Welcome to my presentation for on my live one anyway, for VC 2021. As Anthony said, we're going to talk about improving your ovulation prediction skills. As if any of you have been to a presentation that I've done, you know, I like to try and keep these things as interactive as possible, so.
It's obviously a little bit of a challenge in the environment we've got, but we've got some poll questions which I'm, I'm hoping will work, and they'll give you a chance to make a little bit of input and keep it as interactive as possible. So, why pick this as a, as a topic? Well, yes, everybody perhaps often thinks about pregnancy detection, and dealing with problem mares in equine reproduction, but after practising it for more years than I care to remember, really predicting ovulation is the.
Is is the core of of what we do, that really forms the bulk of, you know, a typical day if I'm looking at a large number of mayors, the majority of them, I'm going to be looking at with an aim of trying to predict ovulation. So what I'd like to share with you over the next 45 minutes, an hour or so, is what I've found useful over the years to try and help me improve my ability to predict ovulation. I, I'll try and avoid a didactic presentation of just talking to you and I'll try and put in some sort of.
Anecdotes and little tips that I've found useful which are are either you don't find them in textbooks or you, or, or they don't, they, they don't come across very well in text. It's better in this speaking format where where I can engage with you via that way. As, Anthony said at the beginning, I set up equine reproductive.
I, I, I worked for a fair time at the vet school in, in, in the Royal Vet College in London. I did my PhD there on problem mares. I then went into private practise, and 20 odd years ago, we set up equine reproductive Services, which now, after me starting at my own, is now, a, a, a, a core of 6 vets, if you count me still as a consultant, and then of course, during the breeding season, we get more people to help us.
So that's a little bit of my background. I, I have written a number of or or edited a number of textbooks which will contain more information than we're gonna be able to get through in this session today, . Many of those are available, and if not all of them.
I mean, current therapy and equine reproduction is several years old now, but I still think that's a great book for practitioners and, some of the techniques we'll talk about and tips we'll share today, you'll find in that. In that book. Our bigger textbooks are McKinnon's and Squires, Wendy Vahl and Dickon Varner's equine reproduction book, which, I've done a few chapters in, that that's a massive, cover all type book.
And then a neat little book which perhaps isn't quite so well known, an Atlas of equine ultrasonography, which is equine work in general, where ultrasound is applicable, and I did a chapter in that on the problem. So, when we're doing a gynaecological examination, first and foremost, we want to be safe. We want to be safe for everybody.
Preferably, we want stocks. Stocks are just the term we use in case it's not translating well, stocks for, you know, Restraining the mayor, they can be. These, these are moderately fancy ones, but you can have a much simpler type, some kind of restraining device for the mayor.
Not only does it mean you're safer because the mayor's restrained, it means you can have your ultrasound machine nearby, and very importantly, of course, in these days where we're focused in on. Disease, precautions to avoid it, and so on. It's much easier to do everything in a clean environment.
If we're bringing the mare into the one place where we're working, we can have gloves in there, we can sanitise that area, and so on and so forth. So, I think, even if you're not doing large numbers of mares, you should encourage any client who wants you to examine a mare, to, to provide you with a safe environment and. I, I think doing it round the corner of a, of, of, of a box, not only is it, is it not particularly safe, I don't think you relax very well and it's much easier to make mistakes.
So, try and get a a a set of stocks to examine the mare in a safe. Clean environment. Work methodically, as you can imagine, is important in many aspects of veterinary medicine.
The same applies to follicle evaluation. Work methodically, have an organised system of palpating. For me, I, I go and, and palpate the left ovary first, then the left uterine horn down to the uterine body, up to the right uterine horn, and onto the right ovary.
And then I repeat the whole examination. For a second time and check the uterine body on the way out of the mare. Of course, if you want to start with the right ovary, that's absolutely fine.
But whatever, I think, develop a methodical system. And I'm sure you all know that, just be careful and gentle with mares when you're examining them. If you're not able to palpate a structure or the mare's straining quite a lot, well.
Come back another day or another time. Graphically, you can have a look at that. Here's a sort of basic palpation technique.
I actually generally palpate mares with my thumb folded inwards. So, I just think there's then less of a risk of doing some iatrogenic damage to the rectal wall of the mare. And I run my, four fingers, for me, my left hand, I palpate and scan measure my left hand, You can palpate the relevant structures.
Very, very, very important, to always palpate the me thoroughly before going in and doing your ultrasound exam. Several reasons for that. Probably the two most important ones are, although you can see in this graphic we've got or image we've got here, it looks like the uterus and, and, and left and right ovary are all laid out neatly.
In, in, in, in the real. Time situation, of course, they may all be intertwined and, you know, displaced by a full bladder or full intestines. And so doing a basic palpation first allows you to organise a structure such that when you go in and perform your ultrasound exam, everything is going to be in a neat, laid out system for you.
The other reason is, you should make an accurate assessment about how the structures palpate. Ultrasound gives you a massive amount of information, but of course it doesn't give you a direct assessment about the texture of structures. So how soft the follicle is or how firm the uterus feels, for example.
That's a palpation skip. So, after our palpation, we're gonna go on then to do an ultrasound examination, and as you can see, I have my thumb folded over the bottom of, of the cable of the transducer, and I think that's better than having your thumb sort of stuck out when I guess there's a, an increased risk of causing some rectal damage, which we don't want to do. And then similar to the palpation we've just performed, we have this methodical approach, so for me, it's onto the left ovary, then I do the left uterine horn, down into the uterine body, up the right uterine horn, onto the right ovary.
Then I. Repeat the whole process coming back down the right ine horn this time, you try and body, back up the left Uri and horn, and onto the left ovary. And by doing everything twice, I think we minimise the risk of any structures being missed.
Now, part of being methodical is we've got to record that information somewhere. Now, we don't want to record it on the back of your hand, the back of the rectal glove box, whatever. You need some kind of system.
