Treatment Instructions

We understand how hard it is to keep track of the various treatment instructions provided by most clinics. That’s why we put them online, so you can access your treatment instructions anytime. Instructions for bowel prep, pre-op and post-op care; Clomid, Metformin and semen analysis; and labor and postpartum care are listed below.


Bowel Prep


Some gynecological surgeries require the patient to perform a bowel prep the day before surgery. Not all surgeries require this preparation, so be sure to ask your physician.

Begin bowel prep the day before surgery. HalfLytely (prescription) and bisacodyl bowel prep tablets (over-the-counter) produce watery stool to cleanse the colon. You should only drink clear liquids* on the day of preparation. Your first bowel movement may occur 1 to 6 hours after starting this regimen.

Bowel Prep Regimen:

  • 8 a.m. to 12 noon: Drink clear liquids* only for breakfast, and then one or more glasses of water and/or clear liquids every hour until noon.
  • 12pm: Take the two bisacodyl tablets with water (do not chew or crush tablets). Antacids should not be taken within one hour.
  • Prepare the HalfLytely solution according to the manufacturer’s instructions. No additional ingredients (other than the flavor packs provided) should be added to this solution.
  • After you have a bowel movement or have waited for a maximum of six hours (6 p.m.), drink all of the 2-liter HalfLytely solution at an average rate of 8 ounces every 10 minutes (for about an hour and a half). Drinking each portion rapidly is better tolerated than gradually drinking in small amounts.
  • Uncomfortable abdominal bloating may occur before your first bowel movement. Your discomfort will improve by temporarily drinking each portion of HalfLytely solution at longer intervals or by stopping altogether until your symptoms disappear.
  • Once completing the HalfLytely solution, do not drink large quantities of clear liquids*.

*Clear Liquids

  • Water
  • Clear juices
  • Clear broth
  • Clear soda: 7-Up, Sprite, Gingerale
  • Coffee or tea (without milk products)
  • Kool-Aid
  • Popsicles
  • Jell-O
  • Gatorade

Do not eat or drink anything after midnight before surgery!

If you are taking any medication for diabetes, hypertension, asthma, seizures or other medical conditions, please consult with your primary care physician or specialist to determine your dosage before surgery.


Pre-Operative Instructions


  • If your surgery is scheduled for early in the morning, do not eat or drink anything after midnight the night before your procedure. In the morning, you may shower, brush your teeth and take your prescribed medicines with a sip of water. If your surgery is planned for the afternoon, you may have water, tea or coffee up to six hours prior to your surgery time, but absolutely nothing thereafter.
  • You must make arrangements for a responsible adult to drive or accompany you home. No one will be discharged from the hospital alone.
  • Please leave all valuables, jewelry and contact lenses at home.
  • You should wear comfortable clothing that you can easily put on after surgery.
  • Remove all nail polish from either your left or right index finger.
  • If you have received a prescription for pain relief prior to your surgery, be sure to have it filled so it will be immediately available to you.
  • If ordered, please have your blood tests completed one to three days before surgery.
  • Do not drink alcohol or smoke cigarettes 10 days before or after surgery.
  • If you smoke, stop smoking before your operation. Any period of not smoking helps. It is best if you quit at least two weeks before surgery because general anesthesia will change the normal function of your lungs for a while. If you quit smoking, your lungs will be in better shape before the operation, you will adjust to the anesthesia better, your lungs will be able to resume their normal function with less effort after surgery, you won’t cough as much, and the risk of infection will decrease.
  • If you are taking medication, ask your doctor if you should keep taking it before or after the operation. Medications may be prescribed for you by a doctor or obtained over-the-counter. Some medications should not be taken before an operation. Others may conflict with other medication your doctor may prescribe.
  • Do not take any of the following medications, which may affect bleeding, for a week prior to your surgery: Vitamin E, ginkgo, aspirin, Empirin, Anacin, Excedrin, Bufferin, ibuprofen, Motrin, Advil or Aleve. If you need pain relief, Tylenol products are fine.

Post-Operative Instructions


  • Make sure that you take your pain medicine according to your doctor’s instructions. Do not wait until your pain is severe to take your medicine because it will be harder to control the pain. Pick up your pain medicine before surgery so you don’t have to do it when you aren’t feeling well.
  • Eat lightly and according to your appetite in the beginning. Make sure you drink adequate fluids and are able to urinate.
  • Make your follow-up appointment before your surgery. The first appointment is usually two weeks after surgery.
  • If you have steri-strips on your incision, you can take them off after 5 to 7 days if they are bothering you. Otherwise, your doctor will remove them on your first post-op visit.

