Sunday, July 15, 2012

A Step By Step Guide To The IVF Process: Step Two -- Follicle Growth And Egg Maturation

Dear Readers:

This is the third part in the series I have begun to help answer what In Vitro Fertilization (IVF) is and how it works with my world-wide Blog audience. What you read here is what I also provide my patients with on a daily basis. I plan on going into some detail but in a way that is understandable to the normal (lay) audience, and not the medical or scientific one. I also hope that this will not only clarify what you will go through, but explain why things are done a certain way and what the goals of each step are. I also want to convey that IVF is actually a replacement for some of the “natural” steps required to get pregnant and not some miraculous high tech fertility treatment that gets patients pregnant artificially, as many think it is. It is somewhat of a miracle that we can do as much as we can, but there are still lots of things/steps that we cannot do or influence. I hope this discussion will benefit you. This series will be posted over the next few weeks in installments.

STEP TWO: FOLLICLE GROWTH AND EGG MATURATION

Under the influence of FSH (follicle stimulating hormone), dormant follicles within the ovary start to grow. Measurement of the dormant follicle number is called the “antral follicle count (AFC)” and also measured by the “Anti-Mullerian Hormone (AMH)”. Both these measurements are used to give one an idea of the ovarian capacity to be stimulated, also known as ovarian reserve, similar to the FSH level. They are additional indirect measurements. Many physicians and patients believe that these two measurements actually tell them how many eggs are left within the ovaries, but that is too broad an interpretation. We do not have the technology to know how many eggs are present without doing a careful dissection of the ovaries. So these are indirect measurements that serve to give warning about your fertility. Their only use is to help predict, as much as possible, whether the ovaries will yield many follicles upon the hyperstimulation that occurs with giving increased amounts of FSH.

So the real interpretation of a low AFC or AMH is that there might be a lower number of follicles produced, and consequently less eggs retrieved. As explained previously, these are additional measurements of “ovarian reserve.” They only predict success from a statistical point of view because part of how IVF enhances your chances of fertility is by increasing the number of eggs that are available for fertilization and hence the number of embryos and hence the increased chance of finding the perfect embryo that will lead to a pregnancy as explained in the previous segment. It is a total misunderstanding or misinterpretation to say that a low AFC or low AMH indicates that you are infertile, that your ovaries won’t stimulate or that you won’t have good eggs! Taken together with an elevated FSH, these measurements serve as red flags from a time point of view. It means that you may not have as much time to get pregnant using your own eggs as you might have thought. Since we cannot predict when you will run out of time, time becomes a critical consideration.

Currently, transvaginal ultrasound is used to monitor the follicular growth by simply measuring the follicles. This measurement is usually an average diameter taken from a horizontal and vertical measurement of the follicle and reported in millimeters (mms). As the ovary is stimulated with FSH, some of the follicles will grow. Follicles grow approximately 2 mms per day so there is some predictability of when the follicles will reach the appropriate size for ovulation or retrieval. As the follicle expands, Estradiol hormone is produced in increasing amounts by the growing follicle and so estradiol levels can be monitored to also help determine progress as well. With IVF, the goal is to have 15-20 total follicles and estradiol levels between 2000-4000. Each mature follicle will produce approximately 150-250 of estradiol. In IVF, we want to keep the estradiol level at less than 4000 because if there are more than 20 growing follicles and the estradiol level goes above 4000, there is an increased risk for an illness called “ovarian hyperstimulation syndrome”. That is a whole other topic so it won’t be explained here. Suffice it to say that OHSS has the potential to cause death in its worst form. A competent physician with experience doing IVF will take appropriate precautions to prevent this from occurring.