We actually use a loose leaf, and individual sheets of A4 paper in a ring binder file for the, for the largest stud farms. You could use a smaller book or something for, for, if you, if you've only 2 or 3 mares to look at at a premise. But on the large stud.
Farms we go to, we tend to have each mayor with this mere gynaecological record. We, we would have the name of the mare, obviously, to identify it, age, breed, which stallion she's going to, which stud farm she's at, how she's being bred so natural for the thoroughbred mares, then with various types of semen for the sports horse mares, maybe even embryo transfer mare. The owner's name and address, which helps us back at the practise for billing purposes.
Contact details probably would be email address now, of course. History, is she a maiden may, just for those of you who, who, who may be listening from overseas, maiden just means being bred for the first time. Barren means not pregnant.
Generally it means, perhaps left empty last year, no one tried to go in foal last year, or people tried and failed. Or she's an info, mayor that fold this season, and then we give the foaling date. And then we record any endometrial cysts, the presence of them, .
And This system works well for us. I'm not putting it down as the approach that you have to use. You use whatever works for you.
But this kind of recording system has worked well for us. I'm not showing you it's on this, this image slide here, but we would have 6 of these boxes, 123, laid out. And then we have a silhouette diagram, as you can see highlighted by the big arrow, LO and right are just obviously left ovary right ovary.
The date of our examination, how the cervix feels, cervix such an important structure in the mare. Underrated by veterinary surgeons. Too many colleagues don't make an accurate assessment of the cervix.
We'll come on to that a little bit later, but. You know, nail that one down as well. Checking the cervix, if you don't already do it as a, as a, as a a important part of every exam you do, then, I, I would suggest you did.
Uterrus, edoema pattern in the uterus, we'll talk about edoema, may even be some free fluid within the lumen of that uterus. Any treatment we're giving to the mare, if it's a post-breeding check, if we're gonna do a lavage or if we're gonna give oxytocin. If it's a pregnancy check, preg scan, well, we'll give the details of the pregnancy, how large it is, whether we can see the embryo, whether the heartbeat looks good, and so on and so forth.
Now, on the ovaries, we actually have a silhouette diagram there of the ovaries, so we can actually record, draw in on those ovaries. Schematic representations, what we actually feel, and that's really what I've put by that arrow there. What do we record in the ovaries?
Well, we record the presence of the corpus luteum. That's another thing I think has served me so well over the years in an area where I find some colleagues don't quite see the significance of doing that. But every time you examine a mare, be it for follicle evaluation, be it for pregnancy testing, always record the presence of a corpus luteum in the left or right ovary.
And then of course, the title of the talk is follicle evaluation. So we're going to have to record the presence of any follicle. Now I've put in there a question mark.
Any follicle over what size? Any follicle over what size in millimetres do you think you could record? Now, we're going to try one of the poll questions here.
You can see I've put above what size should follicle data first be recorded. So have a think. In your practise, you first record the follicle, 15 millimetres, 20 millimetres, 25, 30, 35, or 40 millimetres.
Now, I can see quite a few of you there not voting. Try to remember it's all anonymous, so, we can't see what you, and you've got to be quite quick with these, a little bit of a snappy thing. We're not gonna have it lingering too long.
I think you get 25 seconds, half an hour. We want them to be bold, don't we? Yeah, I've gotta be bold here guys.
Nobody can, nobody can see you. So this was a little starter for 10 for you. We've got, we've got a few more coming, so you'll be able to see those then.
Do you want me to share those numbers or can you see them yourself, Jonathan? I can see them, Anthony. Can everyone see those?
I don't think so, so it's worth going through them. OK. OK, what we found was we've got 15 millimetres, we had a number said that, 20, a number said that, 25.
The majority of us went for 25, some for 30 and some for 35. Now, I should perhaps say here, I was talking about a typical thoroughbred or warm-blood mare, so obviously if you've got different sorts of mares, you may. You know, there could be a difference, heavy draught mare, they may be over 40 millimetres, smaller pony type mare, they may be younger, so, you know, this is how these things, are.
And I, I should also say there probably isn't really a right or wrong answer, . So, as it happens, . I would be with the people who, I think that I can share results, so can I, yeah, yeah, we've talked about those, you don't have to linger those, but I've shown you those results there.
Most of you went for 25 millimetres now. I'll just close that down and go on to the next. Ignore these, these are, but this is quite interesting actually, because this was a poll, back when, back in the day when we could do live presentations in front of people, and here are pretty similar stats actually, which I think's good, that, that's quite an interesting thing to talk about.
The majority of you have gone for 25 millimetres. Almost half of you in this case, and I think that was a similar figure in, in what we had. And I think that's, that, that, I'll nail my colour to the mast, if I put it there.
That's what I do. Any follicle over 25 millimetres. Now I'm not saying those of you who went for 15 millimetres or 20 millimetres are wrong, I think you will, you're just making quite a bit of extra work for yourself because whilst a follicle can ovulate.
Under 30 millimetres. It's very, very rare. Most times, that follicle will be 30 millimetre plus.
So I don't begin to recall the follicle until it's over 25 millimetres. Now, I did see one or two of you have gone for 35 millimetres. You guys will be a little bit bold.
I think if you're doing that, because I think there is a risk if you don't begin recording the presence of that follicle till it's achieved a diameter of 35 millimetres, you are at risk for missing some of those ovulating. So, all in all, for your typical thoroughbred warm blood mare, I'd go with a follicle over 25 millimetres. So, whilst we're on follicle diameter, I want to make this point, which doesn't always get picked up.
I, I'll have, I realised over many years colleagues would ring me up and say, John, the follicle's gone from 37 millimetres to 39 millimetres. Do you think I should be inseminating that mare, or do you think I should be ordering chilled semen, sending her for covering? They were putting a lot of.
