1 / 52

Ovulation Induction

Ovulation Induction. Prof. Dr. Cem FICICIOGLU Yeditepe University Hospital Obstetrics and Gynecology. Foliculogenesis. 60 days. 14 days. 14 days. 1mm. 4-6 mm. 20 mm. Gougeon, 1982. FSH Treshold. FSH. Ovula ti on.

paulinev
Télécharger la présentation

Ovulation Induction

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Ovulation Induction Prof. Dr. Cem FICICIOGLU Yeditepe University Hospital Obstetrics and Gynecology

  2. Foliculogenesis 60 days 14 days 14 days 1mm. 4-6 mm. 20 mm. Gougeon, 1982

  3. FSH Treshold FSH Ovulation Atresia Atresia Baird DT: J Steroid Biochem 27: 15-23, 1987

  4. Ovulation Induction • alone, • Prior to an IUI ( =< 2 follicles) • Prior to an IVF (>5 follicles)

  5. Factors • Demographical ( age, weight…..). • Causes: • OI+Coit • IUI • IVF / ICSI.

  6. Preparation • Treatmen of the causes ( weight loses, PCO + Obesity ) • BMI should be 20-25 kg/m2 • General health status ( anemia ) • Folic support, • Spermiogram/HSG • Hormonal profile

  7. Methods

  8. Ovulation Problems Group I Hipogonadotropik hipogonal anovulasyon ( %10 ) Group II Normogonadotropik normoöstrojenik anovulasyon-PCO (%70) Group III Hipergonadotropik hipoöstrojenik anovulasyon (%10) Group IV Hiperprolaktinemik anovulasyon (%10)

  9. Group III Anovulation • FSH , LH N, E2 • Premature Ovarian Failure • Overian Resistans

  10. Old Gynecologic Exam Vaginal smear Basal Body Temp Progesterone New Basal body temp Serial Ultrasonography E2 levels LH kit Ovulation Follow up Methods

  11. Starting to the treatment • No ovarian cyts • Thin endometrium • ESTRADIOL <50 PG/ML • PROGESTERON <1.6 NG/ML

  12. OI for IUI • Aim Monofollicular development. • Close up follow up. • Dosage should be adjusted based on response.

  13. For < 4 folficular development • CC (clomiphene Citrate). • CC ± FSH veya± HMG. • Aromatase Inhibitors • Gn. Standard step-up protokol. • Gn. Low dose step-up protokol. • Gn. Low dose step-up, step-down protokol.

  14. Cycles Cancellation • >3 Dominant Follicles • ESTRADİOL (E2 )>1500 PG/Ml • DOMİNANT Follicule ( - )

  15. HCG timing • Follicular diameter: 16-18mm • E2 150-250 pg/ml / per dominant foll. • Doz  2.000-10.000 IU • Early HCG -atresia, LUF • Late HCG -postmaturity

  16. SERMs • Binding to Er  ve Er  receptor • Clomiphene • Tamoxifen • Raloxiphene • Bazedoxifene

  17. Clomiphene Citrate(CC)

  18. CC • 2 stereoisomer • zu-clomiphene (38 %)(sis) • en-clomiphene (62 %)(trans),

  19. En-clomiphene rapid degradation, • zu-clomiphene  long half life • Both isomere have estrogenic and antiestrogenic activity • Zu-clomiphenehas much more estragenic activity

  20. Absorbation GIS tract.

  21. Anti-estrogenic activity • uterus • cervix • vagina

  22. HYPOTALAMIC E2 RESEPTORS CC  FSH Endometrium and cervical (mukus) Inhibition OVERIAN STIMULATION

  23. CC - Endications • Normogonadotrophic, normoprolactinemic anovulation • PCOS - Anovulation • Unexplained Infertility • Prior IUI • Hipotalamo-hipofizer aks sağlam olmalı!