It is known that the follicle has to reach an average diameter of a minimum of 15 mms for the egg within to be mature. We cannot see the egg because it is microscopic size. Therefore, maturation is assumed by the size of the follicle, as has been shown in early IVF studies. With most IVF clinics, a follicle is deemed to be mature size and appropriate to trigger once it has reached at least 18 mms, but it can be as low as 15 mms based on previous studies. Because the follicles will grow unevenly, meaning there will be some that grow faster and some that grow slower, most physicians will trigger with HCG when the largest 2-4 follicles reach maturity size, or when the highest number are between 15-24 mms. My preference is for the larger follicles to be 20-24 mms which I have decided to use based on my long term experience. I don’t necessarily trigger when the largest ones reach that size but, rather, I want to get as many follicles into the mature stage as I can without losing the larger ones or have too many smaller ones. The problem with smaller sized follicles is the eggs within them will not have had adequate time to mature and so will be unusable. Also, follicles that grow to over 24 mms tend to have eggs that are over-mature and therefore not viable. Once the majority of the follicles reach a size of 20-24 mms, then you are ready for the “trigger” shot. The decision of when to give this shot is determined by the experience of the doctor part of the art of IVF. If given too soon, you may lose eggs because they will not be mature. Too late and you may lose them because they will be over-mature. The goal is to try to get the majority number of mature eggs as possible because only mature eggs will fertilize.

Until the trigger shot is given (or the body goes through an LH surge if allowed to occur naturally) the egg within the follicle does not go through its final phase of maturation, meiosis stage 2. Eggs within the follicle are usually in the “germinal vesicle (GV)” stage. Once stimulation occurs, they then go through meiosis phase 1 (M1) and then are mature at meiosis phase 2 (M2). In the natural reproductive process, the “trigger” occurs under the influence of a hormone called LH (luteinizing hormone) and is known as the LH surge. This is what is being checked when you use an ovulation detector kit. There is a sudden rise in the LH hormone which then signals the ovary to begin the ovulation event.

In IVF, HCG (human chorionic gonadotropin) hormone, which is chemically similar to LH, is substituted for the LH to make the eggs go through their final maturation phase and begin the process of ovulation. There are three sources for this medication:

(1) Urinary HCG extracted from human urine,
(2) Recombitant HCG (synthesized HCG) and
(3) Lupron, another drug that has a similar chemical structure to LH.

Lupron can only be used if you are on an antagonist protocol, with Ganerelix or Cetrotide, and not in a long Lupron protocol. This trigger shot will also cause the ovary to begin the ovulation process but because we don’t want the ovulation to occur, and thereby lose the eggs into the pelvis, the egg retrieval procedure is timed to occur before ovulation will take place. This is usually scheduled for 35-36 hours from the trigger shot.

We will continue this discussion soon with the next installment, "Step Three And Four: Egg Retrieval". Thank you for joining me today!

Edward J. Ramirez, M.D. F.A.C.O.G.
Medical Director, Monterey Bay IVF
Monterey, CA
http://www.montereybayivf.com/

159 comments:

  1. Thank you so much for your article... It has helped me understand a bit more about what is going on!!! :)

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    1. I was reading your article and I have been going through IVF. I had a very disappointing experience with it. I got a trigger shot of HCG and Lupron and 12 hours later only a shot of Lupron. The next day I was scheduled for egg retrieval. Had ultrasound and bloodwork the same day at 6:30AM. Went in for egg retrieval at 8:00 am and Dr. said that I already ovulated. No eggs to retrieve. I feel the trigger shot was scheduled to late and should have been the day before. What is your opinion on this?

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    2. Hi Anonymous,
      I can't tell you if your trigger shot was too late without a thorough review of your records. Usually, ovulation is prevented by using the long protocol with Lupron daily or the Antagonist protocol with Ganerelix or Cetrotide. These medications are supposed to prevent spontaneous ovulation. The trigger shot, HCG, is then set to be exactly 35-36 hours before egg retrieval. It is this timing that is critical.

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  2. Thank u for this information. ..in future if we need to ask u questions where do we post.

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    1. You can always post your question here.

