Cycle Monitoring

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NICE guidelines recommend ultrasound monitoring only to measure follicle size and follicle number for patient management during multi follicular folliculogenesis for IVF. Specifically, serum E2 monitoring is not recommended. We have minimized the use of serum E2, P4, and LH measurements during cycle monitoring in our IVF program and still find these helpful in our IVF program for basic ovarian stimulation. We do accept that experienced IVF units may have no difficulty in preventing ovarian hyperstimulation in all their patients without using endocrine measurements. However, we find OHSS still unpredictable to prevent and do recommend serum endocrinology to assist clinical IVF decision-making and minimize OHSS risk. That advice is summarized below.

As clinical knowledge about the nature of IVF cycles accumulates, cycle monitoring has become easier and less complicated. In our IVF program, cycle monitoring initially comprised daily serum E2, LH, and P4 estimations and ovarian ultrasound determinations. Currently, cycle monitoring consists of blood sampling for E2 levels at days 7 and 9 of the cycle and ultrasound scan of the ovary only on day 9. According to the results on day 7, a decision about FSH dose is made using the following criteria:

1. 1000 > E2 < 4500pmol/L—continue with the same dose.

2. E2 < 1000 pmol/L—increase FSH dose [except polycystic ovarian syndrome (PCOS)].

On the second visit (day 9), if six or more follicles are >16 mm and E2 is >4000 pmol/L, hCG will be given the following day, followed by oocyte retrieval 36 hr later. If the criteria for hCG administration have not been met, a third blood sample is necessary to determine the right time for hCG injection and egg pick-up.

About 10% of patients on the IVF program are discharged before egg pick-up. Cancellation criteria in our unit are:

2. Fewer than three follicles >16 mm and E2 less than 3000 pmol/L on day 9 or 10.

3. Serum LH >30 IU/L during a clomiphene citrate cycle.

4. Abnormal finding by ultrasonography.

5. Falling serum E2 levels despite increasing FSH dose,

It is uncertain why all women with regular menstrual cycles do not respond to ovarian hyperstimulation protocols in a satisfactory fashion. We investigated spontaneous menstrual cycles after failure of multiple IVF folliculogenesis in 131 consecutive cycles. Thirty-six percent of the cycles were endocrinologically normal, whereas the rest had a range of endocrine abnormalities including low luteal phase P4, premature P4 elevation, occult ovarian failure, and hyperprolactinemia.

Although the importance of plasma P4 levels at the time of hCG administration is still controversial, most authors concluded that the subtle P4 elevation during GnRH agonist/FSH ovulation induction for IVF/ET does not predict IVF outcome (44). We do not measure serum P4 in down-regulation/FSH cycles. Repetition of the same superovulation regimen after inadequate stimulation in an IVF program results in improved folliculogen-esis in only 10% of our patients. A review of patient history and the previous response to IVF folliculogenesis is therefore necessary before a decision is made about the next stimulation cycle protocol.

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