Ultrasound monitoring is the accepted method for monitoring infertility treatment cycles. It allows evaluation of follicle growth, endometrial development, and risk of ovarian hyperstimulation. Transvaginal ultrasound is recommended starting on day 6-8 of stimulation to measure follicle size and number. The leading follicle is typically 18-20mm at the time of hCG trigger. Endometrial thickness should be 7-14mm on the day of trigger. Doppler ultrasound can assess blood flow and predict ovarian response and uterine receptivity. With experienced use of ultrasound alone, additional hormonal monitoring is often unnecessary for cycle monitoring in infertility treatment.

1. Practical tips for monitoring
of an IUI cycle
Dr. Jyoti Agarwal
Director

2. 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.

3. Who should monitor?
Do it yourself
Why add to the burden ?

4. “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 3 – D and colour doppler have a role
to play in managing these infertile patients .

5. 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

6. Monitoring Should Be
• Easy
• Reliable
• Patient friendly
• Not expensive
• Can be done by self

7. How to monitor ?
• BY E 2 ALONE
• BY ULTRASOUND ALONE
• BY BOTH
• BY COLOR POWER DOPPLER
• BY OTHER HORMONES
MINIMUM MONITORING

8. 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.

9. Why TVS ?
• Simple
• Easy
• Reproducible
• Reliable
• Cheap
• Can be done repeatedly
• Patient friendly
• Antral count/ovarian volume /color doppler/ 3 D
An transvaginal probe is an extension of
clinician’s fingers

10. 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)
• Endometrial shedding
• Or any other pelvic pathology
We expect normal sized ovaries with very small follicles
(3—5 mm in diameter)
Follicles are of clinical importance only when their
size is 10 mm
Follicular size is measured by taking mean of 2 or 3
largest perpendicular diameters of each follicle .

11. 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.

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. 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.

14. 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.

15. Follicular doppler flow studies
• A mature follicle shows
vascularity in atleast ¾
th of the follicular
circumference &
• PSV is 10 cm/sec.
• At this time LH surge
starts and
• This is the right time to
give hCG trigger

16. Interpretation of ovarian indices
• Rising PSV & steady low RI suggests follicle is
close to rupture
• Decreasing PSV & rising RI suggests follicle is
likely to become LUF.
• Fertilisation of a follicle with PSV of less than
10 cm /sec may result in an embryo with
chromosomal abnormality.

17. Perifollicular vascularisation
Grade 1 : < 10% Grade 2 : 10-25%
Grade 3 : 25-50% Grade 4 : > 50%

18. Predictors of poor ovarian
response are :
• 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.

19. ENDOMETRIAL EVALUATION
Clear
association
between
endometrial
growth and the
circulating
estrogen &
progesterone
levels.

20. 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

21. • 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

22. D-2
Can show
 anechoic
collection of
blood.
 thick echogenic
endometrial
echo .
 a very thin
endometrium
1-3 mm thick.

23. 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.

24. 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
• Hypoechoic area
surrounding the
lumen—
Endometrium
functionalism
• Hyperechoic ring
outside—
Endometrium

25. In Periovulatory Phase
characteristic changes start only 24 hrs post
ovulation.
Triple line progressively becomes thicker, homogenous
and hyperechoic

27. Applebaum’s uterine scoring system for
reproduction (USSR)

28. Cyclical Endometrial Changes
Power Doppler evaluation

29. Endometrial evaluation
Conception rates according to zones of
vascularity
• Zone 1 5.2 %
• Zone 2 28 %
• Zone 3 52 %
• Zone 4 74%

30. COLOR DOPPLER
UT.ARTERY DAY 2

31. DAY 7-9

32. PERIOVULATORY UT A.

33. 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)

34. Doppler study for uterine
receptivity
Uterine artery RI 0.60 – 0.80
PI 2.22 –3.16
No pregnancy if
VI < 1.0,
FI < 31 and
VFI < 0.25
Smoking is associated with significantly lower VI and VFI.

35. Subendometrial Vascularisation
• Presence of
subendometrial flow
is an indicator of
good endometrial
receptivity
• If pregnancy occurs in
patients with absent
subendometrial flow
more than half of these
pregnancies will result in
abortion

36. 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

37. Cervix and follicular
monitoring
On D – 13 scan
Good cervical mucus
• E2 > 100 pg
• 2 follicles
• ET 7-8 mm

38. 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

39. hCG timing
ALWAYS TIME HCG WITH FOLLICLE SIZE

40. 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

41. Ovulation to be confirmed by
• Disappearance of the follicle
• Presence of free fluid in the cul-de-sac.
• Presence of hyperechoic , smooth
secretary endometrium.

42. Timing of insemination
IUI is done 24 hrs. after LH surge is
detected
IUI is done 36 - 38 hrs. after hCG
injection

43. serum progesterone and
implantation
• Periovulatory progesterone levels are
used as a predictor of outcome.
• Elevated levels of serum progesterone in
the late follicular phase is associated
with diminshed chances of conception.

44. 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

45. 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

46. Luteal phase scan
• A healthy corpus luteum shows a good
vascular ring on colour doppler
• RI of 0.35 – 0.50
• PI of 0.70 – 0.80
• PSV of 10 – 15 cm / sec.
• RI of corpus luteum corelates well with
plasma progesterone level which is an
index of luteal function.

47. To conclude
“ In the hands of experienced
operators , ultrasound and
ultrasound alone suffices for cycle
monitoring , with no necessity for
additional hormonal estimations.”
NEED OF EXTENSIVE HORMONAL
MONITORING IS NO LONGER NEEDED

48. All The Best to all of you to
design your own Minimal
Monitoring Protocol
THANK YOU FOR HEARING ME OUT