Practical tips for monitoring
of an IUI cycle
Dr. Jyoti Agarwal
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.
Who should monitor?
Why add to the burden ?
Do it yourself
“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 .
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
Monitoring Should Be
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Easy
Reliable
Patient friendly
Not expensive
Can be done by self
How to monitor ?
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BY E 2 ALONE
BY ULTRASOUND ALONE
BY BOTH
BY COLOR POWER DOPPLER
BY OTHER HORMONES
MINIMUM MONITORING
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.
Why TVS ?
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Simple
Easy
Reproducible
Reliable
Cheap
Patient friendly
An transvaginal probe is an
extension of clinician’s fingers
‘ marrying palpation with imaging ‘
Importance of D -2 scan
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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)
Follicular size is measured by taking mean of 2 or 3
largest perpendicular diameters of each follicle .
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.
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.
Corelation with serum
oestradiol levels
• Plasma 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.
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.
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
Perifollicular vascularisation
Grade 1 : < 10%
Grade 2 : 10-25%
Grade 3 : 25-50%
Grade 4 : > 50%
Predictors of poor ovarian
response are :
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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.
ENDOMETRIAL EVALUATION
Clear association
between
endometrial
growth and the
circulating
estrogen &
progesterone
levels.
Endocrine implantation
ET – 8 – 14 mm
BEST ENDOMETRIUM ON THE DAY OF HCG TRIGGER
ET > 16 mm or < 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. : < 4 mm
Thickest part of the endometrium
should be measured
D-2
Can show
 anechoic
collection of
blood.
 thick echogenic
endometrial
echo .
 a very thin
endometrium
1-3 mm thick.
D3-7
• Increase in
oestrogenic
biosynthesis leads to
stimulation and
growth of
endometrial glands
and stroma.
• Double line
endometrium is seen
which is usually < 6
mm.
D-7 onwards
• Proliferative
endometrium
continues to grow in
size and thickens and
is seen as a triple
layer or triple
line.
• Middle layer
echogenic—Lumen
In Periovulatory Phase
Triple line progressively becomes thicker,
homogenous and hyperechoic
characteristic changes start only
24 hrs post ovulation.
Applebaum’s uterine scoring system for
reproduction (USSR)
Endometrial evaluation
Conception rates according to zones of
vascularity
• Zone 1 5.2 %
• Zone 2 28 %
• Zone 3 52 %
• Zone 4
74%
COLOR DOPPLER
UT.ARTERY DAY 2
DAY 7-9
PERIOVULATORY UT A.
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)
Cervix and follicular
monitoring
On D – 13 scan
Good cervical mucus
• E2 > 100 pg
• 2 follicles
• ET 7-8 mm
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
18 – 20 mm in diameter.
Leading follicle is
20 – 22 mm in size
hCG timing
ALWAYS TIME HCG WITH FOLLICLE SIZE
Ovulation to be confirmed by
• Disappearance of the follicle
• Presence of free fluid in the cul-de-sac.
• Presence of hyperechoic , smooth
secretary endometrium.
Timing of insemination
IUI is done 36 - 38
hrs. after hCG
injection
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 >10 IU /L correlates with the LH surge
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
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
All The Best to all of you to
design your own Minimal
Monitoring Protocol
THANK YOU FOR HEARING ME OUT