor Joey. When we came out of the room he turned to me and asked 'what the hell was that?'
After the first progress scan I was given an indication of when egg collection was likely to be and whether I remained on target for the speculative date provided at the start of my IVF cycle. Following the second progress scan I was booked in for definite and told exactly when to take my trigger injection. Our clinic aim to have at least 3 or more follicles that are 18mm or above before considering the patient to be ready for egg collection. They aim to set a drugs protocol that ideally allows for collection of between 8 to 12 eggs, although not all women fall within those parameters and still have successful IVF.
Trigger shot - Gonasi (10,000 IU)
The final one, the last shot, the biggy! It is the Trigger Shot. This final injection contains Human Chorionic Gonadotrophin (HCG) and further stimulates the ovaries, preparing the eggs for collection. This injection works in the same way as the natural hormone released from the pituitary to trigger ovulation, however the clinic will be collecting the eggs before ovulation occurs. Other brands of HCG used during IVF include Pregnyl, Profasi, Ovitrelle and Buserelin.
The HCG from the trigger shot can remain in your system for a number of days, giving a false positive pregnancy test if you pee on a stick too soon after egg transfer. According to ConceiveEasy.com (as if!) the rule of thumb that doctors use is that it takes one day for each 1000 units of hCG to leave your body. So, if you get a 10,000 unit injection of hCG, it will take approximately ten days for it to all leave your system.
Do not pull the back off the syringe. It is a different needle with a slightly different set up and new quirks to worry about. Our syringe came with a big warning sticker that went along the lines of 'DON'T pull the syringe back too far or it will come apart, you complete muppet' or something like that. Our nurse also verbally warned us not to pull it back too far, in addition to their being a white plastic guard on the back of the syringe preventing it from coming off. This indicates there must have been huge troubles in the past with Gonasi's arse falling off the back and its innards being wasted on the floor. After my Menopur-meltdown just a few days before I was petrified about making a mistake. I ordered poor Joey to watch me closely as I prepared the needle to ensure I was doing it right. 'What am I looking out for?' he fairly enquired. I unhelpfully responded with 'Just make sure I’m not being a wally.' It went a little down his from this constructive exchange when he followed up with 'I don’t mean to be insulting, but it sometimes is really hard to tell.' Oh boy, did that get a stare. 'Just watch me, OK. Then if it all goes wrong we are both responsible.' Not strictly very fair, but it was probably the hormones talking.
Like planes being given a window for takeoff, an exact time is provided for you to take the trigger injection, which is usually 36 hours before egg collection. For me, this was 11pm on a Wednesday, allowing me to work out that my egg collection time would be 11am on the Friday. 36 hours is the optimal amount of time for the eggs to ripen according to research. The clinic stressed that I must take the injection at the exact time, but how exact was exact? I was panicking about how long it would take me to prepare the needle, so I began the prep 15 minutes before my allocated time slot. It took about 2 minutes, even with being careful not to pull the back off the syringe, asking Joey 10 times if it 'looked right to him' and flicking out the air bubbles. So then I sat with the ready syringe in my hand wondering whether I should go for it or wait. It was 10:50pm. Better wait, I thought. So I placed my iPhone on the table and watched the clock, waiting for it to tick over to 11pm. But then the inevitable panic set in. Does the liquid in the syringe go off? Does it curdle? It mustn't like being mixed too early, otherwise why don't they come pre-prepared and reduce the risk of the patient messing up when mixing the drugs? Should I just do it now, or is that too early? Surely 10 minutes makes no difference? But by the time that smorgasbord of panicking thoughts had worked its way through my mind I only had 3 minutes left, so I held tight, as tightly as I was holding my syringe of slowly curdling hormones. Luckily it went off without a hitch. And that was it, my final injection for my first round of IVF complete.
Lifestyle choices during stimulation treatment
What should and shouldn't I be doing during stimulation? This question puzzled me the most. The advice provided by my clinic was:
It is important, particularly during the stimulation drugs, to drink plenty of fluid. The clinic advised all women to drink 2 litres of water a day from the beginning of the period in which they are commencing treatment. This can help with the prevention of the onset of ovarian hyperstimulation.
Gentle exercise during treatment is good. Although the clinic advise to avoid high impact exercise. Walking, yoga, pilates etc are an excellent way of keeping mobile. Swimming is also excellent, although probably not advised after embryo transfer due to possible infection picked up from public pools. (To note: my yoga teacher advised against yoga during during stimulation in case of inadvertently stretching or straining the swollen ovaries. Advice on yoga is mixed, so follow your instincts and be careful with twisting poses.)
The clinic advised to avoid all Chinese medicines and some aromatherapy oils during treatment. Many patients do have acupuncture and there was information leaflets on this at the IVF clinic.
The IVF clinic advised women to avoid snacking between meals (even 'healthy' snacks). If you want to eat these types of food then add them to one of your 3 or 4 meals a day. Meals should always have some protein content i.e. fish, eggs meat, cheese or pulses. Try to keep the carbohydrate content in each of your meals below the amount of protein. The IVF clinic also recommended avoiding soft cheese, pate, liver, swordfish and shellfish from the day treatment begins. I was also told by the clinic to do my best to control my blood sugar by not eating anything that would dramatically increase it, such as sugary processed foods or white pasta, bread or potatoes.
The IVF clinic advised that women should take 400 mcg of folic acid daily from 3 months before the scheduled treatment cycle. It also recommended taking the folic acid combined in with a multivitamin product specific to pregnancy. The multivitamins I took were Zita West's IVF nutritional support pack and later the Wild Nutrition women's fertility vitamins.
Unscheduling my life
One thing that I did during IVF treatment that really helped me was to unschedule my life. I reduced my social engagements after work, had relaxing weekends, paused all my Spanish and violin classes and instead focused on being home in time for my injections and relaxing. The drugs can make some people incredibly tired, so be kind and retire to bed early on the days when you feel pooped. It really helps.
Coming next in the IVF Series...
Egg collection - Sunday 18 March
Book Review: Get a Life: His & Hers Survival Guide to IVF by Richard Mackney and Rosie Bray - Wednesday 21 March