Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Monitoring
IVF cycle
Prof. Aboubakr
Elnashar
Benha university Hospital,
Egypt
ABOUBAKR ELNASHAR
CONTENTS
I. METHODS OF MONITORING
II. OBJECTIVES OF MONOTORING
1. Prediction of ovarian response prior to COS
2. Monitor t...
Monitoring
close continuous observation ",
monitoring an in IVF-ET cycle
close observation not only of
1. patient’s initi...
I. METHODS OF MONITORING
I. US
1.2D TVUS
2. Power Doppler imaging
3. 3D US.
II. Hormonal
1.E2
2. P
3. LH
ABOUBAKR ELNASHAR
III. Combining US and E2
Controversial.
E2 measurement: unnecessary
Time consuming
Expensive
Anxiety of the couple
I...
Cochrane SR, Kwan et al, 2014
No significant difference in
number of oocytes retrieved
incidence of OHSS
No evidence ...
II. OBJECTIVES OF MONOTORING
1. Prediction of ovarian response prior to COS
2. Monitor the effect of pituitary down-regula...
1.Prediction of ovarian response to Gnt
Aim:
1. Identify poor responder
2. Identify risk of OHSS
Important:
To choose op...
Methods:
AFC, FSH, AMH
 AFC:
 superior to basal FSH.
(Ng et al, 2005)
 ≤6: longer duration
higher dose of Gnt
less ooc...
SELECTION OF PROTOCOL ACCORDING TO
OVARIAN ReserveReserve ‘Low’ ‘Average’ ‘High’
AFC <7 7-14 >14
AMH <1.1 ng/ml 1.1-3.5 >3...
2. Monitoring the effect of pituitary down-
regulation.
Before starting follicular stimulation:
confirm down regulation (...
 TVS:
1. No ovarian cysts
2. Number of small follicles (<8 mm) ≤ 4
3. Endometrial thickness <6 mm predicts down
regulatio...
3. Evaluate whether the dose of GnT is
adequate or not.
1. TVS:
A. 1st US
 D 6 stimulation
In normal responder
Number: 6-...
Day 6 of stimulation
ABOUBAKR ELNASHAR
ABOUBAKR ELNASHAR
B. Follow up
 Daily or Every other day depending on follicle size
 How:
Each follicle is measured in two perpendicular p...
2. E2
In normal responders:
seldom changes the timing of hCG
does not increase PR or the risk of OHSS
(Lass et al, 2003...
Important in
1. If risk for OHSS.
2. Poor responder
E2 D5 stimulation:
•<700 pmol/l: FSH dose is increased by 75-150 u
•U...
4. Prevention of OHSS.
 Predicting of hyper-response
1. Previous history of OHSS
2. The presence of PCOS
3. Younger age
4...
1. US :
a. PCO pattern of response to GnRH before GnT
b. Number of follicles >20
 Number of small & intermediate size (10...
2. E2: High or rapid slope
<1000 pg/ml: No OHSS
>3000-4000 pg/ml: HCG should be withheld
<3500 pg/mL: No OHSS (Asch et al ...
Do not trigger ovulation with the intention of fresh
ET in women who have:
E2>3500 pg/ml or
>20 follicles on US
(NICE, 20...
HCG when?
3 or more follicles of size ≥17-18 mm
Endometrial thickness at least 7 mm
Estrogen levels coinciding with fo...
5. Find the optimal time to give hCG.
Ovulation when?
35-42 h after the onset of LH surge which triggers
resumption of me...
The ovulation trigger is usually timed according to
1. Follicle size and number of follicles
2. E2 concentrations
should ...
OR when?
35-36 hours after the hCG administration.
When most of the follicles are large enough to
suggest the presence ...
US signs of impaired implantation at the time of hCG
administration
1. Endometrial thickness of <7 mm
2. Endometrial volu...
If Endometrial thickness ≤7
1. Prolong ovulation induction until endometrial
thickness of >7 mm is achieved.