Our emphasis on the fact the follicle had increased in diameter by 2 millimetres. Now, I, I don't, clearly that follicle gone from 37 to 39 millimetres was close to ovulation, and when a follicle's close to ovulation. Well, I don't think follicle diameter.
Is particularly useful because when the follicle is close to ovulation, it's become soft and it's changes its shape. It is no longer spherical. So a follicle diameter is a very useful tool early on through to the middle of the follicular phase.
But as the follicle is in the last 24, 36, 48 hours before ovulation, I think we've got to look at other things because the follicle is so soft, it doesn't have a spherical shape. So, let me have another look, if that isn't quite clear what I'm meaning. Follicle diameter is a useful tool, whilst the follicle retains its spherical shape.
Look, this structure is pretty spherical. It's a roughly 3 centimetre follicle. Just shows you, you only really need to measure 1 diameter, which is all we tend to do in practise, because they're so similar.
So, 28 millimetres that way, 29 that way. This is a follicle, perhaps on day 234 of the follicular face. It is spherical, so we can accurately measure that diameter.
Have, have a look at this follicle here. This is a follicle probably within 24 hours of ovulating. What do we think of that follicle?
What if I said to you, let's measure its diameter? Well, yeah, if I put the calliper from there to there. It's gonna be different than if I put it there to there because it's elongated, it's softening at the bottom.
So my point being, when we're in this phase of 24 to 36 hours before ovulation, I don't think follicle diameter is a particularly important parameter to measure. I think we want to look at these other ultrasound changes. We want to look at an increased egogenicity of the follicle wall.
We want to look at these small ecogenic particles that appear in the follicular fluid. They become better indicators of closeness to ovulation when we're in this last 24 to 36 hours, because, Diametter itself isn't isn't the important characteristic, and I don't think that comes across very well in a lot of, a lot of books. So I just wanted to make that point for you.
Now, mayors always break the rules, as, as many things in nature do. So this next series of slides is, is to try and make that point to you, because not all mayors read the textbook. So let's have a look at what's going on here.
This is an ultrasound image of the left ovary of a mare. What can we see? Well, I, I've obviously put a set of callipers top and bottom, and I've come up with 2.68 centimetres, 27 millimetres.
What are we thinking of that? Oh, pretty small, we wouldn't ordinarily think that was close to ovulation. Because, you know, crikey, I said, well, we only begin recording them at around 25 millimetres plus, so I would be expecting us to examine this over the next, +23, maybe even 4 days before it gets up to 35, 38, 40 millimetres, and then going on to ovulate.
But not so. We've got a 27 millimetre follicle, but what do you think of its shape? What do you think of ecogenic particles in it down there?
So we've got a mixed message here and and that's that's life. Welcome to the world of mares. We've got a mare here with a relatively small diameter follicle, 27 millimetres.
But other signs are giving me the impression she's closer to ovulation. Oh, ain't that a shame? Well, yeah, maybe, but there's nothing we can do about it.
We've got to make as clinicians a judgement what we're gonna do here. So the overarching question for us in this situation, and we've got another poll question here, so I think the clever folks at VBC will be able to put up a poll for you, assuming this mayor has an edoema pattern and an open cervix, so I'm setting the scene. She, she's not, it's not a luteal follicle.
It's a, it's an edoema pattern and an open cervix. When do you think she'll ovulate? Within 12 hours, 12 to 24, 24 to 36, 36 to 48, or above 48.
Now you've gotta, you, you've got to begin to sharpen yourselves up a bit. We want to try and get up to, to most, we've got quite a lot of you lurking out there. I mean it's, it's, you know, forgive me if it, English isn't the first language for some of you, and that's fair enough, but.
Shall I, oh, he's in, in my, my hands his hands and to end the polling. Well, I think we've, we've probably had long enough there, yeah, so good, that's perfect, that's perfect, and you can see those. Yeah, within 12 to 24 hours.
That's good. That's, that's what I think. So if it's any consolation to you that the the the the biggest percentage of went within 12 to 24 hours, that's what I think.
But you could well be wrong with this man. It, it could conceivably, it could certainly be within 12 hours, could be within 36 to 48. So, I think everybody who voted here is, is, is right.
But, sometimes we have to, we use an expression nail your colour to the mast, or, you know, we make a. We make a judgement, and I think within 24 to 36, it's possible within 12 to 24 it's possible. So, I don't know, wherever I was last time.
Yes, they were a little bit braver. They were thinking this mayor, the biggest group were 36 to 48, wherever I did it last. I think that's a little bit, risky.
I, I certainly would be either 12 to 24 or 24 to 36. I, I, I wouldn't be going into 36 to 48 hours, but hey ho, what, what do I necessarily know? The point is, nobody knows for sure with that.
But we've got to make a judgement. So, I, this looks like a poll question, but guys, it isn't, it's, it's just an ordinary slide. I did poll it at somewhere, but it would have been made for the session too long.
I didn't want to go over time. So, I took, I, I, I'm all having a theme on this same slide. We've got a man, which is presenting to us with a smallish follicle, so we've got a smallish diameter follicle in terms of thinking she's close to ovulation.
But we've got other signs saying. She could be close to ovulation because we've got a follicle change in shape, and we've got ecogenic particles towards the bottom. So, that's why in the polling question, I got you all to have a think about when you think that may may ovulate, and a number of you went for 12 to 24, some for 24 to 36, 1 or two of you above 36 hours, some for under 12.
So, who would breed this mare with fresh semen or natural cover if she had edoema and an open cervix? Now, this was . 2/3 of people, wherever I asked or 60%, let's put it that way, not quite 2/3, said yes, they would breed her.
A good 40%, almost half, said no. Now, I would, with fresh semen on natural cover, I would be firmly of the opinion to breed this man. Why?
