 Hello everyone, I am Dr. Tejashipatika, consultant at Inno-Pission Sonography and Imaging Centre, Nasek. It's wonderful to be on the Indian Radiology Channel. Women's imaging is area of my interest and I have been working in this field since last 8 years. And this is when I have realised the problems faced while correlating molecular monitoring reports in infertility patients and their clinical outcomes. So I have come up with this presentation giving you all the aspects of follicular monitoring in entire cycle. I hope you all will enjoy it and try to implement it in your clinical practice. Thank you. Now we will focus on how to scan process of ovulation on ultrasound and its practical implications. Basically, follicular monitoring is not only measuring size of follicle but it's something beyond that. Now process of ovulation is release of egg from woman's ovary, which is key for conception. In female having regular cycles, ovulation occurs somewhere in between 12 to 16 days. As we all know, there are four phases of menstrual cycle, early follicular phase, late follicular phase, early luteal phase and late luteal phase. Now to understand scanning techniques in follicular monitoring, we need to know detailed physiology of ovulation and how these hormones work in various phases of menstrual cycle. Now let's try to understand this. Hypothalamus releases gonadotropin releasing hormone, which stimulates anterior pituitary to release follicle stimulating hormone. This FSH stimulates follicle to grow and these follicles release estrogen in the form of estradiol. When the follicle is matured and estrogen secretion is at its peak, pituitary receives positive feedback for L.S. surge in a short loop. And this L.S. surge causes ovulation to occur. Now journey of ovulation begins during late luteal phase of prior menstrual cycle. When due to 5 mm size healthy follicles from the population are selected, from which dominant follicle is to be selected for the next menstrual cycle. And this process is called as recruitment. Now during day 1 to 5 of menstrual cycle, the process of follicular selection begins. When follicle of 5 to 10 mm size are selected. During day 5 to 7, the process of dominance begins when the follicle of 10 mm size text control grows at the rate of 2 to 3 mm per day and becomes dominant and suppresses growth of rest of the follicles. During day 12 to day 16, L.S. surge starts and follicle ruptures to cause ovulation. Now this ovulation was initially monitored by conventional methods like basal body temperature, mid luteal serum progesterone levels at day 21st or 22nd and urinary L.S. levels. But nowadays ultrasound is used for follicular monitoring for both natural cycles and stimulated cycles. Now what is follicular monitoring? In normal 28 day cycle, woman ovulates midway anywhere from day 12 to day 16 or she may occasionally felt ovulate. If she ovulates, there is a small window of opportunity roughly 12 to 24 hours for fertilization before this egg degenerates. Now catching this window of opportunity by monitoring cycle and predicting when she is going to ovulate at least 24 to 36 hours in advance gives more accuracy and increased rate of conception. So here with the help of follicular monitoring, we can evaluate growing follicles on the regular interval to catch functionally active follicle and time of its rupture. Now follicular monitoring gives better idea for functional maturity of follicle. It helps in prediction of impending ovulation and optimal timing for HCG administration, for its dose optimization, for IUI, for ovum pickup in IVF cycle and if the woman is not ovulating she can be treated with ovulation induction agent. And this information helps the clinician to avoid random HCG administration which can cause ovarian hypostimulation syndrome. Now this follicular monitoring is done by ultrasound using 2D, color Doppler, power Doppler, pulse Doppler, 3D and 3D pulse Doppler power Doppler if available in your machines. It is always done with the help of transvergenal ultrasound because transabdominal ultrasound means almost 42% of ovarian anatomical details. Now evaluation of complete cycle instead of only pre-HCG scan is essential and this consists of three scans, baseline scan, pre-ovulatory scan and secretory scan. Now baseline scan is done on day 2 or 3 of menstrual cycle whereas serial follicular monitoring is started from day 7 or day 8 of the cycle. Now we will try to understand these protocols in detail. Now in baseline scan follicular monitoring should begin on day 2 to 3 of menstrual cycle when ovaries are in absolute baseline status with no active follicles. And scanning is done with the help of grayscale imaging, color Doppler and power Doppler TBS. Now in baseline scan we evaluate ovarian diameters, ovarian volumes, the countantral follicles and do qualitative and quantitative assessment of stomal abundance by 2D ultrasound. Whereas presence of vessels in stoma is evaluated with the help of color Doppler or power Doppler. And same things can also be better evaluated on 3D ultrasound. Now we need to understand importance of baseline scan. With the help of baseline scan we evaluate ovarian volumes, antral follicular count, stomal blood flow and rule out any cyst from previous cycle which is more than 3 cm which can suppress growth of recruited follicles. So all these parameters