Make sure you know the warning signs of problems related to surgery. Contact your doctor if you experience any of the following symptoms:

  • Vomiting
  • Fainting
  • Severe abdominal pain or cramping
  • Heavy bleeding
  • Abnormal vaginal discharge
  • Fever or chills
  • Redness or discharge from incisions
  • Shortness of breath or chest pain

Clomid


Clomiphene (Clomid or Serophene) is a medication that has been used to treat infertility for more than 30 years. Clomiphene causes the pituitary gland to secrete an increased amount of follicle stimulating hormones and luteinizing hormones, which stimulate ovulation, increase progesterone secretion during the second half of the menstrual cycle and make menstrual cycle lengths more predictable. These effects are useful in treating absent or irregular menstrual cycles, or to improve the timing of intercourse or artificial insemination.

Clomiphene is taken orally for five days, starting on day two, three, four or five of your cycle. You will be instructed when to begin clomiphene and how much to take. Dosages can vary from 1/2 to five pills per day. If taking more than one pill daily, these may be taken all at once or spread out during the day.

Clomiphene has some side effects. Although not permanent or dangerous, they may be noticeable and even become bothersome. Most patients have no side effects. Side effects include:

  • Hot flashes, or feelings of heat in the neck and face.
  • Mild blurring of vision, often noted at night.
  • Mood changes, or heightened feelings of emotion, sometimes marked by irritability or increased sensitivity. The response is highly individual, as some women do not experience mood changes.
  • Ovulation pain resulting from increased ovarian stimulation. It is not uncommon to notice increased ovarian sensitivity around the time of ovulation.
  • Ovarian cysts; a small, fluid-filled follicle cyst may form from an unreleased egg. These cysts usually do not cause symptoms and disappear spontaneously after the following menstrual period. They almost never require surgical treatment.
  • Twins. There is a 10 percent chance of conceiving twins when taking Clomiphene, but no increased risk of triplets or more. There is no increased risk of birth defects after taking Clomiphene.

Clomiphene is active only in the month it is taken and does not require a “build-up” in order to be effective. It need not be taken in a cycle where pregnancy will not be possible. It is not uncommon to note a decreased menstrual flow when taking Clomiphene. This does not indicate a lack of effectiveness. Your prescription will be refillable, so use a convenient pharmacy.

Preparation for Clomid

Required Blood Tests for Female Partner

  • Follicle-stimulating hormone must be drawn on cycle day two or three
  • Estradiol must be drawn on cycle day two or three
  • Thyroid-stimulating hormone
  • Prolactin

Semen Analysis for Male Partner 
Semen analysis evaluates volume, concentration, motility and morphology. Abstain from ejaculation for three to five days prior to giving a sample.

Test Results
If within normal limits, begin Clomid.

Beginning Clomid
Start Clomiphene (Clomid or Serophene) at 50 mg or one tablet per day for five days, beginning on day three of menstrual cycle. If you experience side effects, it may be helpful to take Clomid before going to sleep.

Ovulation
Take one to two teaspoons of Robitussin cough medicine every four to six hours for two to three days during ovulation (days 13 and 14) to thin out mucous.

Ovulation Kit
We recommend Clear Blue Easy or First Response to determine your fertile time. Ovulation kits should be used with your first morning urine, beginning around day 10 of a 28-day cycle, or according to package directions.

Intercourse 
Have intercourse on the day of the color change and every day or every other day for approximately one week. Sperm can survive in the vaginal mucous for up to three days.

Serum Progesterone Blood Test
This test is done seven to eight days after the color change to check ovulation. If you’re not ovulating, you may increase Clomid to two tablets daily for five days.

Urine Pregnancy Test
A urine pregnancy test is done two to three days after your period is due.

Positive Pregnancy Test
If your pregnancy test is positive, make an appointment for your first prenatal visit around 8 to 10 weeks.

Negative Pregnancy Test
If your  pregnancy test is negative, start Clomid again with the next cycle. Call our office for progesterone blood test results to determine dosage.

Hysterosalpingogram
Your physician may recommend that you have a hysterosalpingogram. During a hysterosalpingogram, dye is injected inside the cervix, which leads to the uterus and fallopian tubes, through a thin plastic tube. X-rays will be taken to detect blocked tubes, fibroids, polyps or scar tissue.


Metformin


There is a well-recognized association between hyperinsulinemia (insulin resistance) and anovulatory hyperandrogenemia (PCO), especially in obese women. Metformin, an oral agent used to treat diabetes mellitus, decreases hepatic glucose production and improves insulin sensitivity. Treatment with metformin reduces hyperinsulinemia, LH levels and free testosterone concentrations in overweight women with PCO. Non-obese women with hyperinsulinemia may also show a clinical response when treated with metformin, and anovulatory patients may ovulate or improve their response to clomiphene.

