Monitoring in iui

Dr Santosh Gupta Consultant-Reproductive Medicine

Manipal Ankur Reproductive Services-MARS

• MS (OBG)2002- Sawai Man Singh medical college & Hospital, Jaipur

• Postdoctoral fellowship- Reproductive Medicine 2010

(Rajiv Gandhi University of Health Sciences, Bengaluru)

• worked as consultant for three years at Gunasheela IVF centreand simultaneously teaching and training of postdoctoral fellows and DNB postgraduates

• Dr Asha Rao award- ISAR 2013 Rourkela for oral presentation on ‘Rescue IVM’

• Prize for presentation ISAR 2012 ,Raipur on IVM in PCOS

• 2nd Prize in International conference, CUTTING EDGE 2011, Bangalore for the presentation on ‘In Vitro Maturation of human oocytes….’,

• Invited faculty at various national conferences..ISAR,ACE

• Publication in international journal of experimental sciences on rescue IVM

Manipal Ankur Andrology & Reproductive Services

Dr Santosh Gupta

MS,FRM (Reproductive Medicine)

www.manipalankur.com

Monitoring IUI


Monitoring……

Maximum success

Minimum complications


IUI ……..


Monitoring….


Modes of monitoring

Serial scan TVS

LH surge (urine strips)

Biochemical assay : E2/LH


LH Surge

36% of IUI timed incorrectly

Liyod etal1989, hum reprd

False negative in 35% of

Ovulatory cycles,Arici etal

1992,humreprd


Transvaginal scan monitoring

Easy

Reproducible

Visual image

Diameter

No of follicles

Endometrium


Combined approach

Ultrasound

And

LH surge

Awonuga etal ,hum reprd 1999

Gp1 : endogenous LH surge : 12% CPR

Gp2 : hCG + endogenous LH surge : 15.6%CPR

Gp3 : hCG without monitoring LH :20.5 %CPR

P value not significant


Starting stimulation


Baseline scan D2/D3


Adnexa….


Normal ovary

Diameter : 2-3 cms

Volume : 3-6 cc

Antral follicle count : 3 – 6

Stromal echogenecity : isoechoic

Stromal flow may be present /absent

If present : RI : 0.60 – 0.65

PSV: 5 – 10 cms / sec.


Follicular monitoring

1to 3 mm/day

Average of 2 longest diameter

perpendicular to each other



Pre ovulatory follicle

.

Ovulation 18-24 mm

Thin walled anechoic

Sonolucent halo 24 hours

prior to ovulation.

Cumulus like shadow 24 -36 hrs

before ovulation

Separation and in folding of inner

layers 6-10hrs before ovulation


On the day of hCG cummulus like echoes not visible in all three planes ,it is less

likely to have mature oocyte


When to give trigger …?


Doppler in IUI

Anatomical maturity variable (16 – 26 mm)

Functional maturity of follicle and endometrium is a

vascular event

2D Doppler vascularity in single plane

3D scan and Doppler : global vascularity of target

organ


Perifollicular Doppler - Day of HCG

• Vascularity - 3/4th of the follicle

• RI 0.4 – 0.48 PSV >10 cms/sec


Perifollicular blood flow

Grade1 <25%

Grade II 26-50%

Grade III 51-75%

Grade IV >75%

BETTER PERFUSION BETTER OOCYTES

HYPOXIC FOLLICLE INCOMP OOCYTES


When to give hcg..?


No of follicles……… ideal is 1or 2

Cancel cycle if >= 3 follicles

NICE guidelines


Eager doctor and overzealous patient


Pregnancy rate and no of follicles

Aim should 1-2 follicles

Meta analysis (Rumste etal 2008,hum reprd)

Only multiple pregnancy rate increases

No of foll Preg rate (OR)

Multiple preg(OR)

2 1.6 1.7

3 2 2.8

4 2 3.3


Preventing OHSS

Low dose stm

Individualized protocol

Agonist trigger

Cancel cycle

Convert to IVF


Did I really ovulate….?


Signs of ovulation…..

Disappearance of follicle

Reduction in size/collapsed foll

Free fluid in POD

Homogenous endometrium

Corpus luteum with internal echoes


Luteinized unruptured follicle

Sudden increase in the size

Thick walled

Usually follicle rupture within 48 hrs of hCG

Luteinized unruptured follicle (LUF)

syndrome is the failure of ovulation

despite secondary ovulatory changes

such as as luteinizing hormone (LH)

peak, a rise of progesterone or the

secretory transformation of the

endometrium


Endometrium

Endometrial thickness

Maximum distance between echogenic interface of

endometrium and myometrium in the plane through

the central longitudinal axis of uterus usually at the

level of fundus

Too thick …..and …..too thin

Kupesic etal ;: no preg : >14mm endometrium

Weiss etal ;: low implantation rate >14 mm

Shapiro etal; : low preg rate ;endometrium <7mm


Grading/pattern of endometrium

Grade A Grade B


Grading of endometrium

Grade C


Applebaum’s endometrial vascularity

zones

Zone 1 :

Endo-myometrial

Interface adjacent to

Zone 2


Applebaum’s endometrial vascularity zones

Zone 2: hyper echoic endometrial outer layer



Zone 3 : intervening hypo echoic area



Zone 4 : endometrial cavity


Vascularity and pregnancy rate


Uterine artery doppler

PI of uterine artery

PI > 3 high negative predictive value ,Steer etal

Resistance index (RI)

RI < 0.9


Pre ovulatory TVS and doppler

Spiral Artery

RI 0.49-0.59

PI 1.1 – 2.3


Endometrial volume : 3D scan


What is ideal endometrium..?


3D/3D power doppler in IUI

Dr Sonal Panchal

Anatomical maturity 16-26mm(variable)

Maturity of follicle and endometrium is a vascular

event doppler

2D vascularity in one plane

3D vascularity in global /target organ

HCG was decided on anatomical as well as 3D

doppler

2500 IUI cycle with superovulation with Gn


3D scan in IUI


3D power doppler


3D power doppler in IUI


Take home message

TVS is most useful tool and

accepted

Follicle and endometrium are

equally important

2D scan should be supplemented

with doppler/3D/3Dpower doppler

careful monitoring will optimize

the success rate

THANK YOU

Health & Medicine

Monitoring in iui