REI Handoff

Address: Duke Arringdon, 2nd Floor, 5601 Arringdon Park Dr Suite 410, Morrisville, NC 27560

OR: Duke Arringdon Ambulatory Surgical Center (AASC), 5th floor

Monitoring: 7:30 AM start → monitoring follicles (TVUS) / procedures (IUI / embryo transfer / egg retrievals).

• •Noon: review labs at noon conference.
• •1–2 OR days/week — mostly HSC, sometimes laparoscopy with Dr. Manvelyan.

Create plans for patient labs and present at Noon Conference (only on days when not in the OR). Responsible for hCG #2, progesterone, LH, estradiol labs only.

• •Can just take notes on sticky: patient name, age, and why getting labs (e.g., 35 y/o underwent FET on ***, beta HCG today was ***, double from 2 days ago).

List patient meds and give plan based on lab findings.

• •If second HCG and appropriate rise (double every 2 days) → OB ultrasound at 6–7 weeks.
• •If hx ectopic, anticoagulation, or RPL → OB U/S at 5 weeks.
• •If inappropriate HCG rise → repeat HCG in 2 days (if going into weekend, repeat in 4 days).

For IVF (April 2026 update: did not need to present these):

• •2w5d pregnant at day of transfer of embryo (even if embryo growth until day 7, because embryos are held to day 5 criteria to be appropriate for implantation).
• •Power statement: include blastocyst status (e.g., diploid, if was programed).

Common for oncofertility.

• •3 days after egg retrieval, assess estradiol. If estradiol >250 → restart letrozole.

Commonly used to determine if a patient has ovulated.

• •Progesterone >3 indicates ovulation — don’t start cycle.
• •Want progesterone <1.5 for FET to initiate estrogen.

• •30–45 min PPT presentation.
• •Email topic to Dr. Manvelyan for approval prior to starting research.

Baseline visit:

• •Ultrasound: antral follicle count (AFC) — estimate of follicles you hope to stimulate. Evaluate for cysts or follicles that may interfere with stimulation.
• •Lab — Estradiol (E2): ensure no E2-producing follicles that may interfere with stimulation.

Monitoring visits:

• •Ultrasound: count follicles and measure size. Goal: as many follicles ≥ 14 mm (ideally 18–20 mm) but <24 mm.
• •Lab — Estradiol (E2): goal: E2 should double over 2 days. Mature follicles make ~200–400 pg/mL.

Trigger — stimulates / induces LH surge to trigger ovulation, resumption of meiosis.

• •hCG (Ovidrel or Pregnyl) — indications: low concern for OHSS; Lupron trigger not an option; hypothalamic or pituitary dysfunction (wouldn’t respond to Lupron trigger).
• •Lupron — stimulates endogenous LH release → ovulation. Needs an intact HPO axis. Indications: concern for OHSS (high E2, many follicles).

Timeline after trigger:

• •Lupron labs 12 hr after trigger (to ensure response): LH >20, progesterone >4. If no response → consider hCG trigger (cancel if high risk for OHSS).
• •Transvaginal oocyte retrieval (TVOR) 36 hr after trigger.

Stimulation meds (stimulate follicles to grow). Choose initial dose based on age, AMH, AFC; titrate based on response:

• •FSH — Gonal or Follistim.
• •FSH/LH combo (hMG) — Menopur.

Surge prevention — prevents premature endogenous LH surge so you can continue stimulating follicles without losing them to ovulation before retrieval:

• •GnRH antagonist — competitively binds to GnRH receptor in pituitary.
• •Provera — negative feedback on hypothalamus to decrease GnRH pulse frequency.
• •Lupron “flare” — short-term: release of gonadotropins (may give follicles an initial “boost”). Long-term: downregulation of GnRH receptor.

Generally responsible for:

• •C-sections, repairs that go to the OR. (If section while Onc rounding or signing out, Chief will do it.)
• •Call into Gyn Onc and Antepartum pagers (may also call into Benign/Urogyn pagers based on your Chief).
• •Write note if anything major happens overnight.
• •Perform BPPs needed for Antepartum.
• •Round Gyn Onc — sign note to attending, not fellow.
• •See ED consults (independently or with Chief, depending).
• •Leveled OR cases (pending no sections).

Tips:

• •At beginning of shift, text oncoming Gyn Onc and Antepartum teams.
• •Gyn Onc: if you foresee you’ll be unable to round, let them know by 5:00 AM.
• •Antepartum: coordinate time to call for sign out.
• •Even if you hold pagers for Benign/Urogyn, your Chief will round on them.
• •Look at ultrasounds/imaging for all consults. Great opportunity to get more comfortable with reading imaging.
• •Develop a spiel for common consults — PUL and AUB.