  24. CC Contrendications • E2< 40 pg/ml • Liver dysfunction • Pregnancy • Overian cyts • Age>35 • FSH>11 IU

  25. CC-Side effects CC- YAN ETKİLER Hot flushes Abdominal tenderness Nausea/vomitting Breast tenderness Visual disturbance Head ache Hair loss Dermatid, Depretion, % 11 7 2 2 2 1. 5 0.3

  26. CC - Treatment • Day 3-5. of the menstruel cycle, 50 mg/g; 5 days • Hiperresponders25 mg/g • No ovulation> 50 > 100 > 150 > 200 > 250 mg/g

  27. When HCG • Follicular diameter18-20mm, • 34-40 hours laterovulation

  28. Ovulation: USG Findings • Disappearnece of the follicles • Shrinkage of the follicles • Corpus Luteum • Fluids in the Douglas

  29. Ovulation:Midluteal Progesterone • >= 5 ng/ml ovulation >= 9 ng/ml pregnancy?

  30. CC-Results • Ovulation: %60-80 • Pregnancy: %20-40 • Multiple Pregnancy: %10 • Abortion : %20

  31. CC Failure • 3 cycles, max dosage CC (150 mg) No ovulation • No pregnancy after successful 6 treatment cycles

  32. CC Resistans Alternative Treatments • Weight loss (BMI) • İnsülin sensitizer agents + CC (metformin 3x500mg, 2x850mg) • Corticosteroids (Deksametazon 0.5 mg/gün) + CC (DHEAS ) • Prolaktin inhibating agent + CC • Aromatase inhibitors • Gonadotrophins + CC • Gonadotrophins • IUI + CC

  33. Insulin Sensitisizer Drugs Hiperinsulinemia • Folliküler gelişimin artan androjen düzeyi ile negatif etkilenmesi • CC cevabının bozulması

  34. Metformin • Glucose decreases Hepatic production ↓ Bowel Absorbtion ↓ LH ve Androgens ↓ Normal blood glucose does not decrease with Metformin

  35. MetforminSide Effects Anorexia,Nausea, Vomitting Diarrheae, constipation, Vit. B12 levels↓ Aplastic anemia, Hemolitic anemia, Trombositopenia, Agranülositosis Laktic asidoz

  36. Tamoxifen HIPOTALAMIC E2 RESEPTORS TAMOXIFEN FSH Endometrial stimulation OVERIAN STIMULATION

  37. Tamoxifen • Pregancy rates looks like CC • Spontanous abortion rate  lower than CC • No side effect to the cervical mucus • Pts with breast cancer can use this for OI.

  38. Aromatase Inhibitors (AI)

  39. Aromataz • Aromatase, an enzyme • Ovarium, • Adipouse tissue, • Muscles, • Liver, • Breast has Aromatase enzyme • Aromatase transforms androgens to estrogens (with FSH stimulation)

  40. Androstenedion Testosteron Aromatase Aromatase Estron Estradiol

  41. ANDROGENS AROMATASE ESTROGENS HYPOTALAMUS FSH    Overian Stimulation

  42. Aromatase Inhibitors • Blocks the E2 reseptors (reversible) • No negative effects on Endometrium and Cervical muucus. • Multiple Pregnancy and OHSS risks are low

  43. Aİ

  44. AI-Endications • CC resistans PCOS • Poor responders • Breast cancer

  45. Aİ Contrendications Hipersensitivity Pregnancy Laktation Renal insufficiency

  46. Aİ - Dosage • 2.5 – 5 (1-2 ) mg / day 3-7

  47. AISide effects • Headache (6.9%) • Nausea (6.3%), • Periferal Edema (6.2%), • Fatigue (5.2%), • Hot flushes(5.2%), • Bone and back ache(4.8%), • Rash (3.4%)

  48. Gonadotrophin Treatments ART WHO-Grup I WHO-Grup II Normogonadotrophic patients Hipogonadotrophic patients

  49. Gonadotrophins CONTRENDICATIONS • Overian Failure • Hiperprolactinemia • No cooperation with patient

More Related