Pretreatment Laboratory Tests
Tests include fasting glucose and insulin; creatinine and LFTs; prolactin, LH, FSH and TSH if not already done. A fasting glucose to insulin ratio of less than 4:1 may be a useful indicator for metformin use.

Dosage and Administration
The optimal dosage of PCOs has not been established for ovulation induction purposes. Nestler (NEJM 338:1876, 1998) suggests 1500 mg per day in divided doses. During the first week, take one pill (500 mg) with dinner. During the second week, add a second pill with breakfast. During the third week, add a third pill with lunch.

If, after eight weeks, there is no significant weight loss (less than four pounds) or no resumption of normal menstrual periods, the dose of metformin can be increased to 850 mg. After an additional six to eight weeks, induce withdrawal bleeding with 10 mg of Provera per day for 10 days. On the fifth day of withdrawal bleeding, start Clomiphene at 100 mg per day for five days, and measure serum progesterone on days 21 and 28 after the initiation of withdrawal bleeding. If there is no ovulatory response, discontinue the Metformin treatment.

Side Effects and Safety
No safe dosages have been established for healthy young women. Metformin is classified as pregnancy Category B. Some physicians use metformin during pregnancy to decrease the risk of miscarriage, but there is no data showing the effectiveness of this approach.
GI side effects are correlated with the dosage. Nausea and/or loose stools are common with dosages above 1,000 mg per day. These subside within one month in most, but not all, women.


Semen Analysis


Testing can be performed from 7 a.m. to 3 p.m. Monday through Friday at the Pacific Campus (excluding weekends and holidays). No appointment is necessary.

Collection Information

  • Have intercourse or ejaculate three to four days before testing. Abstain from sexual activity thereafter.
  • No alcohol or drugs.
  • No hot baths.
  • Maintain normal body temperature.
  • Do not refrigerate.
  • Home collection: Put your sample into a sterile wide-mouth plastic container. Note the date and time of collection.
  • Laboratory collection: You will be given instructions at the lab.

Specimen should be delivered within 60 minutes from the time of collection to:

California Pacific Medical Center, Pacific Campus
2333 Buchanan Street
Clinical Laboratory
Second Floor, Room 2410
San Francisco, CA

Should you have questions, please call the lab at the Pacific Campus at (415) 600-2200.


When You Are In Labor


Call us if you experience:

  • 5-1-1 Contractions. Call when you are having contractions five minutes apart, lasting one minute each, for one hour.
  • Ruptured membranes with clear fluid and no labor pains, if your vaginal culture for Group B strep at 36 weeks was positive. If your membranes rupture during the day, call us. If your membranes rupture after 5:30 p.m. and your Group B strep culture was negative, you can wait for signs of labor. If you are not in active labor by 7:00 a.m., please call our office.
  • Ruptured membranes with green amniotic fluid. This may be meconium (fetal stool) which occasionally signifies fetal distress. You will be instructed to come to the hospital when fluid is this color.
  • Heavy bleeding and/or unremitting, severe pain.

How to reach us:

  • During office hours, please call us at (415) 666-1250, and choose option 2.
  • After or before office hours, please dial (415) 666-1250 and press 0. Our nurse triage service will make an assessment and give you instructions. An on call physician is available 24 hours a day and the nurses can reach us if necessary.
  • If instructed by a physician, call the CPMC hospital triage desk at (415) 600-2100.

Labor pains are typically uniform in their intensity and predictably rhythmic in their timing.

In general, when at term, there is NO need to call if:

  • You are cramping or having erratic contractions, even if some are strong.
  • You note a slight bloody discharge, pass your mucous plug or see blood-tinged mucous in the absence of regular labor pains.

Postpartum Instructions


Follow-up Appointment
When discharged from the hospital, please call to schedule a post-partum appointment at six weeks after a vaginal delivery or two weeks after a cesarean section.

Bleeding and Cramping
Bleeding and cramping should gradually decrease after delivery and may not completely disappear for four to six weeks. You may occasionally pass some clots or have heavy bleeding. Unless you are soaking a pad every hour for four hours, there is no need to worry. If you develop worsening abdominal pain, please call us.

Breastfeeding
Fevers are common as breast milk comes in. Occasionally, a duct or gland may get clogged and form a lactocoele. Continue breastfeeding and eventually the lactocoele will resolve and the fever will abate. If fevers over 101.5 persist and are accompanied by skin redness, this may be a sign of mastitis. Please call us. For other breast feeding problems, the lactation center phone number is (415) 346-BABY or (415) 346-2229.

Stitches
Stitches from repair of an episiotomy will dissolve by your follow-up appointment.