are primary determinants of success in the induced cycle. So we expect normal size ovaries with very small follicles that is 3 to 5 mm in diameter. Now measuring follicle size is pretty easy. You just have to measure 2 diameters of follicle perpendicular to each other and take its mean. Now this baseline scan is done to classify ovaries into 4 categories. Normal ovaries, polycystic ovaries, low reserve ovaries and poorly responding ovaries. To predict ovarian reserve and response to assisted reproductive techniques. Coming to ovarian volumes which is very easy to measure in 3 dimensions. Normal ovarian volume is 3.3 to 6.6 cc whereas polycystic ovaries have volume more than 6.6 cc. Low reserve ovaries have volume less than 3 cc whereas poorly responding ovaries can have any volume. Increase volume indicate polycystic ovaries or multi-cystic ovaries whereas a low ovarian volume does not always lead to unovillatory cycles. Coming to a very important parameter that is antral follicle count which is a surrogate marker of ovarian reserve. Now AFC can be done with the help of 2D ultrasound by scanning across whole ovary while counting follicles by eyeballing. Or you can also number the follicles one by one but it has high chances of errors when follicles are multiple as in case of polycystic ovaries. Where counting of AFC is better done by 3D ultrasound which becomes more precise if it is available in your machines. Now normal ovaries have AFC 5 to 12 per ovary whereas polycystic ovaries have AFC more than 15. AFC less than 5 indicate inactive ovaries whereas AFC less than 3 usually signify possible failure of assisted reproductive therapy. Now few machines have facility of 3D technique available and it is complementary method but have very accurate and attractive tools available in it. Like Inversion mode where follicles are seen as colorful solid balls. Sonoevc for automatic volume calculation of AFC. And Vocal for ovarian stomal volume calculation and various vascular indices. Using such tools we can have better accuracy in our reports. Now in 3D technique such a detailed report is auto-generated in machine mentioning number of follicles, dimensions and volume of each follicle. Now here these are normal ovaries on baseline scan. You can see 13 follicles in right ovary and 9 follicles in left ovary. This is a case of polycystic ovary where ovary volumes are increased and we can see 25 follicles in right ovary and 17 follicles in left ovary. These are probably inactive ovaries with AFC 4 to 5 in both ovaries. Coming to ovarian stomal blood flow it has been highly recommended as a good predictor of ART success. Increased PSV more than 10 cm per second is one of such parameter which has been advocated. Now we have already seen the difference between normal reserve ovaries, low reserve ovaries and polycystic ovaries. Follicular maturity can be assessed by plasma stadial level but frequent assessment of blood stadial is very cumbersome procedure. So ultrasound monitoring has totally replaced stadial monitoring in most of the centres. So we do pre-ovillatory scans for assessing follicular maturity. Now the follicle that grows to 12 mm becomes a dominant follicle. It grows at the rate of 2 to 3 mm per day. Usually ovulation occurs at 18 to 24 mm size follicle. Follicular flow can be first detected when the follicular size is 10 mm and its resistance starts falling 2 days prior to ovulation. Now what are features of mature follicle? On 2D ultrasound the mature follicle is rounded with 18 to 20 mm in size. It has thin walls, unecoic contents. It has cumulus uphorus within which is nothing but a small projection from the wall in the follicular lumen which developed 24 to 38 hours before ovulation. There can be a sonolucent halo or separation or infolding of inner layers of follicles. So important things which we should include in our reports are size of follicle, presence of cumulus uphorus and follicular Doppler indices. Now in female with known unovulatory cycles, ovulation induction is done by plomiphen or injection gonadotropin that is HCG. Now the endpoint of any ovulation induction protocol is to identify best time for triggering ovulation. So in gonadotropin cycles ideally the leading follicle should be 18 to 20 mm in size whereas in plomiphen cycle leading follicle should be ideally 20 to 22 mm in size. Earlier follicle size of 16 to 18 mm was considered as optimum parameter for HCG administration for ovulation trigger but it assesses only anatomical maturity of follicle. So vascular changes need to be considered therefore there came an emerging role of Doppler. Now come into follicular Doppler studies. As follicle starts growing its blood supply goes on increasing which is reflected as perifollicular vascularity. And this vascularity is more than three fourth of follicular circumference in matured follicle. Similarly its PSV is going to increase gradually and RI is going to fall. So PSV and RI of the follicle are important parameters to look for. Now a mature follicle has perifollicular vascularity more than three fourth of follicular circumference and PSV more than 10 cm per second and RI between 0.4 to 0.48. Now if follicular vascular indices are not in defined range it means that the follicle is not yet physiologically matured and therefore stimulation still needs to be continued. 