‘Monitoring’ is a general name for the activities of ultrasound and/or bloodwork testing, to evaluate how a woman is responding to her stimulation treatment. The results of the ultrasound and/or bloodwork are reviewed by the physician, and further instructions for continued treatment are shared by the patient’s nurse.
This is a general explanation of the routine IVF monitoring which all patients undergo during their cycle. But it is not so simple. Often we receive questions like: “what is the best monitoring?”, “should it be done daily?”, “how many scans are needed?”, “Is blood test always necessary”, and many, many, many more!
With this blog I am going to try answering to some of these questions in a very simple way.
Let’s go step by step.
Methods of monitoring
There are basically 2 tools available for monitoring: ultrasound and blood test.
The ultrasound technique used mostly is the 2D trans-vaginal scan. 3D technology can sometimes be added as well as power color Doppler to evaluate vascularization. Trans-abdominal ultrasound (TVUS) is used less but it can be necessary in some cases i.e. when the ovaries are very high in the abdomen.
Hormonal blood testing includes E2 (Estradiol) levels, P (progesterone) and LH (luteinizing hormone). The E2 is produced inside the developing follicle. The blood E2 level helps to the correlate growth of the follicle with maturation of the egg. The blood LH level indicates when a woman is about to ovulate. This helps with the timing of ‘timed intercourse’ and IUI treatment cycles, it is not used in IVF cycles. Progesterone normally rises in serum after ovulation and trigger endometrial maturation necessary for implantation (uterine receptivity). Testing progesterone can be therefore very useful for instance when a premature ovulation of one of the follicles is suspected or in a long stimulation with risk of premature LH surge.
Combining the methods of monitoring
We have established what are the methods available but how shall we use them? Let`s use science and evidence based medicine to help us answer this.
The first controversial question that we tried to answer was whether TVUS and E2 should be combined. Several studies were done and results showed that E2 measurements are unnecessary, time consuming, expensive, create anxiety for the couple and are inconvenient for the women (Rainhorn 1987; howard 1988; Tan 1992). Minimal monitoring (only as less as possible TVUS) showed to have no adverse effect on treatment outcomes and it does not increase the risk of OHSS (Abdalla 1989; Tan 1994; Roest 1995). Based on these results, several IVF programs have abandoned the use of hormonal essay completely without recording any significant change in their outcomes (Kemeter 1989; Vlaisavljevic 1992; Tan 1994).
Many more studies have been conducted after these, investigating different specific outcome of the stimulation cycle like number of oocytes, clinical pregnancy rate and OHSS rate. A study done in 2014 (Gynecol Endocrinol. 2014 Sep;30(9):649-52) clearly showed that adding serum estradiol measurements to ultrasound monitoring does not change the yield of mature oocytes in IVF/ICSI.
Cochrane is a global independent network of researchers and professionals formed to organize medical research findings collecting only high-quality independent evidence to inform healthcare decision-making. In 2008 and then updated in 2014, Cochrane published a systematic review collecting and analyzing together the most reliable and relevant articles on this topic conducted in the UK, France, Spain, Israel and the US with the following results: “This review update found no evidence from randomised trials to suggest that combined monitoring by TVUS and serum estradiol is more efficacious than monitoring by TVUS alone with regard to clinical pregnancy rates and the incidence of OHSS. The number of oocytes retrieved appeared similar for both monitoring protocols. The data suggest that both these monitoring methods are safe and reliable”.
So, what is the best monitoring?
I think the answer to this is personalized monitoring.
We at BFC do not have a “one-size-fits-all” treatment plan for IVF and therefore we do not have inflexible monitoring protocols. We strongly believe in evidence based medicine so we do not practice standard daily combined TVUS and blood test as there is no clinical reason why this would increase your chances of success, nevertheless we know every woman who undergoes IVF treatment is unique. Each couple presenting to an IVF clinic has an individual infertility cause and medical and fertility history. It is essential to customize a unique therapeutic scheme for each couple, offering the opportunity to be flexible during ovarian stimulation. During treatment, your personal physician is monitoring your results, constantly communicating with you and the team about the next best step for your treatment, like asking for an extra ultrasound or blood test, adjusting your medication dosage for your optimal response, and determining the best day for your egg retrieval, taking always into account your personal history.
This is a prerequisite, for achieving the best outcome and defines the success or failure of an IVF treatment cycle.
– Dr Corona