2. If pregna...
6. Avoid Cycle cancellation
Define:
discontinuation of ovarian stimulation prematurely
without oocyte retrival.
Incidenc...
The main reasons
1.No or poor egg production (83%)
2.Patient’s personal reasons (10%)
3.Excessive response to ovarian sti...
Indications
1. Follicular growth is delayed:
ovarian stimulation over 10 days:
< 3 follicles > 16 mm & E2 < 600 pg/ml.
2....
P elevation on HCG day:
Progesterone levels are estimated on
day 2 of the menstrual cycle before COS is
initiated
on t...
For prevention:
Use of Low-dose hCG alone in the late COH stages
Flexible antagonist protocol
Use of mifepristone
hCG...
Sandro Steef, 2016
ABOUBAKR ELNASHAR
ABOUBAKR ELNASHAR
Serum LH
It has been observed that LH surge is unlikely to
occur before
Follicle diameter has reached 15 mm and/or
E2 ...
LH Surge Can Be Detected by Measuring
1. Serum LH levels.
2. Metabolites of LH in urine using urinary LH detection
kits.
...
III. Records of Monitoring
Specially designed charts allows us to see all the
relevant characteristics of the cycle at a ...
ABOUBAKR ELNASHAR
CONCLUSION
Two-dimensional ultrasound scanning of follicular
size is still the method of choice for monitoring IVF
cycles...
ABOUBAKR ELNASHAR
You can get:
 This lecture from:
1.My scientific page on Face book:
Aboubakr Elnashar Lectures.
https:...
Upcoming SlideShare
Loading in …5
×

Monitoring ivf cycle

1,712 views

Published on

monitoring ivf cycle
aboubakr elnashar

Published in: Health & Medicine

Monitoring ivf cycle

  1. 1. Monitoring IVF cycle Prof. Aboubakr Elnashar Benha university Hospital, Egypt ABOUBAKR ELNASHAR
  2. 2. CONTENTS I. METHODS OF MONITORING II. OBJECTIVES OF MONOTORING 1. Prediction of ovarian response prior to COS 2. Monitor the effect of pituitary down-regulation. 3. Evaluate whether the dose of Gnt is adequate or not 4. Prevention of OHSS. 5. Find the optimal time to give hCG. 6. Avoid cycle cancellation III. RECORDS OF MONITORING  CONCLUSION 3ABOUBAKR ELNASHAR
  3. 3. Monitoring close continuous observation ", monitoring an in IVF-ET cycle close observation not only of 1. patient’s initial parameters 2. ovarian response to ovulation induction 3. events after completion of the therapy. ABOUBAKR ELNASHAR
  4. 4. I. METHODS OF MONITORING I. US 1.2D TVUS 2. Power Doppler imaging 3. 3D US. II. Hormonal 1.E2 2. P 3. LH ABOUBAKR ELNASHAR
  5. 5. III. Combining US and E2 Controversial. E2 measurement: unnecessary Time consuming Expensive Anxiety of the couple Inconvenient for the woman (Howard 1988; Rainhorn 1987; Tan 1992). Minimal monitoring  no adverse effects on treatment outcome  no incidence of OHSS (Abdalla 1989; Roest 1995; Tan 1994) Some IVF programs have abandoned the use of the hormone assay completely (Kemeter 1989; Tan 1994; Vlaisavljevic 1992). ABOUBAKR ELNASHAR
  6. 6. Cochrane SR, Kwan et al, 2014 No significant difference in number of oocytes retrieved incidence of OHSS No evidence from RCT to support cycle monitoring by US plus E2 as more effective than cycle monitoring by US only on PR and LBR. A large well-designed RCT is needed Until such a trial is considered feasible, cycle monitoring by TV US plus E2 may need to be retained as a precautionary good practice point. ABOUBAKR ELNASHAR
  7. 7. II. OBJECTIVES OF MONOTORING 1. Prediction of ovarian response prior to COS 2. Monitor the effect of pituitary down-regulation. 3. Evaluate whether the dose of Gnt is adequate or not 4. Prevention of OHSS. 5. Find the optimal time to give hCG. 6. Prevention of cycle cancellation ABOUBAKR ELNASHAR