Because the semen's gonna live with natural cover or fresh AI minimum 345 days. So even if this follicle is gonna take a little bit longer to ovulate, then it's softness and ecogenic particles would think. Well, the semen's still gonna be alive, so I would argue, why take the risk?
Let's get this mare covered. Or inseminated with fresh semen, so I'm making that decision to go ahead and breed this mare, because of the breeding system we we we we we we we we we're selecting. We're using fresh semen on natural cover in this example.
I, and I think all these, these, talks are going to be available on a, on a demand basis. So if, if any of you are wanting to go back and feel so inclined to look at them again, I'm, I'm pretty sure you get the opportunity to do that. Anthony will confirm that at the end, I think, but I'm pretty sure you can.
Because it's quite a conceptual set of slides, is it, but I think it's a good way to illustrate the often problem we get or or situation we get of a mare and, and the follicle diameter not quite correlating with softness and other other things in there. So, remember I said I would breed that mare with fresh semen or or natural cover. Who would breed this mare with chilled semen if she had edoema and an open cervix?
Now. When I polled that, yes, more skewed towards not doing it, because, and I think that's probably right because. I, I, certainly the system in the UK, and I, I don't know whether the majority of you in the UK or wherever you are, semen come that we order chilled comes overnight.
You can make arrangements to pick it up directly, but by and large, it comes overnight. So, the point being here really, look, you know, if, if that mare's ovulated by the time we get the semen, well, the whole thing's a little bit wasted. It seems to me it's going to be very difficult to predict what that follicle's going to do.
So, there could be a, you could back yourself and think, oh well, I'll be able to order that semen and and get it here tomorrow, and she still won't have ovulated. So it's a more difficult decision was the point I was making, to decide to breed this mare with chilled semen. Easier decision for fresh because go get it covered, we know the semen will last.
With chilled semen, we've got the problem of ordering it in a day's time, and then once we've inseminated the mare, she really has to ovulate within 18 to 24 hours of that semen going in. Now finally, in this little scenario, who would breed this mare with frozen semen if she had edoema and an open cervix. What I was looking for here, which was quite good, was no, because with frozen semen.
You've got that semen sitting in the tank. You don't need to pull it out. Don't need to inseminate that mare until she's ovulated.
So if you see a mare like this, which has got, a little bit of, of differing signals, it's giving you a relatively small diameter, but other changes such as shape and follicular particles are giving you the clue she's close to ovulation. Then what you have to do with these mares is just examine them every 6 to 8 hours. There's no way around that.
And don't inseminate them, until you detect an ovulation, because you're examining them regularly with the, you know, she can only have ovulated at most, 456 hours ago, so the ocy should still be viable, so you can quickly take your frozen semen out of the tank, thaw it and put it into the mire. So that's, that's trying to illustrate how not only can we sometimes find mares with different parameters indicating, some one or two indicating a little bit off ovulation, others indicating close. But our decision as to what to do may depend.
On your breeding system. So, there's a lot to think about really with these things. Now, we said follicular particles within the follicle.
Is a sign of that mare being close to ovulation, and that is true. But what do you think here? What can we see here?
We've got a 6.05, so I've measured this follicle at 6 centimetres, 60 millimetres. Now, yes, mares get large follicles, often ovulating around 40 millimetre to 45 millimetre.
60 millimetres is a big follicle for a, for, for a thoroughbred mare, and it's ringing a bit of an alarm bell for me. I, I don't, I was gonna say I don't like to see a follicle that big. I'm not sure like is kind of the thing.
It's, it's not to do with a preference. It's, it's, I, I'm, I'm a little bit, I find a follicle of that size hard to decide what it's going to do. And I find this harder still in this situation because there is a widespread number of follicular particles.
Not only they aren't just in the ventral margin, look, they're kind of spreading almost throughout this whole follicular structure. I don't like to see that neither. I would sooner we just had these ecogenic particles in this lower margin of the follicle.
I don't like to see them widespread throughout all the follicle. So I'm maybe giving you a little bit of a clue. I think we've got this as a, a polling question, a little bit of an easy one, so let's try and get nearly all of you voting here.
After all, it's only a binary choice, so you can take a, take a guess. Will this mare ovulate normally? We've got a 6 centimetre follicle and quite widespread follicular particles.
Now, we've got 11 out of 40, we want to get up better than that. Come on, some of you are lurking out there or. Not voting, so, yeah, come on, let's try and get at least above 20.
Tempt any of you out? Nearly, nearly, it's just like waiting for the last. I've got it to 18, OK, we'll call her.
We'll end it there for you. 84%, good. I, I say good, I don't know, you could, the yes camp could be right, .
My feeling is that that mare won't ovulate normally because I think 6 centimetres is too big, and I think the follicular particles are too widespread. So I don't know for sure, . I don't know for sure, but I think.
I would be in the no camp, and wherever I was, then, yeah, not quite so much. I, I think I'd be quite firmly in the no camp, but could be wrong. You could go back to this mayor tomorrow and.
There there are whites could even be ovulated, but I don't think so, and the two reasons I don't think so are the size. I think it's in inverted commas too big, 6 centimetres and. Too many ecogenic particles, so.
Yeah, I'd be in the, I'd be in the know. I don't think she will ovulate normally. But I'll just make a note, in my, in that mere gynaecological record, I would put query hemorrhagic follicle.
We're not going to talk about abnormal follicles today, but that's what I'm thinking. And those of you who do a reasonable number of mares will know what what we mean by hemorrhagic or anovulatory follicles. That's, that's what I will be tending to think that follicle is gonna do.
It's gonna become an anovulatory hemorrhagic follicle, not ovulate normally. But I could be wrong. Not very often, but I can be.
I'm just gonna try and show you it graphically here, similar sort of thing. I'm gonna block this in a minute, and look, try and stir up those. I'll just show you that again, maybe we'll, we'll try and go to that, look, just having a look at this video.
