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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
www.manipalankur.com
Monitoring……
Maximum success
Minimum complications
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IUI ……..
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Monitoring….
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Modes of monitoring
Serial scan TVS
LH surge (urine strips)
Biochemical assay : E2/LH
www.manipalankur.com
LH Surge
36% of IUI timed incorrectly
Liyod etal1989, hum reprd
False negative in 35% of
Ovulatory cycles,Arici etal
1992,humreprd
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Transvaginal scan monitoring
Easy
Reproducible
Visual image
Diameter
No of follicles
Endometrium
www.manipalankur.com
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
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Starting stimulation
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Baseline scan D2/D3
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Adnexa….
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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.
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Follicular monitoring
1to 3 mm/day
Average of 2 longest diameter
perpendicular to each other
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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
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On the day of hCG cummulus like echoes not visible in all three planes ,it is less
likely to have mature oocyte
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When to give trigger …?
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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
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Perifollicular Doppler - Day of HCG
• Vascularity - 3/4th of the follicle
• RI 0.4 – 0.48 PSV >10 cms/sec
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Perifollicular blood flow
Grade1 <25%
Grade II 26-50%
Grade III 51-75%
Grade IV >75%
BETTER PERFUSION BETTER OOCYTES
HYPOXIC FOLLICLE INCOMP OOCYTES
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When to give hcg..?
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No of follicles……… ideal is 1or 2
Cancel cycle if >= 3 follicles
NICE guidelines
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Eager doctor and overzealous patient
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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
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Preventing OHSS
Low dose stm
Individualized protocol
Agonist trigger
Cancel cycle
Convert to IVF
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Did I really ovulate….?
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Signs of ovulation…..
Disappearance of follicle
Reduction in size/collapsed foll
Free fluid in POD
Homogenous endometrium
Corpus luteum with internal echoes
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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
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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
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Grading/pattern of endometrium
Grade A Grade B
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Grading of endometrium
Grade C
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Applebaum’s endometrial vascularity
zones
Zone 1 :
Endo-myometrial
Interface adjacent to
Zone 2
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Applebaum’s endometrial vascularity zones
Zone 2: hyper echoic endometrial outer layer
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Applebaum’s endometrial vascularity zones
Zone 3 : intervening hypo echoic area
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Applebaum’s endometrial vascularity zones
Zone 4 : endometrial cavity
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Vascularity and pregnancy rate
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Uterine artery doppler
PI of uterine artery
PI > 3 high negative predictive value ,Steer etal
Resistance index (RI)
RI < 0.9
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Pre ovulatory TVS and doppler
Spiral Artery
RI 0.49-0.59
PI 1.1 – 2.3
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Endometrial volume : 3D scan
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What is ideal endometrium..?
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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
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3D scan in IUI
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3D power doppler
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3D power doppler in IUI
www.manipalankur.com
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