Planning for IUI: Tips from uncle:-Tips for IUI:-. How to proceed methodically: Tackling OI in a scientific How to proceed methodically: way:
Try to evaluate the relevance of My Pill (high dose estrogen containing pill to increase the SHBGà decrease in testosterone value, Metformin should ideally be routinely in Indian contest and Decdan 0 .5 mg from day 1 to day 20.Proceed as per following algorithm. Selection of women only who exhibit FSH of < 25 mIU/ml.--> then wait for scan report of Day 3,preferably day-3 & TVS, And during basal scan not only one should watch for ovaries for cysts ,endometriomata, preexisting ovarian neoplasm, ovarian tumours but also for one should assess the endometrial cavity as well. Any ovarian cyst below 2 cm diameter can usually be palpated; USG should be repeated before initiating the second cycle too. Hemorrhagic cyst and luteal cysts are quite common, because presence of such cysts will jeopardized the outcome of OI drugs. From 3rd/ 4th cycles this may not be necessary if previous reports are all right and there is no increase in the dosage,
Q. Should we supplement L. phase by progesterone or Inject hCG ?-
1) No. because those who achieve pregnancy after CC:- in them where the levels of serum P is 200-300 % higher .Similarly serum E-2 is also 66% raised in pregnancies arising out of cc. This RAISED value is maintained at least up to 16 Th of pregnancy. Therefore there is less need of P suppl in CC cycles. Level <15 ng/mL are evidence of LPD.
What to do if serum P on day 21 day is < 18 ng/mL , then vaginal P as luteal suppl is essential, or even oral suppl. Additionally the dose of CC /TMX should be increased by cc 50 mg or in case of TX 25 mg.
Q. Is CC more teratogenic than Letrozole?Possibly yes. In Canadian study-it was observed that major malformation rate for pregnancies out of Letrozole were only 1.2% in contrast to 3% in CC induced pregnancies.
Part III. On the treatment cycle step wise proceed is ideal.
A) See & Evaluate ET:-Having selected the type of agent then one should always perform an USG on day 3= see for endometrium. The ideal thickness should be < 6 mm.
If thickness is < 6 mm on day 2/ day 3 à then rpt USG after 2 days a healthy disease –free Endo will usually shrink. If shrinks then go ahead with pres elected selected protocol.
If not ET remains at 6 mm or beyond than investigate for polyp/ Hysteroscopy. Do not initiate OI agents in that cycle.
B) See & re-evaluate ovaries for:-AFC, ANY RESIDUAL FOLLICULAR CYSTS (follicular cysts are usually < 10 mm in diameter and contain clear fluid). One always postpone cycle if solid/ complex cysts are seen I any ovaries disregarding the size of the cyst. If AFC number is > 8-10 per ovary then there is a possibly of triplet or higher order of births & one need to commence with very low dose of CC/TMX.
What to do if there is persistent residual C L Cysts is above 10 mm à then one has to estimate serum Progesterone - then if reports come as >0.9 ng/ml.--> then do not initiate the cycle.
Therefore as thing stands for optimal response the ET should be < 6 mm & there should not be residual ovarian cysts. / Tumors beyond 10 mm. Intercourse planned relation on alt days from day 10 of cycle.
Cycle MONITORING IS CONTEMPLATED PRIMARILY TO AVERT HIGHER ORDER BIRTHS.
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