24 mm is the follicle size till which one can wait for optimal flow to be achieved. So important points to remember are when PSV of follicle is 10 cm per second there is LH search. Follicle is said to be functionally matured when PSV is more than 10 cm per second which is 36 hours prior to ovulation. Under effect of LH perifollicular PSV keeps on rising constantly and PSV gradually increases from 10 cm per second and reaches almost up to 45 cm per second and R before rupture. So rising PSV and falling RI indicate follicle is proceeding towards maturation. This is how PSV rises when follicle reaches towards ovulation. Now how follicular monitoring help to time IUI? If PSV is more than 15 cm per second single IUI is done 36 to 38 hours after HCG administration whereas double IUI is done at 12 to 14 hours and 36 to 38 hours after HCG administration. This IUI is preferred method for disovulatory infertility, leopathic infertility or male subfertility. So rising PSV with steady low RI suggest follicle is close to rupture. Studies have shown that fertilization of follicle with PSV less than 10 cm per second at ovulation have high chances of embryo with chromosomal abnormalities and decreasing PSV with rising RI suggest that follicle is proceeding towards euthanized and ruptured follicle. Now on the day of HCG if cumulus like ECO is not seen in the follicle it is less likely to be matured fertilizable follicle. So the features of ovulation are disappearance of follicle and presence of cremated follicle and presence of free fluid in cul-de-sac. Now poorly responding ovaries may have any size with low PSV and high RI. So clinicians need high dose of HCG for stimulation of poorly responding ovaries. Now ovarian hyper stimulation syndrome is seen in hyper responsive ovaries. It is a complication of ovarian stimulation treatment for IVF and it is important to diagnose because it has significant risk for miscarriages in early phases after IVF. So it is better to avoid random doses of HCG. More than 4 follicles larger than 16 mm or more than 8 follicles larger than 12 mm is nothing but ovarian hyper stimulation syndrome. Coming to the third scan that is secretory scan. The mature follicle ruptures and leads to formation of corpus luteum which is seen as a cystic structure which has shaggy walls, ground glass ecogeneity within the lumen. Now for doing secretory scan we need to understand function of corpus luteum. The corpus luteum secretes progesterone which stimulates growth of endometrium and prepares it for implantation of fertilized egg or embryo. It is called as luteal phase and is very important in the reproductive cycle. Now corpus luteum is essential for conception to occur and for pregnancy to last. But unfortunately some women have a short luteal phase which lasts for less than 10 days due to failure of corpus luteum to secret enough amount of progesterone. So the uterine lining does not develop properly which makes implantation of fertilized egg impossible causing either infertility or recurrent early miscarriages. And this is called as corpus luteum defect. Colour Doppler ultrasound help in assessing corpus luteum by evaluation of luteal vascularity and can detect luteal phase defect. Now RI of corpus luteum is equal to plasma progesterone levels. Healthy corpus luteum shows surrounding vascular ring RI 0.35 to 0.50 and PSV 10 to 15 cm per second. Abnormal parameters are high RI and low PSV which indicates luteal phase defect. So accordingly if we diagnose corpus luteal defect in women facing infertility, recurrent miscarriages, frequent periods and spotting, the clinician can start proper dose of progesterone supplements after ovulation without the need for additional ovulation boosting medications. Its diagnosis is important because it is highly treatable condition. Now usually the follicle ruptures within 48 hours of HCG administration. But sometimes there is failure of ovulation despite of secondary ovulatory changes in mature follicle leading to formation of luteinized and ruptured follicle. On ultrasound it is seen as a persistent follicle with thick walls for abrasive loss of cystic appearance, luminal ecosgenicity. There is no fluid in POD and high resistance flow is seen on spectral Doppler imaging. Decreasing PSV with rising RI suggests that the follicle is processing towards luteinized and ruptured follicle. Now studies have shown that the incidence of LUF is significantly increased with patient with unexplained infertility who underwent IUI after stimulation with plomifen cycle with high recurrence rate. So in this way by diagnosing LUF syndrome properly we can help our clinician to decide proper treatment so that they can use other options for infertility treatment and increase rate of conception. So to conclude, baseline scan is very important to categorize ovaries. Pre-ovulatory scan is key for decision making, for induction agents in stimulated cycle, predicting time of ovulation trigger to time IUI or for ovum pickup in IVF cycles to achieve better pregnancy rates. It helps in preventing OHS and multiple pregnancy. Secretory scan is equally important to diagnose dutial phase defect and LUF syndrome in patient with sub-fertility, recurrent early miscarriages or unexplained infertility. So in the hands of experienced operator ultrasound and ultrasound alone suffices for cycle monitoring. Thank you very much.