Asymmetric Follicular Growth. /Asynchronous follicular response.
Prevent premature rise of FSH in previous cycle at day 23/ 25 I e the time what
scientists call
luteofollicular transition by OCP, agonist, only progesterone in
pretreatment cycle.
Comments
·
Q.1. What
is the cause/ causes of nonuniform growth of follicles in natural cycles /
Stimulated cycles (non-ART/ ART cycles ) ? Ans:--Causes are unrecognized
raised LH, androgens, high progesterone or high oestrogen in early follicular
phase, All such mild elevations can lead to and can disturb symmetrical
follicular growth & thereby adversely affect oocyte too.
Q.2: What is the overall outcome?? Ans: asymmetrical follicular profile or non uniform growth can in prevented in a large majority of good responder by correcting the adverse offending hormonal imbalance but such may not be possible in poor responders.
Q. 2B What is the definition of Asymmetrical follicular growth:?? Ans: When lead follicle are larger than 4 mm of rest of majority follicles..
Q. 3. What is nonendocrine causes of such an abnormal /asynchronous follicular response : Ans: Scientists believe that It is the differential fsh threshold of antral and preantral follicles. Those follicles which are having least threshold( more responsive even in low dose of FSH) start growing earlier and at a faster speed .
Q. 4: What may be solutions?? Ans: There are three ways to synchronizes follicles. If no obvious endocrine abnormality is detected / established, as is often the case then intelligent manipulation by some drugs in pre-treatment(cycle prior to proposed stimulation) is most relevant and such have to be designed and implemented intelligently preferably by an ART specialist of long experience : It is the luteofollicular transition when we have to react to achieve synchronous growth in next cycle .It is no point to rectify when asynchrony is already in progress(reinstatement cycle) . The very basic principle is that we want to prevent premature appearance or rise FSH rise of luteofollicular transition i.e. very early rise of FSH in later part of previous cycle (pretreatment cycle). This will almost always lead to asynchronous follicles. This have been variously targeted by 1) Pretreatment OCP 1 month/ 2 months 2) Only oestrgen to decrease FSH 3) Only progesterone form day 16 Primolut-N 1 tds in previous cycle for 10 days .It is needless to mention that such pre treatment cycle should be covered by barriers.
Q.5 How can it be prevented inj the indexed cycle? Say, sometimes on stimulation day 6 in CC/ Letroz. In such asymmetric growth-- one can view two/ three follicles already 16 mm while rest all follicles are lagging in the sense that they are very small .In such a set up how optimally one can proceed for further stimulation a) in that cycle without cancellation b) what precautions or adjustments should be made in next cycle-so that uniform /homogenous F growth are reasonably assured??
?
Q. 6 . What is the minimum size of follicle at which trigger can be given and at te same time achieve mature eggs expected?.Ans:-Mature oocytes can be aspirated by ovum pick up when any follicle is more than 14 mm . They usually harbour mature oocytes
Unless it is an empty follicular syndrome discussed on 29-04-20.
Solution 1: Agonist started on previous luteal phase itself will synchronizes the follicle. That is the one of the reason why many ART specialists are still fan of long agonist protocol. But long agonist protocol despite the fact that it is costly, bothersome for couple, requires , frequent follow up & blood testing. Agonist started on previous luteal phase itself will almost always synchronize the follicles.
Solution 2:--One has to control hyperinsulinemia which is often associated with asymmetrical follicular growth:.
Solution 3. For batch IVF if one is using long agonist protocol then this Shoud not be problem. IN that case estrogen progesterone priming before down regulating should solve problem. When more than 50 % crosses 14-15 mm also do give consideration to perifollicular Doppler flow as well as endometrial scoring then can plan trigger in ART cycles.
Trigger-When? To administer trigger when more than 50% growing follicles have crossed 14 mm.
What about in antagonist cycle??
Pretreatment with estradiol in antagonist cycle
In agonist cycles.
