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Practical tips for monitoring of an IUI cycle. Dr. Jyoti Agarwal. Introduction . Ovulation induction though sounds simple but there are many obstacles - Each patient behaves in a different fashion. - Variety of drugs and protocols are available. - PowerPoint PPT Presentation
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Practical tips for monitoring of an IUI cycle
Dr. Jyoti Agarwal
Introduction • Ovulation induction though sounds simple but
there are many obstacles - Each patient behaves in a different fashion. - Variety of drugs and protocols are available.
• Every center has its own pattern of COH but the basic concept of monitoring remains the same.
Who should monitor?
Do it yourself
Why add to the burden ?
“Vision is the art of seeing invisible ” Jonathan swift
• It is difficult to think of managing an infertile couple without resorting to this versatile and easy to use technology.
• All the modalities of ultrasound ranging from basic black and white to the most complex , real time 3D and colour doppler have a role to play in managing these infertile patients .
Five Reasons To MonitorTo evaluate if the dose being used is optimal To adjust the dose of the drug as some patients are hyper responsive and some are poor responders. To find the optimal time for inducing ovulation To time IUI To avoid excessive stimulation , to prevent OHSS and multiple pregnancy
All patients to be monitored
Monitoring Should Be
• Easy• Reliable• Patient friendly• Not expensive• Can be done by self
How to monitor ?
• BY E 2 ALONE• BY ULTRASOUND ALONE• BY BOTH• BY COLOR POWER DOPPLER• BY OTHER HORMONES
MINIMUM MONITORING
Monitoring
Ultrasound states the morphological growth of the follicles
Hormones indicates the functional activity of the follicles
TVS is the accepted method by all ART centers.
Why TVS ?
• Simple• Easy• Reproducible• Reliable• Cheap• Patient friendly
An transvaginal probe is an extension of clinician’s fingers
‘ marrying palpation with imaging ‘
Importance of D -2 scan
• Antral follicle count• To rule out any cyst.( > 3 cm)• Endometrial shedding• Or any other pelvic pathology
We expect normal sized ovaries with very small follicles (3—5 mm in diameter)
Follicular size is measured by taking mean of 2 or 3 largest perpendicular diameters of each follicle .
Ultrasound follicular monitoring
Serial USG follicular monitoring is started from day 7 or 8 of the cycle But in case of gonadotrophins we start scanning
from 6th day of stimulation.
Assessing the follicular maturity
• The follicles normally grow at a rate of 2- 3 mm / day in a stimulated cycle.
• Definitive size of the follicle which confirms the maturity of oocytes is still controversial.
• A follicle measuring 18—20 mm has been found to contain a mature oocyte.
Corelation with serum oestradiol levels
• Plasma estradiol levels correlates closely with the stage of development of the dominant follicle
• Serum estradiol levels >200 pg / ml on day 8 of stimulation indicates adequate dose of gonadotropins.
Ultrasound monitoring has totally replaced estradiol monitoring in most centers.
Predicting the risk of OHSSIf there are more than 4 follicles larger than 16 mmor more than 8 follicles larger than 12 mm
It is best not to give hCG so as to prevent OHSS and high order multiple births.
In case of doubt do serum estradiol levels
Estradiol levels of > 1500 – 2000 pg/ml indicates risk of OHSS and is advisable to withhold hCG trigger.
Follicular doppler flow studies
• A mature follicle shows vascularity in atleast ¾th of the follicular circumference and
• PSV is 10 cm/sec.• At this time LH surge
starts and• This is the right time to
give hCG trigger
Perifollicular vascularisation
Grade 1 : < 10% Grade 2 : 10-25%
Grade 3 : 25-50% Grade 4 : > 50%
Predictors of poor ovarian response are :
• Ovarian volume <3 cc• < 3 antral follicles• Ovarian RI > 0.6• Ovarian PSV < 5 cm / sec• Stromal flow index < 11
• Suggest poor ovarian response &• Higher doses of gonadotropins will
be required for stimulation.
ENDOMETRIAL EVALUATION
Clear association between endometrial growth and the circulating estrogen & progesterone levels.
Endocrine implantation
ET – 8 – 14 mm BEST ENDOMETRIUM ON THE DAY OF HCG TRIGGER
ET > 16 mm or < 7mmIs not associated with good prognosis
• Proliferative phase : 4- 7 mm• Periovulatory period : 6-10 mm• Secretory phase : 8-12 mm• Postmenopausal pd. : < 4 mm
Thickest part of the endometrium should be measured
D-2Can show
anechoic collection of blood.
thick echogenic endometrial echo .
a very thin endometrium 1-3 mm thick.
D3-7• Increase in
oestrogenic biosynthesis leads to stimulation and growth of endometrial glands and stroma.
• Double line endometrium is seen which is usually < 6 mm.
D-7 onwards• Proliferative
endometrium continues to grow in size and thickens and is seen as a triple layer or triple line.
• Middle layerechogenic—
Lumen
In Periovulatory Phase
Triple line progressively becomes thicker,
homogenous and hyperechoic
characteristic changes start only 24 hrs post ovulation.
Applebaum’s uterine scoring system for reproduction (USSR)
Endometrial evaluation Conception rates according to zones of
vascularity• Zone 1 5.2 %• Zone 2 28 %• Zone 3 52 %• Zone 4 74%
COLOR DOPPLER UT.ARTERY DAY 2
DAY 7-9
PERIOVULATORY UT A.
Uterine Artery Doppler
The chance for pregnancy is almost zero if the PI is more than 3.019 on the day of hCG administration
Patients who get pregnant have a lower RI (0.53 vs 0.64)
Cervix and follicular monitoring
On D – 13 scanGood cervical mucus• E2 > 100 pg • 2 follicles • ET 7-8 mm
Ovulation triggerThe end point of any ovulation induction protocol is to indentify the best time for triggering ovulation. most crucial step
In a gonadotrophin In clomiphene
Leading follicle is Leading follicle is 18 – 20 mm in diameter. 20 – 22 mm in size
hCG timing
ALWAYS TIME HCG WITH FOLLICLE SIZE
Ovulation to be confirmed by
• Disappearance of the follicle• Presence of free fluid in the cul-de-sac.• Presence of hyperechoic , smooth
secretary endometrium.
Timing of insemination
IUI is done 36 - 38 hrs. after hCG
injection
Premature LH surge• Premature LH surge is known to occur in
approx 15-25 % of patients once the leading follicle is 16 mm.
• Urinary LH kits are available to detect LH surge.
A blood level of >10 IU /L correlates with the LH surge
Premature LH surge• If an LH surge is detected , injection hCG
is given immediately.
• The hCG injection is required to supplement the LH secreted by the body as it is not adequate enough to induce the final maturational changes in all the follicles .
IUI is done 24 hrs after the LH surge
To conclude
“ In the hands of experienced operators , ultrasound and ultrasound alone suffices for cycle monitoring .”
NEED OF EXTENSIVE HORMONAL MONITORING IS NO LONGER NEEDED
All The Best to all of you to design your own Minimal
Monitoring Protocol
THANK YOU FOR HEARING ME OUT