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.
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
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
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
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
