Practical tips for monitoring of an IUI cycle

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Practical tips for monitoring of an IUI cycle
Dr. Jyoti Agarwal
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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.

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Who should monitor?
Why add to the burden ?

• Do it yourself

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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 .

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Five Reasons To Monitor
To 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
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Monitoring Should Be

• Easy
• Reliable
• Patient friendly
• Not expensive
• Can be done by self

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How to monitor ?

• BY E 2 ALONE
• BY ULTRASOUND ALONE
• BY BOTH
• BY COLOR POWER DOPPLER
• BY OTHER HORMONES

MINIMUM MONITORING
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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.

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Why TVS ?

• Simple
• Easy
• Reproducible
• Reliable
• Cheap
• Patient friendly

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An transvaginal probe is an extension of
clinicians fingers
marrying palpation with imaging
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Importance of D -2 scan

• Antral follicle count
• To rule out any cyst.( gt 3 cm)
• Endometrial shedding
• Or any other pelvic pathology
• We expect normal sized ovaries with very small
  follicles
• (35 mm in diameter)
• Follicular size is measured by taking mean of 2
  or 3 largest perpendicular diameters of each
  follicle .

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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.

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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 1820 mm has been found to
  contain a mature oocyte.

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Corelation with serum oestradiol levels

• Plasma estradiol levels correlates closely with
  the stage of development of the dominant follicle
  
• Serum estradiol levels gt200 pg / ml on day 8 of
  stimulation indicates adequate dose of
  gonadotropins.
• Ultrasound monitoring has totally replaced
  estradiol monitoring in most centers.

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Predicting the risk of OHSS

• If there are
• more than 4 follicles larger than 16 mm
• or 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 gt 1500 2000 pg/ml indicates
  risk of OHSS and is advisable to withhold hCG
  trigger.

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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

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Perifollicular vascularisation
Grade 1 lt 10
Grade 2 10-25
Grade 3 25-50
Grade 4 gt 50
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Predictors of poor ovarian response are

• Ovarian volume lt3 cc
• lt 3 antral follicles
• Ovarian RI gt 0.6
• Ovarian PSV lt 5 cm / sec
• Stromal flow index lt 11
• Suggest poor ovarian response
• Higher doses of gonadotropins will be required
  for stimulation.

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ENDOMETRIAL EVALUATION
Clear association between endometrial growth and
the circulating estrogen progesterone levels.
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Endocrine implantation
ET 8 14 mm BEST ENDOMETRIUM ON THE DAY OF
HCG TRIGGER
ET gt 16 mm or lt 7mm Is not associated with good
prognosis
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• Proliferative phase 4- 7 mm
• Periovulatory period 6-10 mm
• Secretory phase 8-12 mm
• Postmenopausal pd. lt 4 mm
• Thickest part of the endometrium should be
  measured

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D-2

• Can show
• anechoic collection of blood.
• thick echogenic endometrial echo .
• a very thin endometrium 1-3 mm thick.

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D3-7

• Increase in oestrogenic biosynthesis leads to
  stimulation and growth of endometrial glands and
  stroma.
• Double line endometrium is seen which is usually
  lt 6 mm.

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D-7 onwards

• Proliferative endometrium continues to grow in
  size and thickens and is seen as a triple layer
  or triple line.
• Middle layer
• echogenicLumen

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In Periovulatory Phase

• Triple line progressively becomes thicker,
  homogenous and hyperechoic

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characteristic changes start only 24 hrs post
ovulation.
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Applebaums uterine scoring system for
reproduction (USSR)
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Endometrial evaluation

• Conception rates according to zones of
  vascularity
• Zone 1 5.2
• Zone 2 28
• Zone 3 52
• Zone 4 74

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COLOR DOPPLER UT.ARTERY DAY 2
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DAY 7-9
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PERIOVULATORY UT A.
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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)

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Cervix and follicular monitoring

• On D 13 scan
• Good cervical mucus
• E2 gt 100 pg
• 2 follicles
• ET 7-8 mm

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Ovulation trigger
The 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
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hCG timing
ALWAYS TIME HCG WITH FOLLICLE SIZE
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Ovulation to be confirmed by

• Disappearance of the follicle
• Presence of free fluid in the cul-de-sac.
• Presence of hyperechoic , smooth secretary
  endometrium.

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Timing of insemination

• IUI is done 36 - 38 hrs. after hCG injection

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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 gt10 IU /L correlates with
the LH surge
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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

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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

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All The Best to all of you to design your own
Minimal Monitoring Protocol
THANK YOU FOR HEARING ME OUT