BY DR. C.B.NAGORI. MD., DGO. DR. SONAL., MD. Dr. Nagori’s Institute for Infertility and IVF...
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BY DR. C.B.NAGORI. MD., DGO. DR. SONAL., MD. Dr. Nagori’s Institute for Infertility and IVF “KEDAR”, Opp. Petrol pump, Nr. Parimal garden, Ellisbridge,
BY DR. C.B.NAGORI. MD., DGO. DR. SONAL., MD. Dr. Nagoris
Institute for Infertility and IVF KEDAR, Opp. Petrol pump, Nr.
Parimal garden, Ellisbridge, Ahmedabad 380006
Slide 2
Introduction As has been studied by Prof. Kurjak and many other
authors, the optimum perifollicular PSV, on the day of HCG has been
confirmed as > 10cms/sec.
Slide 3
Vascular changes at the time of impending ovulation include
increased vascularity of the inner wall of the follicle and a
coincident surge in blood velocity just prior to erruption. Bourne
et al, Intrafollicular blood flow during human ovulation,
Ultrasound Obstet Gynecol 1991; 1:53
Slide 4
A marked increase in the peak systolic velocity around the
follicle, in the presence of a relatively constant PI, could be a
sign of follicle maturity and impending ovulation. Tan SL, et al,
Blood flow changes in the ovarian and uterine arteries during the
normal menstrual cycle Am J Obstet Gynecol 1996;175:625-31
Slide 5
Another study also says that the perifollicular PSV of
42cms/sec is reached about an hour before the spontaneous rupture
of the follicle.
Slide 6
This means that if the follicle is said to be functionally
mature when PSV is 10cms/sec, that is the time when the LH surge
starts and under the effect of that LH, the perifollicular PSV
keeps on rising constantly.
Slide 7
10cms/sec 45cms/sec
Slide 8
That means if higher the PSV, the follicle is closer to
rupture.
Slide 9
Keeping this in mind, a study was done on patients undergoing
IUI for their treatment of infertility.
Slide 10
Aim The aim of the study was to find out if double IUI can
increase the pregnancy rate in patients who have a pre HCG
perifollicular PSV > 15cms/sec.
Slide 11
Material and method 300 IUI cycles were included in the study.
Patients were stimulated with clomiphene citrate, r FSH and
letrazole + rFSH.
Slide 12
Monitoring was done with B mode as well as colour Doppler
ultrasound. All patients were denied intercourse when at least one
follicle was more then 14mm in diameter.
Slide 13
Inclusion criteria Patients with unexplained and dysovulatory
infertility Age group 22 40 years Primary or secondary infertility
of more than 3 years.
Slide 14
Exclusion criteria Post wash count < 7 million / ml
Endometriosis grade 2 and 3 Age > 40 years More than two mature
follicles
Slide 15
Method Patients on stimulation were scanned by transvaginal
route with 6-12MHz probe, on Voluson E8, Expert ultrasound machine
(GE). Patients were first scanned on 3rd day to assess the
follicular size in each ovary and to assess the uterus for any
abnormality. After stimulation was started they were called on 7 th
day for reassessment and then intermittently till follicular size
of 18mm is achieved.
Slide 16
Follicle is measured as single vertical diameter when it is
seen as a circle. If follicle appears oval or polygonal, three
diameters are taken AP, transverse and longitudinal, in two
sections perpendicular to each other and the mean of the three is
taken as diameter. When desired follicular diameter is achieved,
the endometrium is evaluated.
Slide 17
Follicular evaluation
Slide 18
Endometrial evaluation Endometrial thickness of minimum 8 mm is
considered as optimum. It is measured as the broadest part of the
endometrium, in the most longitudinal section of the uterus.
Endometrium is always measured from outer to outer margins of the
echogenic margins of the endometrium. The endometrium should be
multilayered.
Slide 19
Endometrial evaluation
Slide 20
Endometrial Doppler
Slide 21
6mm, grade A/B Volume > 3cc Zone 3,4, RI < 0.6, PI 2
Vascular area> 5mm 2 RI < 0.9, PI < 3 Uterine art Zaidi J
et al, Endometrial thickness, morphology, vascular penetration and
velocimetry in predicting implantation in an IVF program.
Ultrasound Obstet Gynecol 1995;6:191-8 Kupesic S, Kurjak A, et al,
Luteal phase defect:comparison between doppler velocimetry,
histological and hormonal markers. Ultrasound Obstet Gynecol
1997;9:105-12. Steer CV et al, Vaginal colour doppler assessment on
the day of ET accurately predicts patients in an IVF programme with
suboptimal uterine perfusion who fail to become pregnant.
Ultrasound Obstet Gynecol 1991;1(Suppl):79-82
Slide 22
When follicle and endometrium both met the required criteria on
B mode ultrasound, colour doppler assesment was done for follicle
and endometrium. For endometrium, when branches of spiral artery
reached at least zone 3(hypoechoic area in between echogenic lines)
and there were more than ten vessels reaching this zone, the
endometrium was considered mature for implantation.
Slide 23
Follicular assessment: CD Good follicle on colour doppler was
expected to have blood vessels covering more than 3/4 th of its
circumference and these blood vessels should have RI 10cms/sec.
Vessels, that obliterated the visualization of follicular walls are
perifollicular vessels. When these parameters are reached,
injection of hCG is planned and IUI is done usually after 34-36
hours, routinely. But in this study only those patients were
included in whom the perifollicular PSV > 15 cms/sec, RI <
0.48.
Slide 24
Follicular Doppler
Slide 25
16mm RI < 0.5, PSV 10cms/s 3/4 th vascularity Nargund G et
al, Ultrasound derived indices of follicular blood flow before hCG
administration and the prediction of oocyte recovery and
preimplantation embryo quality. Human reprod 196; 11:2512-17
Nargund G et al, Associations between ultrasound indices of
follicular blood flow, oocyte recovery and preimplantation embryo
quality. Hum Reprod 1996; 11: 10-13 Bhal PS et al, Is follicular
vascularity an index of pregnancy potential among women undergoing
assisted reproduction treatment cycles? Hum Reprod 1997; 12:72
Slide 26
Method hCG 10,000 was given to all patients for ovulation
trigger. Of all these patients, single IUI was done at 34-36 hours
in half the patients and in half the patients, apart from the 34-36
hours IUI, an additional IUI was done at 12-14 hours. Patient
selection was at random for 50% each.
Slide 27
Method HCG 10,000 was given for ovulation trigger when all
these parameters were satisfied. For half the patients with
perifollicular PSV > 15 cms/sec, single IUI and for half double
IUI was done randomly. They were grouped into a PSV of 15 20, 20 -
25 and > 25 cms/sec.
Slide 28
Method The results of the cycles were studied. Conception was
considered as a desired result and nonconception, an undesired
result.