Lot of particles there in some sort of almost like clumping things that could be a bit of an artefact. And it was quite large. Look at this one, Stranger still, huh?
I mean, you know, it's always hard when you look at structures which look quite bizarre. That, that, that structure looks quite bizarre. But in fact, this was just a hemorrhagic follicle.
It was referred into us at the practise as as a granulosa cell tumour and arian neoplasia, and I, I can fully understand that. It's very hard, . If you don't perhaps examine large numbers of mares to think, oh, goodness me, what on earth is this on this mare's ovary, it's got to be something, you know, it's something large, it's 660 odd millimetres.
It's got all these bands in it. Oh, I, I, I, I remember about granulosa cell tumours. It'll be a granulosa cell tumour.
Well, it isn't this may and again we can't go into a talk on, on ovarian abnormalities. You would notice I did a little bit of that blotting with the, with the transducer. As a, as a rough rule, a helpful guide you might find, if those strands move around when you block them.
That always steers me away from being a granulosis cell tumour and much more likely to be a hemorrhagic, and ovulatory follicle. Of, of course, you, you look at the other ovary in a granule cell tumour is very small, and of course we can do blood samples for In, in, in Hibbing and all kinds of things. So, you know, we can diagnose granulosa cell tumours, relatively straightforwardly, but you get a quick clinical impression, and if you can blot it and those strange looking strands wave around, then it's unlikely.
In, in, in my experience to be a granulosis cell tumour, it's much more likely to be. An anovulatory follicle. OK, we're moving quite nicely through for time.
Now, endometrial edoema. I said we would talk about edoema at the beginning. And great friend of mine, Juan Samper, some of you may know, may have been lucky enough to hear him.
Juan did two papers, he's actually two presentations at the American Association of Equine Practitioners, the AEP. So in 1997, quite a few years ago now, when first documented, or was one of the first to document that there's an edoema pattern. As the mare progresses through the follicular phase, I'm gonna come on in a minute to what we mean by edoema, I'm sure most of you know, Then W 10 years later, did another presentation at the AEP.
Also an end aral edoema, but with a different angle to it, and I'm gonna talk about both of those papers over the next 3 or 4 slides. First off the bat, we've got to establish our grading system. what I would say is it doesn't matter how you grade endometrial edoema.
But you must develop a system that works for you. It's a, it's a relative thing, so it doesn't matter whether you pick scores from uterus E1 to E5, E1 to E3, whether you give it names, slight, moderate, or marked. It does not matter because in essence it's a relative thing, it's what you need to understand, is it more or less than what you saw the day before.
So I'm, I'm, I'm going through my system which we grade edoema, . 0 to 4, or 0 to 3 plus some, some, I think some colleagues in, in the practise do. But whatever, the point being, it does not matter as long as you develop a grading system which works for you, so when you look at the mere record, you know what you meant.
So I, I'd call this a grade one uterus a D. One I'd call this a grade 2, a nice 35 millimetre follicle plus, it'll just be starting to lose its spherical shape. There we've got a grade 3, and, and this would be your grade 4 or 3 plus, whatever you want to call it.
Very, very intense edoema pan, edoema being, it's a it's a bit of a mouthful to say, but it's alternating and intertwining areas of hyper. And hypoecogenicity. So these would be the hyper ecogenic areas.
The black areas would be the hypo ecogenic, and that's, are you trying to deem a score of 4. There's even some free, you know, edoema being fluid within a tissue. We, we, we know about intraluminal fluid in mares.
That's a big problem for those of us in equine reproduction, free fluid within the actual uterine luminum. This mare would appear to have some to meet, you know, a, a small depth of free luminal fluid in, in, in, in, in the uterus. So, this is what we would grade in our practise, a score of 4.
But you know, you use whatever system you like, just use a system. And grading endometrial edoema is really useful because when we think we've got an edoema at its maximal level, Ben Mas don't reach a grade 4, that their maximal edoema pattern is a, is, is an E3. And at that point, that point.
That's when I think I'll be reaching for my ovulatory induction agent, be that HCG Coriollo, or be it a GNRH implant or or a a a a Desloelin injection. Whatever you're gonna use, whatever ovulation induction agent you use, I use maximal edoema pattern, along with other parameters such as size of follicle, . Softness, open cervix and so on, but using that marked, the, the, the endometrial edoema pattern to say right, this is when I think my ovulation induction agent will have most likely to have the best effects.
Now, I think we've got another, polling question here. What percentage of mares have no edoema pattern in the uterus at any stage of the follicular phase? I, I prefer the term follicular phase to ester, but many of you may know it as ester.
The same thing. I'm talking about a mare with a growing follicle, open cervix. Does not develop an edoema pattern.
What percentage do you think it is? And again, folks, there isn't a right or wrong necessarily answer here, . I'm just curious what what you guys think.
And yeah, I know it's a little bit quick, but we we we. I like polling questions, but they are quite time consuming, so I've deliberately cut down the number we're using, so I'm not gonna give you too long to think . And yeah, it's working, there you are, the ones who who are coming up with the answer and getting it it pretty quickly.
10%. That's absolutely fair enough. I would, I, I, I'd be in 5%.
I think it's, it's, it's, it's, it's, it's 5%, possibly even 3 or 4%, but, you know, that's just an observation I have, so, . I certainly would go, go with the, go with the 10%'s perfectly reasonable. I don't know what, out of interest, let's see.
Yeah, similar to you there, probably more to 5. A good number of you went for 10%. I, I just personally think it's less than 10%.
I think it's quite unusual to be monitoring a mare through the follicular phase, and she doesn't develop an edoema path. I'm gonna use that word like again. I don't like to see that.
I get nervous, well, I don't know whether nervous is a slight exaggeration. I don't get nervous about much, but it it it's, it's. The follicle growing, the cervix is open.
