The KARMA Network – How to Understand Your Results

As part of the Investigative Cycle, you will have access to the KARMA Network, our online system of viewing your daily results. This is used as an aid to help you better understand your ultrasound and blood test monitoring. If you have any questions, please don’t hesitate to contact the nursing team for further clarification at 519-570-0090 x 2. The KARMA Network is complimentary for the first cycle and then $30 for 6 months of access.

When you first log in you can select Schedule to see all your upcoming appointments, Flowsheet to see your daily results, Messaging to contact the clinic, or Discussion Forum to chat with other patients.

 

Ultrasound

When you click on Flowsheet, the default view is the Ultrasound report.

In the Endometrium column, the ultrasound staff will record the thickness and brightness of the endometrial lining. The lining increases in thickness as you get closer to ovulation to prepare the lining for a potential pregnancy. The lining sheds every month with your menstruation when you are not pregnant. When you are pregnant, this is where the egg implants and the lining will remain complete.

The endometrium is hyper-echoic early in the cycle and is thin and brighter then the surrounding tissue. As the cycle progresses, it will become more hypo-echoic (darker than surroundings) on outer edges of the lining and after ovulation, the uterus will be mostly iso-echoic, or the same darkness as the other tissues as the lining prepares to shed. When assessing the uterus, we can determine if the appearance is typical at each stage of the cycle.

Uterine contractions are also measured. Early in the cycle, the entire uterus can contract from the cervix to the fundus (top of the uterus). This type of movement is beneficial as it can help draw sperm upwards and into the fallopian tubes. We may also identify the endometrium moving back and forth or “to and fro” as it prepares for implantation. If a pregnancy does not occur the endometrium tends to contract from the fundus toward the cervix as it prepares to be sloughed off.

“Ut art avg PI” measures the resistance to flow of the uterine artery that feeds blood to the uterus. A measurement less than 3 is optimal for this arterial pressure. If it is greater than 3, it could indicate decreased blood flow to the uterus, which may cause the endometrial lining to be affected for implantation of a fertilized egg. The doctor or nursing team will discuss treatment for this if the value remains to be greater than 3 through your investigative cycle.

Right and Left Side Follicle columns show the number of follicles each ovary has. At the beginning of the cycle, there will be small (<0.5cm) follicles called Antral Follicles, that are not currently growing but have the potential to begin maturing. The Antral Follicle Count (AFC) can vary with each cycle and the significance of how many are seen on Cycle Day 3 can be discussed with the nurse or doctor. Usually, one follicle will grow and mature each cycle; this follicle is usually detectable by Cycle Day 9 but may be variable depending on your average cycle length. The follicle tends to grow between 0.1 and 0.2cm daily, but this is variable as well. How the follicle develops will be discussed with the doctor at your review appointment.

There is also a column for Right and Left Cysts, if you have a measurable cyst it will be listed here. Cysts are quite common and usually unremarkable. If there is any concern, this will be discussed at your review appointment with the doctor.

Free Fluid refers to fluid that is within the pelvic cavity; a small amount of fluid in the pelvis can be normal. It has been documented that when ovulation occurs, a larger amount of fluid can be seen because when the follicle ruptures, the released follicular fluid accumulates in the pelvis. This can be helpful when trying to determine if ovulation has occurred.

 

Blood Results

Oocytes (eggs) are too small for ultrasound to see. The blood work we draw helps us determine the presence and the growth of an egg inside the follicle(s). To see your blood results on the Flowsheet, select “Lab” in the Cycle Type drop-down menu and click update view.

LH – Luteinizing Hormone – The final trigger for the maturation of a follicle. The level will generally be steady throughout the cycle and then “surge,” or approximately double in value, one day and the egg will mature and ovulate 36 - 42 hours later.

E2 – Estradiol – This is a type of estrogen that is produced by the follicle, this level can indicate if a growing follicle has a maturing egg inside. As a follicle grows larger or more follicles develop, the E2 level should rise and peak at ovulation where it will then drop after the egg(s) are released. If a pregnancy occurs, E2 will rise again and stay elevated, if no pregnancy occurs, the level drops and menstruation will occur.

Prog – Progesterone – This hormone is responsible for maintaining the lining of the uterus for implantation of the embryo. Like E2, it will rise after ovulation and stay high if you are pregnant but will drop if you are not pregnant.

FSH – Follicle stimulating hormone – Measured on Cycle Day 3, this hormone is sent from the brain to the ovaries, telling them to start producing oocytes. A higher number means that your body has to work harder to get eggs to develop; a value of less than 10 is ideal. This level will be discussed at your review appointment with the doctor.

PRL – Prolactin – This is the hormone that stimulates milk production during breastfeeding. It has fertility-inhibiting properties and can prevent ovulation. It can be elevated due to other reasons such as stress or a physical abnormality of the pituitary gland (where it is produced). If your level is high, treatment would be discussed at your review appointment.

 

Medication

To see your medication on the Flowsheet, select “Medication” from the Cycle Type drop-down menu and click update view.

Verbally Ordered and Ordered is the record of what the doctor instructed you to take that day (either told to the nurse or written down in your chart). Dispensed is the medication that was given to you by the nurse to take home. Administered is the medication that the nurse gave to you directly while you were at the clinic (usually an injection).

Depending on your daily ultrasound and blood work results, the doctor may order more or less medication each day. Depending on the treatment type, they may also trigger ovulation and schedule a procedure.

If you ever have any questions about the type of medication you are given or how much medication to take, call the nursing team at 519-570-0090 x 2.