  8. 8. 1.Prediction of ovarian response to Gnt Aim: 1. Identify poor responder 2. Identify risk of OHSS Important: To choose optimal starting dose of FSH. ABOUBAKR ELNASHAR
  9. 9. Methods: AFC, FSH, AMH  AFC:  superior to basal FSH. (Ng et al, 2005)  ≤6: longer duration higher dose of Gnt less oocytes retrieved. increased risk of cycle cancellation before OR  ≥16: High responder ABOUBAKR ELNASHAR
  10. 10. SELECTION OF PROTOCOL ACCORDING TO OVARIAN ReserveReserve ‘Low’ ‘Average’ ‘High’ AFC <7 7-14 >14 AMH <1.1 ng/ml 1.1-3.5 >3.5 Starting FSH dose IU Amp 375 5 225 3 150 2 Protocol Antagonist Microdose flare Agonist stop Natural Modified natural GH Long protocol Antagonist Antagonist ABOUBAKR ELNASHAR
  11. 11. 2. Monitoring the effect of pituitary down- regulation. Before starting follicular stimulation: confirm down regulation (Criteria of suppression): Hormonal assay 1. E2 < 50 ng/ml 2. LH < 5.0 IU/ml, 3. P4 < 1 ng/m ng/ml ABOUBAKR ELNASHAR
  12. 12.  TVS: 1. No ovarian cysts 2. Number of small follicles (<8 mm) ≤ 4 3. Endometrial thickness <6 mm predicts down regulation in 95% of cases 4. Ovarian artery resistance index: 0.9 have the highest specificity and PPV If not: stimulation is postponed assays repeated after 2—4 further days of down- regulation. ABOUBAKR ELNASHAR
  13. 13. 3. Evaluate whether the dose of GnT is adequate or not. 1. TVS: A. 1st US  D 6 stimulation In normal responder Number: 6-8 each ovary With diameter: 11- 12 mm  D4 Stimulation In PCO ABOUBAKR ELNASHAR
  14. 14. Day 6 of stimulation ABOUBAKR ELNASHAR
  15. 15. ABOUBAKR ELNASHAR
  16. 16. B. Follow up  Daily or Every other day depending on follicle size  How: Each follicle is measured in two perpendicular planes. Then, the average of the four largest diameters is calculated.  mean of two, three or four diameters, measured in one or two planes.  Measure the internal diameter of the follicle in two planes and the average diameter is then calculated.  Follicles usually grow by 2-3 mm/d. ABOUBAKR ELNASHAR
  17. 17. 2. E2 In normal responders: seldom changes the timing of hCG does not increase PR or the risk of OHSS (Lass et al, 2003) E2 D6 300 -600 pg/ml  D6 E2 < 60 pg/ml: PR 7.8 % If ok: continue the same dose. If less than that: increase by one ampoule. If greater than that: decrease the dose by ½ -1 amp ABOUBAKR ELNASHAR
  18. 18. Important in 1. If risk for OHSS. 2. Poor responder E2 D5 stimulation: •<700 pmol/l: FSH dose is increased by 75-150 u •US on stimulation D9 or 10. This is a simple way of early discovery that the starting dose has been sufficient. 3. US monitoring shows adequate follicular growth but inadequate endometrial growth {low E production/follicle due to a low endogenous LH level}: add rec LH ABOUBAKR ELNASHAR
  19. 19. 4. Prevention of OHSS.  Predicting of hyper-response 1. Previous history of OHSS 2. The presence of PCOS 3. Younger age 4. Lower BMI 5. High AMH ABOUBAKR ELNASHAR
  20. 20. 1. US : a. PCO pattern of response to GnRH before GnT b. Number of follicles >20  Number of small & intermediate size (10-14 mm) >15  No risk when immature follicles are < 15. {Number of the immature follicles is more important than the number of mature follicles in predicting OHSS. c. Doppler: low intraovarian vascular resistance Combination of E2 & US: best chance for prediction ABOUBAKR ELNASHAR