That's all looking good, but no edoema patterns developing in this me. Oh dear, I don't like that. Do you know what I do with those myths?
It's an interesting little tip for you. You won't, you won't read this anyway. Do you know what I do with those myths?
Do you know what I think might be happening in them? And I didn't used to believe it was possible. I think there may be a little remnant.
Of luteal tissue. I don't want to get too much into endocrinology, but if you will, an endocrinologist will think this is incredible oversimplification. But of the two steroid hormones, oestrogen and progesterone.
Progesterone is the dominant follicle. You can have, sorry, is the dominant hormone. You can have a.
Three follicles, but if you've got 1 CL that mare will not be in the follicular phase. She won't have an edoema pattern, and she won't show estres if you were able to tease her, and her cervix won't be open. So if I have a mare which is, is, is the follicle is growing, I, I, I'm, I'll obviously be looking at the, the two ovaries, and I'm not seeing an obvious corpus lute, and that's the point.
We, we get, when, when we first observed this phenomenon of not producing an edoema pattern in the practise, we sat down with her, well, what's going on? And we thought, well, I, I don't know, maybe somehow. The oestrogen for the follicle is being suppressed, well, that can only be via progesterone.
Well, I can't see CLs in any of these ovaries. Maybe there's just a kind of remnant of luteal tissue. I took some time to buy into that idea.
Well, I, I think that you either have a CL or you don't. But now I think you can have mares where you cannot see an obvious corpus luteum. But there must be a remnant of luteal tissue.
Of course, you could take blood samples, but I'm, I, I see such large numbers. I haven't really often got time and I want to try and work out an answer for myself as a clinician straight away. So I tell you what we do with those mas.
I asked you that beginning, I'm now going to tell you what we do. We give them a very, very, very low dose of prostaglandin. And it's amazing in how many of those mares with a 30, 35 millimetre follicle.
No edoema pattern. You give the the prostaglandin to them the next day. Marked edoema score and maybe a 38 millimetre, and I feel much more comfortable about going on and breeding those mares.
So, I think it's, it's, it's personally nearer 5% of mares only have no edoema pattern. And when I'm discovering that happening, monitoring the follicle, I'll always give those mares a little touch of prostaglandin. So, here's our, our final poll question I think.
Is it normal? Normal's an interesting word, is it normal for a mare in the follicular phase, estrus to have no edoema pattern in the uterus? Now this I'd like to see.
Moses, what do you think? It's a little bit of a, a kind of play on normal, I think, really. You probably could put is it, is it, well, that was really the point of this slide.
It's, we know it's not usual for a mayor in the follicular phase to have no edem. We've just answered that in the previous slide, so it's not usual. I've kind of moved on to this.
Is it normal? Is it normal for a mayor in the follicular phase to have no edoema pattern? Well, I'm in the no camp, I, I, I I don't think it is normal and.
We, we thought that, and I think, yeah, I don't know where I was. We did a lot of work for this in the Netherlands, and maybe I was in the . I was in the Netherlands when we saw that, .
Because 100%, everybody in that audience said no, it's not normal. And I don't think it is. And we, so I thought, well, we'll do a little bit of work on that.
So I'll tell you what we did. That's what I think, more than 95%. So that's why I said most of you are in the 10%, don't have edoema.
I said it's, it's, it's less than 10%. I said it's 5%. So that's, hence it's my bullet point.
More than 95% of mares have detectable endometrial edoema when in estrus. Meres that do not display edoema when progesterone levels are based on an oestrogen is high, should be considered abnormal. Back, whoa, crikey, possibly some of you weren't born then, but years ago, look, we did this study while I worked at the university in Utrecht for a couple of years, and we had a wonderful endocrinology lab and we found hormone levels were just all wrong.
Our y quality was poor, they didn't ovulate normally. So I think if you don't see an edoema pattern when you have truly got a basal progesterone level, there's something abnormal in that man. Most times, when we see it in practise, most mayors, even if we go with your 10% of, of, of mayors not producing an edoema pan while the follicle's growing.
If you give those meds, . Prostaglandin, which will take their progesterone levels to basal values. Like I said, oftentimes, 90% of times, they will develop an edoema pattern.
So, they, they're, I'm only, I'm saying they're abnormal only when we have got progesterone levels of basal values. So giving those mares prostaglandin isn't gonna do anything because there clearly isn't any luteal tissue to eliminate. Now, What I want to just draw things to a conclusion with is To talk about mas which have this intense edoema pattern, grade 3 or grade 4.
And Normally edoema begins to decrease immediately prior to ovulation. We know that, that most of you know that, and probably all of you, but there are some mares which will ovulate. While still having a marked edoema score.
And this was the gist of Juan Sampa's subsequent second presentation back in early 2000s, I think. And Wang suggested, and I agree with him, that mares which ovulate with a marked edoema score, either that edoema score not reducing, must be considered suspicious of being wind suckers, challenging pneumovagina, challenging air into the uterus, pooling some urine. I irritating the endometrial lining, because irritation will cause edoema.
Edoema doesn't only have an endocrinological, endocrinological basis. If you have a challenge to the uterus, be it wind sucking, setting up a bit of inflammation or urine pooling, again, those mares, don't wait for the edoema score to go to ones and twos in those mares. Before breeding them, because they, they'll they'll catch you out, they'll ovulate with, with a grade 3 or grade 4 edoema pack.
And also mares which are susceptible to fluid accumulation. We know about those, the mares which we need to lavage, oxytocin after breeding. We've talked, you know, any of you'll know, I've talked about that for, for many years now.
These mares susceptible to fluid accumulation. And, and I think that's right. I totally agree with what, Juan Samper, you can go online and, and, and, and, and, and get a hold of that AEP proceedings relatively easily, I think.
