Why would you be doing an IM injection?
While most of the stimulant drugs are administered via sub-cue injection, some injections, including progesterone in oil (PIO) and some “trigger” shots (Human Chorionic Gonadotropin, or HCG) are given by intra-muscular (IM) injection.
What to expect
For those of us scared of needles (even despite administering hundreds, if not thousands, of sub-cue injections), the prospect of an IM injection can be utterly horrifying. The needle is 1 ½ inches long and often 22 or 25 gauge (remember that the lower the number, the thicker the needle so an 18 gauge is much thicker than a 25 gauge needle.) But take it from a recovering needle-phobe, these injections are actually much less painful than the size and gauge of the needle would indicate.
As with any injection, get everything ready beforehand: extra needles, gauze pads, and, for IM injections, plug in a heating pad for post-injection. I always iced the area for 5-10 minutes (sometimes 15 when I was particularly nervous!) beforehand. I know people who didn’t ice the area beforehand—they are much braver than I, but it just goes to show you that it is possible to do without icing. Do what makes you feel most comfortable.
Often, you will draw up the medication with a larger (18 or 22 gauge) needle, and will then switch to a smaller (22 or 25 gauge) needle for administration. Since it is extremely thick, PIO typically needs to be drawn up and administered with a thicker needle. You can administer it with the thinner (25 gauge) needle, but it will take a little longer to inject the oil and I personally never felt any difference between the 22 and 25 gauge needles, so if you want the needle out of you as fast as possible, go with the thicker (22 gauge) needle for administration.
A couple of things to remember: first of all, switch needles after drawing up the medication and before administering it, even if you are using the same size needle to draw and administer. The needle can get just a little bit dull after it is placed into the vial of medication, and you want as sharp a needle as possible for administration—dull needles hurt a lot more than extra sharp ones! Also, remember to tap all air bubbles to the top of the syringe and depress the plunger a small amount to get the bubbles out (I usually pushed the plunger until a tiny bead of the medication came out of the tip of the needle, which indicated to me that the air was out.)
Now, for the dreaded injection. IM injections must be done in the large muscle of the buttock. To locate the correct area, imagine the buttock is divided into four areas (like an x/y axis). The injection should be given in the upper, outer portions. Another easy way of locating the correct area was demonstrated by my nurse: place your hands on your hipbone, with your thumb pointing toward your butt crack and your other fingers on the front of your hip, with the area in between the thumb and forefinger flat against your hip bone (like you’re putting your hands on your hips). The injection can be given below the thumb, but not past the tip of the thumb—that area gets close to your sciatica nerve and you want to avoid that area.
The easiest way to administer the injection is to have someone do it for you. However, it is possible to do it by yourself—I traveled on business during the 2ww and had to do it myself two nights in a row unless I wanted to as a business associate to help me (granted, she is also a good friend and knew about our IF treatments, so she even volunteered to help if necessary but I just couldn’t bring myself to have her injecting me in the butt.)
If you have someone to do it for you, the easiest position is to lean against a counter and put all of your weight on the leg opposite the side of the injection (you should alternate sides each night from left to right to avoid over-irritating one side). Don’t look back. The person administering the injection should hold the skin taut with his/her thumb and forefinger of the hand not holding the syringe, and should be holding the syringe in the other hand like a dart. Have the other person count to three if you’d like, and then go in at a 90 degree angle as quickly as possible— you will feel a slow injection more than a quick one, so make sure they go quickly.
If you are doing the injection yourself, find a comfortable position where you can hold the needle steady and still keep all weight off of the side you are injecting. I leaned against the counter similar to when my husband did the injection, but you can also try sitting in a chair and leaning to one side. Twist yourself around so that the hand not holding the needle holds the skin taut between your forefinger and thumb. With the other hand holding the syringe like a dart, inject as quickly as possible at a 90 degree angle.
Once the needle is in (make sure all 1 ½ inches are in the skin/muscle), pull back the plunger just a small amount to make sure there is no blood, which would mean the needle is in the incorrect position. IF you see blood, DO NOT PANIC. Simply pull the needle out slowly, attach a new needle, and inject again in a different location. You do not need to discard the medication because of the blood. The blood is your own and can be re-injected (with a clean needle) along with the medication. I have a friend who wasted a lot of PIO because she thought she had to throw it away if she drew blood.
If there is no blood in the syringe, slowly depress the plunger to inject the medication. When done, quickly pull the needle out in a straight line. Do not panic if you have a little (or even a lot) of blood coming out of the injection site—just put pressure on with a gauze pad for a minute or so and the bleeding will stop. You can put a band-aid on the area if necessary.
Massage the injection area to help spread the medication (especially PIO) around. I always put a heating pad on the injection area for 10-15 minutes after the injection, especially with PIO because the heat can dissipate the oil so that it does not harden in an uncomfortable lump. I also made sure to walk around a bit to avoid any muscle soreness and, for PIO, to further spread the oil around. The few times I did not use a heating pad and/or walk around after the injection, I felt more soreness the next day.
Some problems that might arise (and ways to troubleshoot)
As mentioned above, there is always the chance that you will hit a blood vessel and draw blood when you draw back the syringe. Do not panic—just withdraw the needle, make sure to change the needle, and re-inject in a different spot.
You may also experience soreness—some people experience more soreness than others. The best ways I found to eliminate, or at least reduce, soreness was to consistently use a heating pad after the injection, massage the injection area, and walk around a bit. Soreness is more likely with PIO because the oil has a tendency to coagulate in the muscle and cause an uncomfortable lump. Massage, heat, and moving around can help the oil spread out and prevent these lumps.
Finally, there is a chance that you could hit a nerve when administering the injection. If you are careful, this will not happen (it never happened to me). To avoid this possibility, make sure you are giving the injection closer to the hip than to the middle of the buttocks. Remember the “thumb” rule mentioned above—put your hands on your hips with your thumbs pointed towards the back, and do the injection below the thumb and not past the tip.
My personal tips
I covered my personal tips above, but one additional tip would be to have a nurse do your first IM injection, if possible, with your significant other (or whoever will be administering your injections) present. We did this for our first IM injection and we both felt better knowing that a professional had gone over the procedure before we tried it ourselves. Remember, I was needle-phobic before this whole IF journey, and I found the IM injections very easy. I almost preferred them to the sub-cue injections because they were actually less painful (stung less than the stim drugs). So take a deep breath and just do it. You’ll realize that it isn’t as bad as you are probably imagining!