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

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    • 1. Practical tips for monitoring of an IUI cycle Dr. Jyoti Agarwal Life care IVF center
    • 2. At Certificate Course IUI & Ovarian Stimulation
    • 3. Faculty • Dr. Sharda Jain Prog. Director , Course Chairperson • Dr Jyoti Agarwal Director /Course Co- Chair person • Dr. Aruna saxena Director Course Co- Chairperson • Dr. Jyoti Bhaskar Director • Dr. Abhishek Singh Parihar Director • Dr. Sushma Ved Director
    • 4. 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.
    • 5. Who should monitor? Do it yourself Why add to the burden ?
    • 6. 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
    • 7. Monitoring Should Be • Easy • Reliable • Patient friendly • Not expensive • Can be done by self
    • 8. How to monitor ? • BY E 2 ALONE • BY ULTRASOUND ALONE • BY BOTH MINIMUM MONITORING
    • 9. 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.
    • 10. An transvaginal probe is an extension of clinician’s fingers ‘ marrying palpation with imaging ‘
    • 11. 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) • 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 .
    • 12. 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.
    • 13. 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 > 1500 – 2000 pg/ml indicates risk of OHSS and is advisable to withhold hCG trigger.
    • 14. Follicular doppler flow studies • A mature follicle shows vascularity in atleast ¾ th of the follicular circumference & its PSV is 10 cm/sec. • At this time LH surge starts and • This is the right time to give hCG trigger
    • 15. Perifollicular vascularisation Grade 1 : < 10% Grade 2 : 10-25% Grade 3 : 25-50% Grade 4 : > 50%
    • 16. 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.
    • 17. ENDOMETRIAL EVALUATION Clear association between endometrial growth and the circulating estrogen & progesterone levels.
    • 18. Endometrial Implantation ET – 8 – 14 mm BEST ENDOMETRIUM ON THE DAY OF HCG TRIGGER ET > 16 mm or < 7mm Is not associated with good prognosis
    • 19. • Periovulatory period : 6-10 mm • Proliferative phase : 4- 7 mm • Secretory phase : 8-12 mm • Postmenopausal pd. : < 4 mm Thickest part of the endometrium should be measured
    • 20. D-2 Can show  anechoic collection of fluid.  thick echogenic endometrial echo .  a very thin or thick endometrium
    • 21. D3-7 • Increase in oestrogen synthesis leads to stimulation and growth of endometrial glands and stroma. • Double line endometrium is seen which is usually < 6 mm.
    • 22. D-7 onwards • Proliferative endometrium continues to grow in size and thickens and is seen as a triple layer or triple line. • Middle echogenic layer —Lumen • Hypoechoic area surrounding the lumen— Endometrium functionalism • Hyperechoic ring outside— Endometrium basalis
    • 23. In Periovulatory Phase characteristic changes start only 24 hrs post ovulation. Triple line progressively becomes thicker, homogenous and hyperechoic
    • 24. Endometrium grows at a rate of 0.5 mm / day in the proliferative phase 0.1 mm / day in luteal phase
    • 25. Applebaum’s uterine scoring system for reproduction (USSR)
    • 26. Endometrial evaluation Conception rates according to zones of vascularity • Zone 1 5.2 % • Zone 2 28 % • Zone 3 52 % • Zone 4 74%
    • 27. Cyclical Endometrial Changes Power Doppler evaluation
    • 28. COLOR DOPPLER UT.ARTERY DAY 2
    • 29. DAY 7-9
    • 30. PERIOVULATORY UT A.
    • 31. 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)
    • 32. 3 D power doppler for endometrial receptivity • Endometrial volume is a more reliable parameter than endometrial thickness • Favourable 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 and the endometrial volume
    • 33. Cervix and follicular monitoring On D – 13 scan Good cervical mucus • E2 > 100 pg • 2 follicles • ET 7-8 mm • Good spinbarkiet
    • 34. Application of 3 D us for follicular assessment • Cumulus 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. Infolding of inner cell mass of granulosa layers
    • 35. 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
    • 36. Ovulation to be confirmed by • Disappearance of the follicle • Presence of free fluid in the cul-de-sac. • Presence of hyperechoic , smooth secretary endometrium.
    • 37. 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.
    • 38. Timing of insemination IUI is done 24 hrs. after LH surge is detected IUI is done 38 - 40 hrs. after hCG injection
    • 39. Thank You Say No to Cervical Cancer

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