Progesterone - Preparing the Uterus for an Embryo

by Samantha Wake

Introduction

Inadequate uterine receptivity is responsible for many implantation failures in IVF. In light of this, KARMA IVF has updated the protocol for preparing the uterus for an embryo transfer. Consequently, you may notice some changes to the way medication is administered and you may find you are coming in for additional ultrasound appointments/bloodwork prior to having an embryo transfer; we want you to understand the rationale for this!

Background

At KARMA we predominantly use a ‘Freeze All’ protocol for IVF cycles. This refers to freezing any embryos that have developed into a blastocyst, provided they are of adequate quality, and transferring them at a later date. The main reason for this is that prior to an egg retrieval, the ovaries have been stimulated in order to increase the number of eggs retrieved. The uterine environment may be negatively affected by this and it may hinder the chances of an embryo implanting. It is also dangerous to proceed with a ‘fresh’ transfer when a patient is at risk of ovarian hyperstimulation syndrome (OHSS).

Fresh vs. frozen embryo transfers

We can determine if someone is at risk of OHSS by monitoring their estrogen level; if the estrogen level is high on the day of the hCG trigger (2 days prior to the retrieval), a fresh transfer will not be considered. However, for patients with low levels of estrogen and progesterone, we can consider doing a fresh transfer.

If you are one of these patients, you will be directed to start taking Crinone 2 times a day vaginally, from the day of the retrieval up to the tentatively scheduled fresh transfer date (Day 5) and thereafter. Estrace is not given during a fresh cycle as estrogen is naturally high following a retrieval. You will return to the clinic 4 days after your retrieval for an ultrasound and bloodwork before the final decision to proceed with a fresh transfer is made by the Doctor. If the ultrasound and bloodwork indicate the uterus is not in the best condition to receive an embryo (more on this later!), the cycle will be converted to a “Freeze All’ and the embryo(s) will be stored for future use.

How is the uterus prepared for a frozen embryo transfer (FET)?

It is common practice to prepare the uterine lining in a medicated FET cycle. Estrogen (in the form of estrace) and progesterone (in the form of Crinone and progesterone in oil (PIO)) are administered concurrently to mimic the hormonal conditions that would occur naturally in a cycle. 

Estrace is to be taken 3 times a day orally and 2 times a day vaginally starting on Day 1 of your cycle (first day of full menstrual bleed) until your ultrasound lining check appointment (Day 10-14). At this initial lining check, the sonographer will measure the thickness of your uterine lining. If it is less than 0.7cm, you will continue taking Estrace for a few more days and then repeat the ultrasound. 

Once the nurse confirms the lining has reached a thickness of 0.7cm, you will start taking Crinone 2 times a day vaginally and have your first injection of PIO administered intra-muscularly by the nurse. You will also continue taking estrace. The PIO is administered every other day until the transfer date and once more 9 days later.

You will be asked to come in for another lining check the day before the transfer as a precaution. Following the embryo transfer, you will continue taking Estrace and Crinone for the next 2 weeks until your pregnancy test. It is at the discretion of the medical team whether any more PIO injections are needed following a positive bHCG result.

Why might my transfer be cancelled?

There are many important checks that take place the day before your scheduled fresh or frozen embryo transfer to determine whether the uterine environment is in an optimal state. For example, a uterine lining measuring less than 0.7cm is sub-optimal and will require a repeat lining check the following morning. If it is still not thick enough, the transfer may be cancelled. We use 0.7cm as a cut-off point as we know linings thinner than this are associated with lower pregnancy rates.

The sonographer will be monitoring the uterine muscle contractions during your ultrasound. If there are 3 contractions per minute or more, you will be asked to come in the following morning for a re-check. If the contraction count is still 3/min or higher, the transfer may be cancelled as it indicates high muscular contractile activity of the uterus. This is known to negatively influence implantation and may cause expulsion of the embryo from the uterus.

Your blood will also be drawn on this day to assess your progesterone level. If the progesterone level is above 35ng/mL, the transfer may be cancelled. If your level is below 10ng/mL, your transfer may be pushed back 1 more day to allow for more absorption of progesterone. If it remains too low, the transfer may be cancelled.  We closely monitor your progesterone level because it plays an important role in embryo implantation and maintenance of a pregnancy.

Can ERA improve my chances of a successful FET?

The purpose of ERA (endometrial receptivity assay) is to undergo a mock FET cycle whereby the uterus is prepared with medication in the same way as a FET cycle except, instead of undergoing a transfer on the specified date, a biopsy is taken of the endometrial cells.

These cells are sent off to a genetics lab for analysis to determine on which day the endometrium is most receptive. Patients’ results can range from P+4 to P+7; this denotes how many days of progesterone is needed prior to the embryo transfer date to ensure it takes place during the ‘window of implantation’. Ultimately, this will increase the likelihood of an embryo attaching to the endometrium.

Igenomix™ (the company that analyses the ERA samples) reports that in patients who previously had a regular FET on a non-receptive day and later had an FET on a receptive day (determined by ERA), their pregnancy rate increased from 19.4% to 60%. It is your choice whether you wish to first proceed with this ERA testing cycle before an FET cycle.

Conclusion

Although we are conscious that these extra appointments and injections are time-consuming and make it less convenient for our patients, we are acting based on current recommendations from leading reproductive research with the aim of improving ongoing pregnancy rates across the clinic. If you have any questions about the new protocol or assessments, please ask the nursing staff.