He doesn't quite flag up, but, but I always like to point this out, and I think there are two exceptions to that. There are two examples where I think mares will ovulate with a marked edoema score that aren't wind suckers, aren't urine poolers, or aren't susceptible to fluid accumulation. And they are mares which have been given ovullant.
I think Deslorein will drive the follicle to ovulate. So don't, once you've injected a mare with Desloelin or put a, a desserelin implant in a mare. Then I think you are playing a risky game if you wait for the edoema pattern to decrease before breeding the mare.
Desiwein will, will drive that follic to ovulate, even with a marked 3, grade 3, grade 4 edoema score. And the other exception is if you're breeding a mare at Foley, that's the whole talk in itself, whether or not you should breed a mare at Foley, but if you breed a mare at the foalley, the first postpartum ovulation. They will quite often ovulate with a marked endometrial edoema score.
If you wait for that endometrial edoema score to drop down. Then, then I think you're gonna be at risk for missing those mares, not getting them bred before they ovulate, because all this grade 3 edoema, this mare isn't going to ovulate for 24, 36 hours. Oh, bang, go back the next day.
Still got your grade 3 edoema score. The mare's ovulated. You'll see that at Foley's, I promise you.
We did a published a couple of papers on that now. So, this, if you will, would be Wan's first paper on endometrial edoema. Ssays you're just standing heat.
So look, 34567 days of Easter, as he calls it. I, I prefer follicular phase, but it doesn't matter. Endometrial edoema score peaks here, they got to somewhere between 3, 3.5, 36 hours or so before over.
Ovulating. So, we, we kind of know that bell-shaped curve, and that's for the normal, the normal mare. These abnormal mares, mares that may urine pool, that may take in air to challenge the endometrium, or may be susceptible to fluid accumulation post-breeding.
They ovulate still with a marked endometrial edoema score, and that's something very important to remember. And, if you will remember the two exceptions. There are two normal categories of normal mares which will have this endometrial edoema pattern of ovulation.
They're mares which you've put in a, Desslarein implant and the mares which you've bred at foal heat. So, how do we actually know the mare's ovulated? Well, in most cases, relatively straightforward, a 38, 40 millimetre plus anechoic, non-ecogenic, black, whatever you want to describe it, follicle is replaced by, in the 1st 24 to 36 hours, is, is an intensely ecogenic, quite grey, white almost structure, the early corpus luteum.
Let's have a look on. As it happens, this is a left ovary there with two follicles, 240 millimetre follicles. Common enough to see multiple ovulations.
Here they're gonna be slightly asynchronous because this was the next day, when I looked the next day, Pingo, one of the follicles had ovulated, one hasn't. Now, I, I like this slide because it makes a point to. Detecting ovulation is easy if you went the day before.
So, yes, we, we know, if, if we examine this mare on, on Thursday, yesterday, and we look again Friday, oh well, that, that 40 millimetre black follicle's gone. So yes, I can see a fresh ovulation. But a very fresh ovulation can be difficult to detect.
Imagine if you just examined the mare for the first time. On this occasion, you would think, oh, yeah, here we've got a nice 38, 40 millimetre follicle growing. You may well miss not detect that fresh ovulation.
So that can be problematical for you. Of course, the one day on again from that image, oh, it's, oh, yeah, wow. Actually this multiple ovulates.
She's got two follicles, because we've got 2 CLs, 2 corppo lutea. So that's gonna have an impact, of course, when you do your pregnancy detection. Because you're going to look very carefully for twins here.
So yes, notionally it's very easy to detect ovulation with ultrasound, but a fresh ovulation can be quite difficult to detect. So getting used to, I, I, I said at the very beginning, very important to record the number of corpora lute. So, here, look, not actually, it's this slide shows you not only how it's important to count numbers, it shows you the the the num the massive number of appearances.
There's no set appearance for the early corpus luteum. So look, here we've got one CL, quite a degree of central lacuna, some hypoechoic areas there. This may have had a double ovulation, one CL there, one CL there.
This may actually had a triple ovulation, 1 CL there, 1 CL there, and then a third CL in the middle. So try and develop your skill. Excuse me, try and develop your skill for detecting the number of ovulations.
But Also, remember the point that the first time you examine the mirror, it can be quite difficult to see an ovulation. You may have to make your mind up the next day. So, say you examine this mirror, cervix may well still be open, and you think, oh yeah, well, we've got a 25 millimetre follicle growing here, early days.
Mm, OK. What, what can be difficult to see is this. Fresh ovulation here.
I've, I've just outlined it there for you. It can be quite difficult to detect that. But of course, if you go back the next, so I would often write in my book, you know, oh, query, fresh CL.
I can't be sure, none of us can be sure. I'm gonna see this mayor again tomorrow. When you go back tomorrow, you'll see a much more obvious, you know, white ecogenic corpus luteum there.
And just making the point, look at all these different types of CL, some with a lacuna, some more solid. Some with the, you know, there. That's a normal corpus luteum just has a thinnish border of luteal tissue, that can be difficult to detect.
You know, some people can say, oh, that follicle's still there, no, that is ovulated. Just a thinnish border of luteal tissue. And like I say, we'll just finish, we can't get into an ovulatory follicles because it's, it's a topic for another day, but just as we're talking about ovulation, I just want to make the point, .
When you get these abnormal ovulations, they're quite difficult to tell. You can't always be certain. I showed you, you remember I showed you that example of a 60 millimetre follicle with, with those ecogenic particles, and we asked, will that ovulate normally, will it not?
You have to just factor in, well, it's a little bit large, there's a lot of parts. There, it's not going to be, I don't think it's going to ovulate properly. Easy with this structure because it's gone straight from a 35 millimetre follicle to this structure.
The odds are that is not gonna be a normal, you know, you, you haven't had the collapse stage in the refill. That's gone straight to an anovulatory hemorrhagic follicle. But, you know.
