Ultrasound Monitoring of Ovarian Stimulation
Ovarian stimulation (OS) is an umbrella term covering (i) induction of monofollicular growth in anovulatory women, i.e., ovulation induction (OI), and (ii) induction of multifollicular growth for intrauterine insemination, sometimes referred to as superov
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Ultrasound Monitoring of Ovarian Stimulation Ayse Seyhan, Engin Turkgeldi, and Baris Ata
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Introduction
Ovarian stimulation (OS) is an umbrella term covering (i) induction of monofollicular growth in anovulatory women, i.e., ovulation induction (OI), and (ii) induction of multifollicular growth for intrauterine insemination, sometimes referred to as superovulation, or for in vitro fertilization (IVF), i.e., controlled ovarian stimulation (COS). OI and COS differ in the desired number of growing follicles. While the goal of OI is to grow up to three dominant follicles, conventional COS aims to enable the collection of 10–15 mature oocytes for IVF. OS depends on increasing follicle-stimulating hormone (FSH) supply to the ovary. This is achieved either by increasing endogenous FSH by oral antiestrogens, i.e., clomiphene citrate (CC) or aromatase inhibitors, or by exogenous FSH injections. The choice of medication can have implications for monitoring and management of an OS cycle. Serum FSH levels and the number of FSH responsive antral follicles are the two major determinants of the number of growing follicles. OS typically starts at early follicular phase of a spontaneous or induced menstrual cycle. Multifollicular growth can induce a premature luteinizing hormone (LH) surge before follicular maturation; thus, endogenous LH surge is suppressed by gonadotropin-releasing hormone (GnRH) analogues in COS cycles. When follicles
A. Seyhan, MD Assisted Reproduction Unit & Women’s Health Center, American Hospital, Istanbul, Turkey E. Turkgeldi, MD Department of Obstetrics and Gynecology, Koc University School of Medicine Hospital, Istanbul, Turkey B. Ata, MD, MSc (*) Department of Obstetrics and Gynecology, Koc University School of Medicine, Office M4217, Davutpasa Caddesi No:4, Topkapi, Istanbul 34010, Turkey e-mail: [email protected] © Springer International Publishing Switzerland 2017 S. Guerriero et al. (eds.), Managing Ultrasonography in Human Reproduction, DOI 10.1007/978-3-319-41037-1_9
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are adequately grown, final oocyte maturation requires either imitation of the LH surge by administration of exogenous human chorionic gonadotropin (hCG) or induction of an endogenous LH surge with a GnRH agonist injection in GnRH antagonist-suppressed COS cycles. Even implantation-competent embryos will fail to implant in the absence of a receptive endometrium. Thus, OS also aims to stimulate proper endometrial growth under the orderly influence of gonadal sex steroids. Monitoring of OS enables clinicians to take proper actions required to ensure the growth of the desired number of follicles and adequate endometrial growth, to prevent a premature LH surge, and for occurrence of timely oocyte maturation/ovulation. In the vast majority of cases, transvaginal ultrasound (TVUS) examination of the uterus and the ovaries provides the clinician with adequate information to manage the OS cycle. While follicular growth is directly observed, endometrial growth and appearance inform the clinician of estrogen
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