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Gonadotropins, which are the hormones used to treat infertility, are administered by injection. Many patients do not realize that mixing medications and administering an injection can play an important role in the success of treatment. The following guidelines are designed to help pa-tients administer the necessary injections related to infertility treatment safely, successfully and with maximum comfort.

Before you begin

Before beginning the injection process, make sure your hands, materials and work area are all clean. This is important because you will be handling needles, which must remain sterile. If you are concerned that a needle may be contaminated, immediately throw it away and use a new one. A needle can become contaminated if it touches anything other than the inside of the am-pule or needle cap. Fertility medications are administered through either a subcutaneous or an intramuscular in-jection. It is important that you understand the difference between these two types of injections: Subcutaneous - Subcutaneous injections are administered through a shorter (usually ½ inch) needle that delivers medication to the tissue just under the skin, usually through the back of the arm, abdomen or top of the thigh. Intramuscular - Intramuscular injections require the use of a longer (1-2 inch) needle that de-livers medication deep into muscle tissue. These injections are most often administered to the mid-thigh or buttock. While this guide is designed to take you step-by-step through the entire injection process, please be sure to consult your doctor if you have any questions or concerns relating to this or any other aspect of your treatment.

Getting ready

To complete an injection successfully, you will need the following materials, which you should gather in advance:

• soap and water/alcohol
• clean towel
• mixing needle
• syringe
• ampule(s) / vial(s)
• gauze pad/alcohol swabs
• injection needle
• disposal container

Choose a comfortable location for your injection—It is very important for you to identify a comfortable place to administer your injection. Ideally, you should choose an area with enough space to line up all of your injection materials within easy reach. Make sure that the area is clean, and wash your hands to prevent the risk of infection. Attach mixing needle to syringe - Your treatment kit will include a “mixing needle,” which is usually the largest needle. Affix the mixing needle to the top of the syringe until it is firmly in place. To prevent contamination, only touch the outside of the barrel and handle of the plunger.

Ampules and Vials

Your fertility medication will come in one of two types of containers: ampules or vials. Although the mixing procedures are similar for both, be sure to follow the instructions on page 2 for the specific type of container you use.

Ampules

For this step, you will need:

• ampule(s)
• gauze pad/alcohol swabs
• mixing needle
• syringe
• disposal container

Open the ampule(s)

The first step is to remove the liquid from the top of the ampule. To do this, hold the ampule in one hand between your index finger and thumb. With your other hand, tap the ampule to remove the liquid. Now that you have completed this step, find the dot on the ampule and turn it away from you. Place a square of gauze or an alcohol swab over the top of the ampule. Snap the top away from you.

Mix medication

Pull the cap straight off of the mixing needle without twisting it. Using the syringe, with-draw more than 1ml (or 1cc) of diluent or liquid from the ampule. Turn the syringe over so the needle is pointing upward. Tap the syringe barrel so the air bubbles travel to the top. Expel the air and excess diluent from the syringe by depressing the plunger. The measurement should read 1 ml.

Now, inject 1ml of diluent into the ampule of powder medication. With the needle still in the ampule, roll it between your finger and thumb until the solution is clear. Draw all of the mixed medication back into the syringe; you may have to tilt the ampule slightly.You have now mixed one ampule of medication.

If you are only prescribed one ampule of medication, replace the mixing needle with an injection-sized needle.

If you are prescribed more than one ampule, inject the contents of the syringe directly into the second ampule of powder. Slowly inject the solution into the ampule. As before, roll the ampule making sure the solution is clear. Draw the mixed medication back into the syringe. Use this same procedure for mixing the remainder of your medication. When you are finished, replace the mixing needle with an injection-sized needle.

Vials

For this step, you will need:

• vial(s)
• gauze pad/alcohol swabs
• mixing needle
• syringe

Open the vial(s)

To open, pop off the plastic tops. Clean the top of each vial with a gauze pad/alcohol swab to prevent contamination.

Mix medication

Attach the mixing needle to the syringe by twisting it firmly. Draw 1ml of air into the syringe by pulling the plunger back to the 1ml mark. Inject it through the rubber stopper into the vial of diluent. With the syringe still in the vial, pull the plunger to withdraw more than 1ml of liquid. Remove the needle from the rubber stopper. Turn the vial upside down. Tap the syringe barrel to get the air bubbles to travel to the top. Check the measurement. The uppermost ridge of the plunger should be at 1ml.

Inject the diluent into the vial of powder medication. With the needle in the vial, roll it until the solution is clear. Turn the vial upside down. Pull the needle below the liquid line and withdraw the solution, making sure to draw out all of the mixed medication. You have now mixed one vial of medication.

If you are prescribed one vial of medication, replace the mixing needle with an injection-sized needle.

If you are prescribed more than one vial, inject the contents of the syringe directly into the second vial of powder. In-ject the solution slowly into the vial. As before, roll the vial with the needle still in place, until the solution is clear. Turn the vial upside down. Draw the mixed medication back into the syringe. Use this same procedure for mixing the remainder of your medication. Recap the mixing needle. Replace the mixing needle with an injection-sized needle.

Injection

For this step, you will need:

• injection needle
• gauze pad/alcohol swabs
• syringe
• disposal container

Prepare for injection

Once you have chosen the site for your injection, cleanse the area with an alcohol swab, begin-ning at the center and cleaning around in a circle of about two inches in diameter. Remove the needle cap by pulling it straight off. While holding the syringe straight up, tap the side so any air bubbles travel to the top. Push the plunger slowly until you see one or two drops of medication come out of the top, which ensures that all of the air is out.

To administer a subcutaneous injection

You are now ready to administer your subcutaneous injection. First, hold the syringe like a pen-cil in your dominant hand. With the other hand, pinch the injection site. Insert the needle into the pinched skin. Because the medication is being deposited into fatty tissue, the needle can be inserted at either a 45-degree or a 90-degree angle. Depress the plunger quickly and steadily. Now, remove the needle and syringe. You have successfully completed your injection.

Place the needle and syringe into the disposal container without recapping the needle.

To administer an intramuscular injection

You are now ready to administer your intramuscular injection. With your dominant hand, hold the syringe like a pencil. With the other hand, stretch the skin of the injection site. This will help the needle to go in easier. To minimize discomfort, insert the needle at a 90-degree angle with a smooth, dart-like motion. With one hand, stabilize the syringe, while you gently pull back on the plunger. It is normal to feel resistance or to see a small air bubble. Although it is rare, you should watch to see if there is any blood. If there is no blood, the needle is properly placed in the injection site. Slowly and steadily depress the plunger. Quickly pull out the syringe and throw it in the disposal container. With a gauze pad, apply pressure to the injection site. Mas-sage the area to disperse the medication and ease any discomfort. If you think you need an ad-hesive bandage, place one on. You have successfully completed your injection.

If there is blood, you have two options. First, you may remove the needle and apply pressure with a gauze pad to the injection site. Remove the used needle from the syringe and discard it. Replace it with a clean needle and reinject at a nearby location. A second option is to pull the needle back slightly (about 1/4 inch) and redirect it away from the vein. Gently draw it back again in the new site and, if no more blood is seen, inject as usual.

edited by:
Frederick Licciardi, M.D.
Reproductive Endocrinologist
Assistant Professor of Obstetrics & Gynecology
New York University School of Medicine

Jessica Brown, M.D.
Reproductive Endocrinologist
Assistant Professor of Obstetrics & Gynecology
New York University School of Medicine

This fact sheet was funded by an unrestricted educational grant from
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