Dr Jyoti Agarwal Introduction Ovulation induction though sounds simple but there are many obstacles as each patient behaves in a different fashion Variety of drugs and protocols are available ID: 1037047
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1. Practical tips for monitoring of an IUI cycleDr. Jyoti Agarwal
2. Introduction Ovulation induction though sounds simple but there are many obstacles , as 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.
3. Who should monitor? Do it yourselfWhy add to the burden ?
4. “Vision is the art of seeing invisible ” Jonathan swiftIt 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 3 – D and colour doppler have a role to play in managing these infertile patients .
5. 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 pregnancyAll patients to be monitored
6. Monitoring Should Be EasyReliablePatient friendlyNot expensiveCan be done by self
7. How to monitor ?BY E 2 ALONEBY ULTRASOUND ALONEBY BOTHBY COLOR POWER DOPPLERBY OTHER HORMONESMINIMUM MONITORING
8. 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.
9. Why TVS ?SimpleEasyReproducibleReliableCheapCan be done repeatedlyPatient friendlyAntral count/ovarian volume /color doppler/ 3 DAn transvaginal probe is an extension of clinician’s fingers
10. Importance of D -2 scan TVS is performed on day 2 of the cycle to see for 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)Follicles are of clinical importance only when their size is 10 mm Follicular size is measured by taking mean of 2 or 3 largest perpendicular diameters of each follicle .
11. 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.
12. Assessing the follicular maturityThe 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.
13. Corelation with serum oestradiol levelsPlasma 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.
14. Predicting the risk of OHSSIf there are more than 4 follicles larger than 16 mmor more than 8 follicles larger than 12 mmIt is best not to give hCG so as to prevent OHSS and high order multiple births.In case of doubt do serum estradiol levelsEstradiol levels of > 1500 – 2000 pg/ml indicates risk of OHSS and is advisable to withhold hCG trigger.
15. Follicular doppler flow studiesA mature follicle shows vascularity in atleast ¾ th of the follicular circumference & PSV is 10 cm/sec.At this time LH surge starts andThis is the right time to give hCG trigger
16. Interpretation of ovarian indicesRising PSV & steady low RI suggests follicle is close to ruptureDecreasing PSV & rising RI suggests follicle is likely to become LUF.Fertilisation of a follicle with PSV of less than 10 cm /sec may result in an embryo with chromosomal abnormality.
17. Perifollicular vascularisationGrade 1 : < 10%Grade 2 : 10-25%Grade 3 : 25-50%Grade 4 : > 50%
18. Predictors of poor ovarian response are :Ovarian volume <3 cc< 3 antral folliclesOvarian RI > 0.6Ovarian PSV < 5 cm / secStromal flow index < 11Suggest poor ovarian response &Higher doses of gonadotropins will be required for stimulation.
19. ENDOMETRIAL EVALUATIONClear association between endometrial growth and the circulating estrogen & progesterone levels.
20. Endocrine implantation ET – 8 – 14 mm BEST ENDOMETRIUM ON THE DAY OF HCG TRIGGERET > 16 mm or < 7mmIs not associated with good prognosis
21. Proliferative phase : 4- 7 mmPeriovulatory period : 6-10 mmSecretory phase : 8-12 mmPostmenopausal pd. : < 4 mmThickest part of the endometrium should be measured
22. D-2Can showanechoic collection of blood.thick echogenic endometrial echo . a very thin endometrium 1-3 mm thick.
23. D3-7Increase in oestrogenic biosynthesis leads to stimulation and growth of endometrial glands and stroma.Double line endometrium is seen which is usually < 6 mm.
24. D-7 onwardsProliferative endometrium continues to grow in size and thickens and is seen as a triple layer or triple line.Middle layer echogenic—LumenHypoechoic area surrounding the lumen—Endometrium functionalismHyperechoic ring outside—Endometrium basalis
25. In Periovulatory Phase characteristic changes start only 24 hrs post ovulation.Triple line progressively becomes thicker, homogenous and hyperechoic
26.
27. Applebaum’s uterine scoring system for reproduction (USSR)
28. Cyclical Endometrial Changes Power Doppler evaluation
29. Endometrial evaluation Conception rates according to zones of vascularityZone 1 5.2 %Zone 2 28 %Zone 3 52 %Zone 4 74%
30. COLOR DOPPLER UT.ARTERY DAY 2
31. DAY 7-9
32. PERIOVULATORY UT A.
33. 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)
34. Doppler study for uterine receptivity Uterine artery RI 0.60 – 0.80 PI 2.22 –3.16 No pregnancy if VI < 1.0, FI < 31 and VFI < 0.25 Smoking is associated with significantly lower VI and VFI.
35. Subendometrial VascularisationPresence of subendometrial flow is an indicator of good endometrial receptivity If pregnancy occurs in patients with absent subendometrial flow more than half of these pregnancies will result in abortion
36. 3 D power doppler for endometrial receptivityEndometrial volume is a more reliable parameter than endometrial thicknessFavourable endometrial volume is 4.28 – 1.9 ml.No pregnancy occurred if endometrial volume is <1 ml. 3D tells us also about global vascularity of the endometrium
37. Cervix and follicular monitoring On D – 13 scanGood cervical mucusE2 > 100 pg 2 follicles ET 7-8 mm
38. Application of 3 D us for follicular assessmentCumulus may be seen in almost 90 % of the follicles using 3 D usg rendering. Where as it is seen only in 25 % of follicles by 2D usg.On the day of hCG if cumulus is not seen in all the three planes by 3D usg , it is less likely to be mature follicle.3D Infolding of inner cell mass of granulosa layers
39. hCG timing ALWAYS TIME HCG WITH FOLLICLE SIZE
40. 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
41. Ovulation to be confirmed byDisappearance of the folliclePresence of free fluid in the cul-de-sac.Presence of hyperechoic , smooth secretary endometrium.
42. Timing of insemination IUI is done 24 hrs. after LH surge is detectedIUI is done 36 - 38 hrs. after hCG injection
43. serum progesterone and implantationPeriovulatory progesterone levels are used as a predictor of outcome.Elevated levels of serum progesterone in the late follicular phase is associated with diminshed chances of conception.
44. Premature LH surgePremature 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
45. Premature LH surgeIf 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
46. Luteal phase scanA healthy corpus luteum shows a good vascular ring on colour doppler RI of 0.35 – 0.50PI of 0.70 – 0.80PSV of 10 – 15 cm / sec.RI of corpus luteum corelates well with plasma progesterone level which is an index of luteal function.
47. To conclude “ In the hands of experienced operators , ultrasound and ultrasound alone suffices for cycle monitoring , with no necessity for additional hormonal estimations.” NEED OF EXTENSIVE HORMONAL MONITORING IS NO LONGER NEEDED
48. All The Best to all of you to design your own Minimal Monitoring ProtocolTHANK YOU FOR HEARING ME OUT