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OP ED
Oral Meds to Injections
By The American Fertility Association
If you’re dealing with infertility there’s a good chance the day will come when you make the transition from popping pills to sticking yourself with a needle. Oral meds are sort of the first rung of the ladder, so to speak; injections are a few to several steps higher.
Fertility Nurse Specialist
Jeanette Yates |
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Jeanette Yates is a Fertility Nurse Specialist with Huntsville Reproductive Medicine in Alabama. Yates says it’s not uncommon for women to become frightened at the first mention of injections.
“When we suggest injectables, the first reaction, a lot of times, is a little shock and disbelief. The first thing they think is ‘John and Kate Plus 8’. They think I don’t want to have multiples or am I going to have six kids? Am I going to have a quad? Then they realize that we’re bringing out the big guns now,” says Yates.
Yates says the first challenge is getting couples ‘over the hump’, to accept the fact that injections are needed in order for the fertility treatment to work. Then comes the task of convincing the couple they probably won’t become ‘John and Kate Plus 8’.
“It’s not like the pills where we say take two pills a night for five nights. This will be a very specific dose based on your lab work and your ovaries’ appearance. Once they understand it they tend to be a little more at ease with it,” says Yates.
Approximately one third of all patients going through cycles at Huntsville Reproductive Medicine are using injections. Patients come in for a thirty minute self injection training session where couples will actually be able to give injections into a pretend plastic belly. This alleviates some of the stress, but it’s not until after the first couple of nights of actual injections when they start to become less nervous and realize it’s going to be okay – especially considering the payoff for doing so.
Who gets injections and who doesn’t
Yates says if a 40 year old woman comes in she’s probably going straight to injections unlike a 25 year old who will probably start with oral meds. For ovulation induction, one injection nightly is typically needed for six to ten days. For IVF patients, 1-3 nightly injections are usually required. The protocol for the patient determines whether one, two, or three nightly injections are needed. Some doctors and nurses, including Yates, will mix two products together in one injection, opposed to making a woman stick herself twice. They also do what they can to ensure couples that things could be worse.
“It’s a subcutaneous injection in the fat part of your belly. We have them pinch an inch and it’s a very small needle, but no less intimidating. A needle is a needle. Just to get the fear factor out of their minds, I always show them a large needle, because when I show them the little needle they say Ahhhh,” says Yates.
Women who need progesterone supplementation often choose the method of administration. They can choose a vaginal inserts or intramuscular injections into the hip.
“Probably 90% of my patients opt for the vaginal insert (Endometrin or progesterone suppositories) over the injections. If they start on the injections they inevitably switch over to get out of those injections because it’s painful, you know? You have to have someone give it and there are all kinds of other issues with it,” Yates says.
The Changing Nurse’s Role
Nurse Practitioner Barbara
Alice |
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Breaking the news to a patient that she’ll have to start giving herself injections is often left in the hands of the nurse. Nurse Practitioner Barbara Alice of the South Jersey Fertility Clinic says women struggling with infertility tend to confide in the nursing staff before the doctor. Nurses are the first point of contact and are usually with patients one-on-one for longer periods of time, giving patients a certain comfort level.
“The nurses who work for me, the RNs specifically, are the ones who work with the patients directly to schedule their cycles. They’re the ones who’d be doing medication instruction, giving the first injection. We do medication instruction one-on-one and make sure they understand what is going to happen step-by-step. They do a lot of phone triage to answer questions. A lot of them offer emotional support because of the intensity of what we do. It helps,” says Alice.
The nurse’s role in a fertility clinic is crucial whether it means telling a patient she’ll have to switch over to injections or just reassuring them everything will be okay. Times are changing and nurses are being called upon more and more.
Alice says, “Now they’re (the doctors) only getting the more intense complicated questions and the nurses are getting triaged a whole heck of a lot more. Patients call more often because they know they will get an answer right away.”
Nurses bring a variety of backgrounds, but it takes a special person who can deal with this. There are a lot of highs and lows.
Alice says, “You need to be calm and supportive. It’s tough, but very rewarding when it works. My favorite part of the job is when I do pregnancy ultrasounds. They’re the best. They are the best part of my day.”
Barbara Alice is a Certified Nurse Practitioner who has been with the South Jersey Fertility Center in Marlton, NJ for the past 9 years. As clinician, nurse manager, and coordinator of the In Vitro Fertilization program, Barbara is a nationally recognized speaker presenting on the advances in IVF and the strategies for balancing professional and personal life. She initiated the “balanced approach to fertility” program, which allows patients the opportunity to incorporate acupuncture, meditation, and stress reduction techniques into their treatment plan.
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Gay and Lesbian Family Building – a Starter Kit
By Dr Guy Ringler
For many couples the process of starting a family can be as simple as putting aside birth control and having sex. For gay men and lesbian women it takes much more planning and research. The purpose of this article is to serve as a starter kit by providing an overview of options and resources available to help you plan your family.
The initial step for lesbian women should include an appointment with an obstetrician/gynecologist. Inform him or her of your desire to start a family and ask for an evaluation of your reproductive health. This exam should include a pelvic exam, Pap smear, and screening blood tests. In addition, a uterine evaluation (hysterosalpingogram or sonohysterogram) and test of ovarian reserve (cycle day three estradiol and FSH blood tests) should be done.
Many obstetrician and gynecologists offer basic fertility treatment services in their practice. If you are planning to pursue treatment with your gynecologist, be sure to ask if their office provides coverage on weekends and holidays for ovulations that may occur at these times, and ask about their ability to handle sperm specimens for the procedures.
It is equally important to inquire when they refer to fertility specialists – the Reproductive Endocrinologists. Do they refer only after six months without conception, or after review of the reproductive health exam? This issue is especially important for women in their late thirties or older. Age is one of the most important factors affecting pregnancy rates and you want to use your time wisely. By asking the questions at the start you can help guide your care in a proactive manner.