  21. 21. 2. E2: High or rapid slope <1000 pg/ml: No OHSS >3000-4000 pg/ml: HCG should be withheld <3500 pg/mL: No OHSS (Asch et al 2005) 3500-5999 pg/mL: 1.5% 6000 pg/mL: 38% Cases with severe OHSS are seen with E2 <1500 pg/ml. Small fraction of cases will be with excessive E2: slope of rise of E2 is more accurate (considered if the value is doubled). ABOUBAKR ELNASHAR
  22. 22. Do not trigger ovulation with the intention of fresh ET in women who have: E2>3500 pg/ml or >20 follicles on US (NICE, 2013) ABOUBAKR ELNASHAR
  23. 23. HCG when? 3 or more follicles of size ≥17-18 mm Endometrial thickness at least 7 mm Estrogen levels coinciding with follicle diameter and number (about 1,500-1,800pmol/Lper follicle ≥18mm) If LH and progesterone levels increase early or E2 level plateaus: hCG can be administrated earlier. ABOUBAKR ELNASHAR
  24. 24. 5. Find the optimal time to give hCG. Ovulation when? 35-42 h after the onset of LH surge which triggers resumption of meiosis inside the oocyte Optimal timing of hCG administration is necessary to retrieve high quality oocytes. Too early administration of hCG: more immature oocytes. Too late: high progesterone levels: negative effects on oocytes quality and endometrial receptivity. ABOUBAKR ELNASHAR
  25. 25. The ovulation trigger is usually timed according to 1. Follicle size and number of follicles 2. E2 concentrations should be correlated to the number of mature follicles at the time of hCG administration. As a guide, each mature follicle may produce about 1000 pmol/L E2. 3. Endometrium thickness and morphology 4. LH and progesterone levels ABOUBAKR ELNASHAR
  26. 26. OR when? 35-36 hours after the hCG administration. When most of the follicles are large enough to suggest the presence of mature oocytes. Optimal oocyte recovery and fertilization rates can be obtained from follicles between 14 and 24 mm in diameter. Oocyte recovery rates start to decrease after the follicles exceed 24 mm in diameter. No difference in the oocyte quality obtained from follicles between 18 and 22 mm in diameter: more convenient and predictable planning of oocyte collection. ABOUBAKR ELNASHAR
  27. 27. US signs of impaired implantation at the time of hCG administration 1. Endometrial thickness of <7 mm 2. Endometrial volume <2 cm3 3. Endometrial thickness >14 mm? 4. Absence of multilayered endometrium 5. Uterine artery PI >3.0 6. Absence of subendometrial or reduction in the endometrial vascularized area ABOUBAKR ELNASHAR
  28. 28. If Endometrial thickness ≤7 1. Prolong ovulation induction until endometrial thickness of >7 mm is achieved. 2. If pregnancy is not achieved, in a subsequent cycle the ovulation induction regimen is changed to allow for a better endometrial development. ABOUBAKR ELNASHAR
  29. 29. 6. Avoid Cycle cancellation Define: discontinuation of ovarian stimulation prematurely without oocyte retrival. Incidence 12% of all IVF cycles are cancelled before egg collection. Women's age Cancellation rate Less than 35 7.7-10% 35-37 11.6-14.7% 38-40 14.6-19.5% Over 40 19.1-24.6% ABOUBAKR ELNASHAR
  30. 30. The main reasons 1.No or poor egg production (83%) 2.Patient’s personal reasons (10%) 3.Excessive response to ovarian stimulation and risk of developing OHSS (5%) 4.Medical illness (1%). (SART 2005 and HFEA 2006 Reports). AMH: all cases that was cancelled due to poor response had AMH < 0.4 ng/ml. (La Marca et al., 2006) all cases that was cancelled due to high risk of OHSS had AMH >7 ng/ml. ABOUBAKR ELNASHAR