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    2. Hi Dr while reading and searching your page I'm on day 10 of follistim for the time intercourse . earlier got the phone call from Dr said my estrogen level was 1600 high so I,need to cancel this circle .my follicle was 14mm and lots more growing but below that size. It kind of upset and want me to give up coz I been trying for two years 6 to 7 treatments ans still not successfully. My question is , is it ok or danger if we do intercourse.? Will we facing with the multiple birth ? I want to try to do intercourse since we already in this stage,please reply thank you Dr,

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    3. Your doctor is incompetent if the number was 1600. That is NOT high. 16,000 is high. My goal is to have the estradiol to reach 2000-4000 at the time of the HCG trigger. In patients who have lots of follicles whereby the Estradiol will go up faster, there are ways to modify the protocol to reduce the risk of ovarian hyperstimulation syndrome (OHSS) and your doctor should know how to do that. Because of the recommendation you received, I suspect that your doctor does not have expertise in IVF.

      NO DO NOT HAVE INTERCOURSE because there would be the risk of a super-multiple pregnancy (>3). Your doctor should have advised you about this caution and put you on something to prevent pregnancy!

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  3. Hello!
    I am currently in an IUI cycle, with a new practice, and new medications. I am noticing different procedures.

    What size follicle is considered 'too ripe'? I have a 25mm which is much larger than I have had (4 prior IUI's with clomid- now on Femara) my old clinic Triggered at 18mm.

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    1. Hello,

      Once a follicle is larger than 24 mms., the egg within it is over maturea and therefore not viable. Most clinics will trigger ovulation when the follicle is between 18-24 mms.

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  4. Hello docter
    I am posting here my problem with a hope of your direction.

    On 16 set 2013 we consult a docter who did ultrasound and measured follicle size of 11 mm, and advised folic acid.
    We tried to concieve but today on 12 oct periods came delayed by 6 days.and also pregnancy test shows negative result.
    really in stress kindly suggest.

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    1. I'm sorry but there is nothing to suggest because you have not provided me with any specific information. Folic acid is appropriate to take if you are trying for pregnancy but does nothing for helping one become pregnant. A single ultrasound showing an 11 mm follicle gives no information. I'd be happy to help you but ou need to gie me more information for me to do that.

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  5. Hello Dr. Ramirez, I just had my embryo transfer on November 11, 2013. So far everything is going well. (Its only been two days) However, my question for you, is there anything I can do to help the success of the transfer? Its like two weeks of not knowing and that is stressful. I am trying not to stress and my husband is great with helping me with the Progesterone and we are both being positive. My friend said to eat Pineapple and not to do this or that. I have actually gone back to work. I am a programmer so I don't have heavy lifting with my arms or legs only my brain. And other than feeling tired and my body feels somewhat sensitive but that was from all of the hormones I had to take before the transfer. Any positive advice will be appreciated. Thank you.

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    1. Hello Payton, I know that by now you should have your result, but let me answer your question any ways. The steps that occur after the transfer are completely natural. They are in God's hands and we don't have the technology to make them happen. Sorry. Hopefully, your clinic is giving you all the hormonal support that you need for implantation. There are some other medications that I use as well such as low dose aspirin, CoQ10, medrol, extra progesterone and sometimes low dose heparin, but these are personal choices that not all doctors agree with. These subtle things are what makes one clinic and each doctor different from eachother. This is where the "art" of A.R.T. lies.

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  6. Wondering if I triggered with a 24 and 22 follicle and IuI 36 hrs later. I am now pregnant with a blighten ovum, could that be because my 24 follicle was around 28 and too ripe at ovulation?

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    1. No. The follicle size and egg quality are not related except that if the follicle gets too big at the time of ovulation (and 24 mm is not too big), either ovulation of that follicle will not occur or the egg with be over mature and not fertilize.

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  7. Hi doctor I read your blog it gave me enough information. Now I am going through IVF cycle. I had 14 follicles but only 4 eggs. Tomorrow they will tell me how many eggs are fertilized.. Now I m stressed for this low number of eggs. Does low number of eggs matter?