Inquire how many insemination procedures are performed in the office each month. If these procedures are rare, they may not be able to optimally schedule and perform the inseminations. Confirm that their staff is comfortable treating lesbians for family building. Fertility treatments can be stressful and you want to feel safe and well cared for in the practice environment.
The fertility options for lesbian women include donor insemination, in vitro fertilization, donor egg IVF, and gestational surrogacy, when indicated.
The next decision is whether to use an anonymous or a known sperm donor. Donor sperm may be selected from various licensed companies throughout the country. Sperm banks are licensed facilities that recruit and screen donor candidates and then collect, freeze and quarantine specimens for six months. Infectious disease tests are repeated after the quarantine period before specimens are released.
The amount of information on the sperm donors varies among facilities. Some banks provide purely descriptive information on physical appearance, family history and educational/social histories, while others provide photographs, audiotapes, or videotapes. It is helpful to explore a couple of different facilities to compare the information offered on their donors.
The alternative to using an anonymous sperm donor is to use a friend or a “known” donor. In this situation, it is important to obtain a detailed medical history, family disease history, as well as the donor’s past sexual history – including any prior sexually transmitted diseases. It is appropriate to inquire about his current and past sexual practices to ascertain the level of risk for disease transmission. He will be required to have blood and urine tests for infectious diseases to comply with FDA guidelines. The treating facility may require specimen collection, screening, quarantine of the specimen and then repeat infectious disease screening before using the sperm for inseminations.
Before starting any treatment procedure it is wise to consult with a reproductive attorney to discuss parenting rights and responsibilities between you, your partner and sperm donor. This consultation is especially important if you’re planning to use a known donor. The laws in this area of reproductive medicine are rapidly changing, and it is best to define everyone’s rights and responsibilities before getting started.
The decision to initiate a family is huge. Many individuals and couples find it helpful to meet with a clinical psychologist to review the decision process prior to starting treatment. The AFA can provide a list of clinical psychologists with experience in helping people deal with reproductive choices and decisions. There are also many support groups available online for women having children through donor insemination.
Gay men who are interested in building families require additional resources. In addition to providing or banking sperm, they need a surrogate and egg donor. There are two types of surrogacy: traditional and gestational. The distinction between the two is who provides the eggs. Traditional surrogates ovulate (and therefore provide the egg), undergo insemination using the intended parent’s sperm, and thus have a genetic link to the fetus. Gestational surrogates undergo an embryo transfer in which a genetically unrelated embryo is placed into the uterine cavity. The legal aspects are more defined in gestational surrogacy by prior case law, and therefore less risky. A more detailed discussion should be handled with a reproductive attorney.
Prior to getting started, gay men should also seek out an evaluation of their reproductive health by having a semen analysis and blood screening tests. If there is a significant sperm abnormality it can change the treatment options. For example, in men with low sperm counts or abnormally shaped sperm, the sperm can have difficulty fertilizing an egg and would benefit from in vitro fertilization with assisted fertilization, ICSI, to enhance fertilization rates and the chance of conception, rather than doing inseminations.
The semen analysis can be ordered by your internist or through a fertility program. If an abnormality is found, be sure to ask for a referral to a Reproductive Endocrinologist or to an infertility urologist for additional testing and/or treatment.
Gay men can start their planning with a surrogacy agency or a reproductive attorney. A surrogacy agency carries out the initial recruitment and screening of surrogate candidates, provides legal referrals, matches intended parents with appropriate surrogates, and provides medical referrals for the treatment process. It takes an incredible amount of screening and coordination to create a baby with assisted reproduction and the agencies can facilitate all aspects of this process.
Some men prefer to start with a reproductive attorney who will then refer them to select surrogacy agencies. In both options, both experienced attorneys and surrogacy agencies will work together to organize and provide professional support throughout the process.
You can find additional resources and support groups in your community or online. In Los Angeles there is a support group for gay dads: the Pop-Luck Club. It was started a decade ago by several gay dads and now provides support, advice, and resources for gay men with children, as well as men just starting out in the process.
Additional information on all aspects of this process can be found through the American Fertility Association. The AFA is dedicated to providing education, support and advocacy for all individuals interested in building families.
Resources:
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Media Request from Parenting Magazine
Dear Members and Constituents of The AFA
I’m working on a story for Parenting magazine about the dilemma many couples have after successfully overcoming a struggle with infertility: what to do with unused embryos. I think for many, if not most parents, this is one of the hardest decisions they have ever faced. Often, parents don’t have a lot of good information about what the options are — which is why I’m writing this article. As you can imagine, couples facing this decision value most the views of others who have been there. That’s why I’m hoping to find those willing to share their experiences with me, in the hopes that their thoughts might help others.
I will make it clear in the story that there is no right or wrong choice. What’s right for one couple might not be for another, and that’s partly the point. Only the parents can make a decision, and while they can take as long as they need, they do eventually have to decide.
Please pass long my contact information to anyone who might be willing to speak with me. I would want to use their real names, but knowing how sensitive it is, I will go over with them the parts of our discussion I use in my story to make sure it correctly conveys their thoughts. I think a story like this might be of great comfort and help to the thousands of couples with embryos in storage, paying their monthly fees and unsure what to do.
My email address is [email protected]. If anyone would like to see some of my previous work, it is on my web site at www.laurabeil.com. Before freelancing, I was the longtime medical writer at the Dallas Morning News. In addition, I will probably have a story next week in Newsweek on another sensitive topic — abstinence education.
Thank you--
Laura Beil
The
American Fertility Association, 305 Madison Avenue Suite
449, New York NY 10165.
Support Line: 888-917-3777. www.theafa.org |