In agonist cycles- 1) coasting for 4-5 days and simultaneously use 2) testosterone gel till trigger, continue agonist, 3) resume gonadotropins after 5 days, it will help in catching up growth of less than 10.mm sized follicles.
Prophylaxis :-1) testosterone gel What's the dose of testosterone gel ?It is :-25 mg daily .
2) Estradiol pretreatment before stimulation or before trigger
Q.2: What is the overall outcome?? Ans: asymmetrical follicular profile or non uniform growth can in prevented in a large majority of good responder by correcting the adverse offending hormonal imbalance but such may not be possible in poor responders.
Q. 2B What is the definition of Asymmetrical follicular growth:?? Ans: When lead follicle are larger than 4 mm of rest of majority follicles..
Q. 3. What is nonendocrine causes of such an abnormal /asynchronous follicular response : Ans: Scientists believe that It is the differential fsh threshold of antral and preantral follicles. Those follicles which are having least threshold( more responsive even in low dose of FSH) start growing earlier and at a faster speed .
Q. 4: What may be solutions?? Ans: There are three ways to synchronizes follicles. If no obvious endocrine abnormality is detected / established, as is often the case then intelligent manipulation by some drugs in pre-treatment(cycle prior to proposed stimulation) is most relevant and such have to be designed and implemented intelligently preferably by an ART specialist of long experience : It is the luteofollicular transition when we have to react to achieve synchronous growth in next cycle .It is no point to rectify when asynchrony is already in progress(reinstatement cycle) . The very basic principle is that we want to prevent premature appearance or rise FSH rise of luteofollicular transition i.e. very early rise of FSH in later part of previous cycle (pretreatment cycle). This will almost always lead to asynchronous follicles. This have been variously targeted by 1) Pretreatment OCP 1 month/ 2 months 2) Only oestrgen to decrease FSH 3) Only progesterone form day 16 Primolut-N 1 tds in previous cycle for 10 days .It is needless to mention that such pre treatment cycle should be covered by barriers.
Q.5 How can it be prevented inj the indexed cycle? Say, sometimes on stimulation day 6 in CC/ Letroz. In such asymmetric growth-- one can view two/ three follicles already 16 mm while rest all follicles are lagging in the sense that they are very small .In such a set up how optimally one can proceed for further stimulation a) in that cycle without cancellation b) what precautions or adjustments should be made in next cycle-so that uniform /homogenous F growth are reasonably assured??
?
Q. 6 . What is the minimum size of follicle at which trigger can be given and at te same time achieve mature eggs expected?.Ans:-Mature oocytes can be aspirated by ovum pick up when any follicle is more than 14 mm . They usually harbour mature oocytes
Unless it is an empty follicular syndrome discussed on 29-04-20.
Solution 1: Agonist started on previous luteal phase itself will synchronizes the follicle. That is the one of the reason why many ART specialists are still fan of long agonist protocol. But long agonist protocol despite the fact that it is costly, bothersome for couple, requires , frequent follow up & blood testing. Agonist started on previous luteal phase itself will almost always synchronize the follicles.
Solution 2:--One has to control hyperinsulinemia which is often associated with asymmetrical follicular growth:.
Solution 3. For batch IVF if one is using long agonist protocol then this Shoud not be problem. IN that case estrogen progesterone priming before down regulating should solve problem. When more than 50 % crosses 14-15 mm also do give consideration to perifollicular Doppler flow as well as endometrial scoring then can plan trigger in ART cycles.
Trigger-When? To administer trigger when more than 50% growing follicles have crossed 14 mm.
What about in antagonist cycle??
Pretreatment with estradiol in antagonist cycle
In agonist cycles.
In agonist cycles- 1) coasting for 4-5 days and simultaneously use 2) testosterone gel till trigger, continue agonist, 3) resume gonadotropins after 5 days, it will help in catching up growth of less than 10.mm sized follicles.
Prophylaxis :-1) testosterone gel What's the dose of testosterone gel ?It is :-25 mg daily .
2) Estradiol pretreatment before stimulation or before trigger
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