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    1. Ultimately, the number of eggs doesn't matter. What matters is having at least one perfect egg. Where the number matters is there is an attrition rate (decrease in number) at every stage of IVF. We want higher numbers because we know that the numbers will decrease as you proceed through the process (less eggs than follicles, less mature than eggs, less fertilized than mature, less quality than fertilized).

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  8. HELLO DOCTOR IWAS LUCKY TO HAVE 1 YEAR GIRL FROM OUR ATTEMPT, BUT LAST MONTH WE TRIED AGAIN WITH FAILED ONE FOUR FOLLICLE 15 ,16 ,18,19.THREE WERE GV AND ONE GHOST I AM 30 AND WE WENT FOR IVF FOR LOW SPERM MOTILITY IDONOT WHAT WAS WRONG THIS TIME

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    1. Hi. There is insufficient infomation for me to give you any specific feedback on your cycle, but maybe your retrieval was a little early? Also, four follicle total is a very small number which indicates that either you did not get a strong enough stimulation or your ovaries are not stimulating well (decreased ovarian reserve).

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  9. Hi dr I am a bit overweight have been placed on clomid 100mg and metformin 1700mg daily. I have insulin resistance but my levels have come down to about 4. I also have a problem with recurrent bacterial vaginosis around ovulation and am concerned that there is a link btween that and not falling pregnant. I do have pcos. I ovulate on my own and haven't skipped a period yet in the last year although it is still irregular. Please help n let me know if there is hope with iths cycle as I am going to try iui this time

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    1. Before you should proceed to any further treatments, including IUI, you need to have a full infertility evaluation. If you have been having regular periods over the past year, that is an indication that you have been ovulating and so ovulation is NOT the problem. PCOD causes an ovulatory dysfunction. It's not a problem at this time. So, the problem might be something else, and I don't think it is bacterial vaginosis. At this point, I would highly recommend that you see a competent infertility specialist for further evaluation before spending any more money on a treatment that might not be helping.

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  10. Hi Dr Edward, I am 35 years old with 8 years infertility. I underwent cystectomy for endometriosis recently.
    Now I am on first ivf cycle. I am on sc buserelin 0.25ml since day 1 and gonal f 125 IU since day 2.
    Today is day 9. TVS showed 28 follicles in the right ovary, average diameter 9-17.5 mm, 3 follicles are 17.5mm. In the left ovary, there are 20 follicles with average diameter of 8-15mm, 3 follicles are 15 mm.
    Endometrial thickness is 7.9 mm.
    In your expert opinion,with these follicle size, is today (day9) the best time to trigger or day 11 would be better?
    I am worried that not many follicle reach 18 mm if trigger today ; and too late/ over maturation if trigger on day 11.
    Can the follicle that reach 22 mm rupture by itself prior to trigger?
    Is ovarian hyperstimulation more overt after trigger or ovum retrieval?
    Thank you.

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    1. Hi. The decision of when to trigger is really your doctor's decision since he/she is caring for you. But, it looks like you are hyperstimulating (over stimulating) based on the number of follicles that you have, which also figures into when to trigger. Whenever I see my IVF patients, the goal is to get as many mature sized (>16mm) follicles as possible. Sometimes this means that I have to sacrifice some larger follicles to get a higher number of smaller follicles to the appropriate size. This is basically where the "art" comes into play since it is a very individual decision. I don't necessarily go based on the largest follicles but I always want my largest follicles to be at least 20 mms. Some doctors use 18 mms as their end point and trigger when their largest 2 or 3 follicles reach 18 mms. That would then leave a lot of immature eggs, and so I look to balance the large follicles with the small.

      In your case, because you are stimulating so much, letting you go too long whereby your estradiol level goes over 4000 is also a problem. That would put you at increased risk or OHSS (ovarian hyperstimulation syndrome). Already, you are at risk because of the number of follicles you have and the fact that you are on an agonist protocol so HCG has to be used to trigger you (as opposed to an antagonist protocol whereby Lupron can be used to trigger and reduce the OHSS risk). So in your situation, I might want to trigger when many of the follicles reach 18 mms and before the estradiol reaches 4000. Based on the information you've given me, I would not trigger today, but wait one more day. However, without being able to see all the sizes and all the information, it is hard to say for sure.