  31. 31. Indications 1. Follicular growth is delayed: ovarian stimulation over 10 days: < 3 follicles > 16 mm & E2 < 600 pg/ml. 2.OHSS is suspected: each ovary contains > 10 follicles 16 mm & E2 > 3500 pg/ml Ovary size > 80 mm 3. Basal LH is elevated: LH > 10 IU/l or a premature LH surge occurs 4. Elevated serum P4: >1.5 ng/ml is detected prior to ovulation induction. ABOUBAKR ELNASHAR
  32. 32. P elevation on HCG day: Progesterone levels are estimated on day 2 of the menstrual cycle before COS is initiated on the day of hCG. A detrimental effect of PE on PR General IVF population and poor responders: 0.8-1.1 ng/ml High responders: 1.9–3.0 ng/ml. ABOUBAKR ELNASHAR
  33. 33. For prevention: Use of Low-dose hCG alone in the late COH stages Flexible antagonist protocol Use of mifepristone hCG administration when the levels of P>1.0 ng/mL. Aspiration of a single leading follicle use milder stimulation protocols ABOUBAKR ELNASHAR
  34. 34. Sandro Steef, 2016 ABOUBAKR ELNASHAR
  35. 35. ABOUBAKR ELNASHAR
  36. 36. Serum LH It has been observed that LH surge is unlikely to occur before Follicle diameter has reached 15 mm and/or E2 level has reached 164 pg/mL. LH levels should be measured daily once the follicle reaches 15–16 mm to determine the LH surge and the exact time of ovulation. The LH surges that result in ovulation are extremely variable in configuration, amplitude, and duration. ABOUBAKR ELNASHAR
  37. 37. LH Surge Can Be Detected by Measuring 1. Serum LH levels. 2. Metabolites of LH in urine using urinary LH detection kits. Urinary hormone metabolites accurately reflect LH and correspond to serum patterns and thus, a high predictive value for detecting ovulation. Detection of the LH surge by a urinary LH test may have false-negative results. • When peak levels are 40 IU/L • When women have surges of 10 h in duration • When diluted urine is tested A study by Lloyd et al. showed that when LH kits alone were used to time IUI • 36 % of inseminations were timed incorrectly • 15 % of women had already ovulated ABOUBAKR ELNASHAR
  38. 38. III. Records of Monitoring Specially designed charts allows us to see all the relevant characteristics of the cycle at a glance. • Date and day of cycle • Number of developing follicles in each ovary • Dynamics of follicular growth • Endometrial thickness • Type of ovulation regimen • Quantity of medication used • Baseline hormone levels • E2, if required, in the proliferative phase • E2 and P4 on the day of hCG • Any change in the dose and hormonal evaluation done must also noted • Date and time of administration of hCG ABOUBAKR ELNASHAR
  39. 39. ABOUBAKR ELNASHAR
  40. 40. CONCLUSION Two-dimensional ultrasound scanning of follicular size is still the method of choice for monitoring IVF cycles, irrespective of the protocol used for COH. It is the most practical, and is still reliable enough for monitoring ovarian stimulation with gonadotropins. Combining ultrasound monitoring of follicular size with E2 is particularly valuable for monitoring poor responders as well as those at risk for OHSS. ABOUBAKR ELNASHAR
  41. 41. ABOUBAKR ELNASHAR You can get:  This lecture from: 1.My scientific page on Face book: Aboubakr Elnashar Lectures. https://www.facebook.com/groups/2 27744884091351/ 2.Slide share web site 3.elnashar53@hotmail.com  All lectures from: My clinic, 3 Althawra St. Almansura

×