Background

hCG is the hormone which is administered to allow for the final maturation of the eggs and to prepare for ovulation. hCG has historically been given intramuscularly (IM) when used for triggering ovulation. More recently, data has suggested that the subcutaneous route of administration is as safe and effective as the intramuscular injection. Although hCG is not U.S. FDA approved for this method of administration, there is both practical experience (in the United States and Internationally) as well as medical literature suggesting that subcutaneous administration is works just as well as an intramuscular injection. Giving hCG subcutaneously may sting more than the other medication you have used. It can also leave a reddish bump the size of a quarter at the site of injection. This will go away in a day or 2 and has no impact on it effectiveness.

Once follicular development is considered complete, you are instructed to take an injection of hCG.

For controlled ovarian hyperstimulation (COH) or ovulation induction with FSH, hCG is used to mature the eggs and allow you to ovulate. Following this injection you may be instructed to time intercourse or, alternatively, undergo an artificial insemination.

For in vitro fertilization (IVF), hCG is used to mature the eggs. In an IVF cycle, you will undergo an egg retrieval 36 hours after you take your hCG injection. This is the last step in the “stimulation phase” before your egg retrieval. The time that you take your hCG is extremely important because your egg retrieval is timed to take place approximately 36 hours after this injection. Once you receive the instructions to take your hCG, you should not take any more FSH injections. In other words, do not take your evening dose of FSH. If you take Lupron or a GnRH Antagonist in the morning, you will not need to take either again during the cycle. If you take Lupron or a GnRH Antagonist in the evening, you will need to take your evening dose the night you give yourself your hCG shot. Your preoperative instructions will also be reviewed. You should not eat or drink anything after midnight the night before your egg retrieval. You should not wear any make-up, contact lenses, jewelry (wedding rings are O.K.), fingernail polish or false nails on your thumbs on the day of the egg retrieval. The night of your hCG injection is the last night that intercourse or ejaculation is allowed before the specimen collection on egg retrieval day. You will also be starting your antibiotics (doxycycline) at this time. When producing a specimen, a picture ID is needed for the male for identification purposes.

The hCG instructions will also include a time for your partner’s specimen collection, your arrival time and place for your egg retrieval or artificial insemination.

Following your hCG injection, you should begin weighing yourself daily to monitor yourself for Ovarian Hyperstimulation Syndrome. Use the same scale at the same time of day (with no clothes on) and weigh yourself only once each day. If you notice that you have gained 5 pounds over the next two weeks, please call us. Other symptoms to watch for are decreased urination, shortness of breath, nausea, vomiting, or shoulder pain. We would also like for you to call us, if you become nauseous or are vomiting, or your abdomen begins to look bloated and tight. Although many women find that their stomach becomes distended and full during this time period, we become concerned if you feel very uncomfortable because of the changes.

Medication administration: hCG (Profasi, Pregnyl, Novarel, Ovidrel)

The hCG comes packaged as a powder containing 10,000 units of hCG. A diluent (liquid vial) is supplied to make a solution for injection. Wash your hands well with soap and water prior to administering the injection. In order to prepare your injection:

1. Using the 3 cc syringe, draw up only 1 cc (1.0 cc = 1.0 ml) of liquid (diluent). Slowly inject this liquid into the powder vial down the side of the vial to avoid foam. Remove the syringe (and recap it) to make mixing easier. This bottle will need to be gently rotated to get all of the powder into solution. Do not shake the bottle is this adds bubbles to the solution. After mixing, this solution may be clear or milky white in color. You will not need any extra liquid left over in the original diluent vial.
2. Once the powder is completely dissolved, invert the bottle in order to draw up the entire contents back into the syringe. (Always make sure that the tip of the needle is below the liquid level in the bottle to recover as much of the solution into the syringe as possible. It will be necessary to slowly back the tip of the needle out of the vial as you withdraw the fluid.) Make certain that the powder has completely gone into suspension, that there are no clumps of undissolved powder on the sides of the bottle.)
3. Continue to pull back on the plunger of the syringe so that there is an air space of about 1 cc near the needle end of the syringe. You will be removing the long needle from this syringe and replacing it with a small needle for your injection. Pulling back on the plunger of the syringe insures that you will not leave any medication in the needle which is to be removed.
4. Remove the long needle from the syringe after CAREFULLY capping it by untwisting it from the syringe. Dispose of the needle in a safe, puncture proof container. BE CAREFUL WHEN YOU REMOVE THIS NEEDLE SO THAT YOU DO NOT STICK YOURSELF.
5. Replace this needle with the 27 or 30 gauge needle by screwing the smaller needle onto the syringe.
6. Keeping the syringe in a upright (vertical) position so that the needle is at the top, slowly push up on the plunger of the needle to remove any air from the syringe. Keep pushing until all visible signs of air are removed from the syringe and you see a tiny droplet of liquid being expressed from the point of the needle.
7. Choose the location where you plan to administer the subcutaneous injection. Most patients give the injection in the lower portion of the abdominal wall between the pubic hair line and the belly button. For the hCG injection, this area seems to be less sensitive. However, the medication can also be administered in the upper outer arm, buttocks, or thigh. Wipe the area in circles going outward with an alcohol wipe. The rationale for this is to drag any bacteria away from the site of the injection. Let the alcohol air dry (do not blow on it) prior to injecting to minimize any stinging. Please see the sheet at the end of this section for pictures of the possible sites.
8. Pinch the skin between your thumb and forefinger at the injection site. Holding the needle like a dart in your other hand, insert the needle into the area of pinched skin, the entire length of the needle. Let go of the pinched skin.
9. Completely depress the plunger to deposit the medication into the tissue. There is no need to draw back on the plunger prior to injecting this medication.
10. Remove needle from skin. Cover with Band-Aid if necessary.
11. Your egg retrieval will be scheduled to take place approximately 36 hours after your hCG injection, so it is important to take the hCG as close to the exact time specified by the physician as possible.

Helpful Hints

1. If you contaminate the needle in the process of making the solutions, recap the needle, twist it off, and take a fresh needle from another syringe.
2. Syringes should be discarded appropriately after a single use. They may be deposited in the syringe disposal container that you may have been given. Alternatives include any hard container such as a empty peanut butter jar, an old coffee can, or an empty 2-liter plastic soda bottle. When your container is filled, you can seal it with heavy tape, label it "Do Not Recycle" and dispose of it with your regular household trash. If you are getting your medications and syringe disposal container through a mail order service, you can contact them about disposal.
3. After mixing the diluent and powder it may be easier to withdraw the mixed solution by placing the needle just through the rubber seal and turning the vial over to withdraw the solution. This is because the needle may not reach the bottom of the vial and this will bring the solution to the needle.
4. Try to administer the medication immediately after mixing it, but certainly within 30 minutes, since it may not be as effective after that time.
5. Consider making yourself comfortable when giving the injection by lying down or sitting. As noted earlier, consider administering the hCG shot into the lower part of your abdomen (between your belly button and your pubic hairline) as this area is less sensitive.

Side effects of hCG (Profasi, Pregnyl, Novarel, Ovidrel)

It is important to know that while hCG can cause ovarian hyperstimulation, there are usually no side effects associated with the hCG injection and most women tolerate this medication quite well. Do not be alarmed if there is some reddening or a small red raised area at the injection site or if you feel some itching or stinging. If you develop a blister or swelling greater than the size of a half dollar, please call the office.

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