It's difficult to tell and and anovulatory follicles are are are really important structures for us to recognise, but they'd be a. They'd be a topic for another day. That's, you've done well to hang on there for that hour folks.
I'll, do you want me to stop sharing the screen now, Antony? No, that's fine, you can keep the screen OK. OK, Jonathan, and if people do have any questions, I'm sure we can.
We can get one or two in, before we finish, then we've got a gap for an hour and we've got Stefanos Clodais gonna be talking about perineal hernias in dogs next, just so everyone knows. You give a varied topics there. We are very very very fabulous you guys.
I would just say I, I saw you if any of you, if anybody comes up with a question later, . I, I, I'm sure Anthony or his team are very welcome. If I don't pick it up on your various apps and things, you're always welcome to forward, the, the, the team will forward them on to me and I'll answer them for you.
So that's great. I, I know some of you maybe don't think of, of, of it at the time, so you, you can forward it on and and Anton and his colleagues will send it to me and I'll, I can get back to you that way, . Which because sometimes you think you, you, they are available to rerun through these, are they, if somebody hasn't.
Yes, they're available for 12 months, so there's plenty of time, and I must say, Jonathan, I, I, I am taken by your COVID curls there. Yeah, yes, you're letting the hair go a bit long. Yeah, yes, yes, I thought that.
It's always hard. I, I love anyone who've been to my talks on the live. I, I, I, I tell quite a few jokes.
It's a little bit harder to tell jokes when you've, in, in a virtual environment, but I would have made a good joke. My hair, I thought it looked marginally better than Boris Johnson's I must say. Well, it, it definitely does.
But I think if it grows a little bit longer, you could get an electric guitar and auction for audition for some of the heavy metal groups. You're always very kind, very kind. Let me see if anybody's come up with any questions just so we'll give.
Well, I often find they want to think of them afterwards, so if somebody does digest it, as I say, they're welcome, but if anyone's got anything burning now, I can. Christopher has just said the small dose of prostaglandinomeral edoema, have you got a dose for that? Yes, yes, let, let's talk a little bit about that.
Let's just set the scene. It's those mares where we're monitoring them during the follicular phase and we, we, we're seeing a follicle grow, and we're, we're doing a speculum exam, we think the cervix is opening but we can't be quite sure. And, and it's so great for us that.
The majority of those mayors will be developing edoema patterns, so once we see edoema, we're home and hosed, we know that that mare is under oestrogen dominance, and she's gonna be ready to be covered or inseminated. Now, the scenario is, we've got this follicle growing. We think the cervix might be open, but we're not quite sure for whatever reason.
But we're not seeing an edoema pack. And what I think happens in the majority of cases, or or is happening in the majority of cases, is there is a remnant of luteal tissue, not such an obvious corpus luteum that you can detect it in the left or right ovary, but there's there there there is is some residual luteal tissue, luteolysis, the start of the follicular phase. We, we didn't get complete luteolysis.
So we've got a remnant of luteal tissue. And we want to give prostaglandin. Now, what, what has been shown is that the, the dose we've been using of prostaglandin, which in the UK or our practise, there are two main types in the UK I think possibly 3 now, but we, we tend to use estromate, which is cloprostinol.
And the dose in the UK, Is 1 ml, but, but under normal circumstances, we only use 0.5 mL. When I'm using it for this low dose, we call it, you know, our stud managers get very, they know what we're doing.
They'll put low dose PG when they know what we're gonna do. We mean for that, literally 0.1 or 0.2 of a mL, so a very low dose of prostaglandin.
I, I actually inject it just we get those 1 CC syringes because well, at most the two c. Cringe. So it's a very low dose of, it would be the same, I don't know, I think, I think loutilize is a bigger dose, as I say, I don't use it, so I can't remember offhand, but it's, it's certainly, it would be about a 50% of what the recommended dose is.
So something like that, Richard, so, yeah, a low dose. I mean, I, it probably doesn't, I'm just we, the difficulty if you give two bigger doses, what, what a lot of people don't remember is that. Prostaglandin actually has a slight luteolytic, yes, has a slight ability to indu LH like activity as well.
So if you give too big a dose, I think that the big follicle that you've got there may go on and ovulate before your prostaglandin has had time to drop the progesterone levels down, the cervix open better and your edoema score develop. So that's why I'd caution you to use a low dose. Whether it's 0.1 of the 0.2 of a mil doesn't really matter.
Don't use the full 1 mL recommended by the manufacturers. I hope that makes sense. That's great, thanks, Jonathan.
It looks at a fabulous picture there and of course, not a lot of social distancing going on, but quite a while ago this photograph. That was quite a while ago, yes, that's quite a while ago. That's out in Switzerland, a lovely part of the world.
It looks beautiful. Let's hope we can start getting out before too long and we will, I might come down to Shropshire and see you again. I'm sure we will and thank you very much for putting this on, Antony, it's great you and your colleagues put .
I mean, you know, this fantastic source of . Of educational content and as a speaker I found it It it's a great way that we can still, you know, we all enjoy teaching and most of us who, who do these do and and without organisations like yours, we'd be, we'd be stuck. So I think it's been a tremendous service and I hope everyone has enjoyed it and well, we'll get something out of it.
So thanks to you and your team, Anthony. As, as I've been saying to people recently, I, I've spent the last 11 years preparing for the pandemic. You were ahead of the game.
I just didn't realise. I just didn't realise. But anyway, it's great to see you.
Fabulous. Thank you so much for the other lectures that you've given, which people can go and view if they've got an interest in this topic. If you haven't got a full, ticket, then do get in touch with us and we can sort you out with one of those.
But it's been great to have you on, Jonathan. I'm going for a little lie down and I think, and then 3 o'clock it's back on with Stefanos on perineal hernias, but thanks once again Jonathan. Thanks everybody, and thanks Anthony and the rest of your team.
Bye bye.