      Since you are taking Buserelin, ovulation will not occur without a trigger, so you don't need to worry about spontaneous ovulation. OHSS occurs once HCG is given. It is not a result of the retrieval. Based on your ovarian response, you probably have PCO-type ovaries and are known as a hyper-responder. In that case, I would recommend a very low dose gonadotropin + antagonist protocol with Lupron trigger. It's too late for that in this cycle.

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  11. Thank you Dr Ramirez for your prompt reply. Your explanation is very clear and informative. My doctor is too busy. Now I understand what is going on after your explanation.
    On day 9 scan:
    right ovary (total 28 follicles): <9.5mm ( 3 follicles) ; 11.0mm (2); 11.5mm (3); 13.0 mm(3); 13.5mm(4); 14.0mm(2); 14.5mm(2); 15.0mm(2); 15.5mm(1); 16.5mm(2); 17.5mm(4)
    Left ovary (total 20 follicles): <9.5mm(8); 10.5mm(2); 11.0mm(1); 11.5mm(1); 12.0mm(2); 13.0mm(1); 14.0 (2); 15.0mm(3)
    I think he will trigger me on day 11 and retrieve on day 13. I will get ovidrel for trigger.
    My dr has told me that I am at risk of OHSS. He will give me carbegoline 0.5mg for 3 days after retrieval.
    Can ganirelix be given to prevent OHSS in my case since this is an agonist protocol ?
    My dr told me that he will freeze all the embryos and do FET later.
    In this institution, serum estradiol is not taken during ivf.
    Now I am also worried that too many immature ovum are retrieved in this cycle (looking at the number of follicles) and I am left with less ovum for next cycle if this cycle is not successful.
    Going through Ivf is really a stressful journey. Today is just day 10 and I have so many things to worry.. it is really nice to have a good doctor like you.
    Thank you Dr Ramirez.

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    1. Hi. You don't give your estradiol but you are stimulating too strong! You are definitely at risk of OHSS! An antagonist will not trigger/put the eggs through the final phase of ovulation. If you are on the agonist protocol, you cannot use an agonist, like you could in an antagonist protocol, to trigger. You'll have to use HCG which will increase the chances of OHSS. Cabergonline works somewhat but will not necessarily prevent OHSS. It is highly likely that you will have lots of immature eggs. It is not possible to get mature eggs from all the follicles based on the number of follicles that you have but you don't need a lot. You only need one good egg to get a pregnancy. I will be frank with you and say that any IVF center that does not monitor estradiol during an IVF stimulation is putting you at great risk of getting very sick. OHSS still causes deaths in some parts of the world. The purpose of the estradiol is to determine if you are at risk and to consider using measures such as "coasting". OHSS is increased when the estradiol is above 4000.

      Good Luck











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  12. Hi dr Ramirez,
    Thank you for your reply.
    I am having OHSS: mild ascites, ovary size 12 cm, white cell count 17,000,
    (serum estradiol on the day of trigger was 15000, the result came back 6 days later)

    Ovum retrieved: 30, only 20 can be used; immature egg M1:5; abnormal:4; poor oocyte quality, thick zona pellucida
    Low sperm count n motility
    ICSI done but only 6 fertilized, 6 cleaved
    5 embryo were frozen on day 3 for FET later....T4 G5 C8
    All grade 2 embryo:
    - 5 cells fragment 10
    - 6-7 cells fragment 25
    - 4 cells fragment 10
    - 5 cells fragment 30 ( I think this is grade 3)
    - 5 cells fragment 20
    I am heartbroken seeing this results.
    looking at the oocyte fertilization and embryo grading, I think I need to pray hard for a successful pregnancy in this cycle.

    I would like to know:

    1) is it possible that PCO is not visualized during laparoscopic surgery for endometriosis?.ie a PCO ovary appears normal intra-op?

    2) Day 2 LH is 6.9, FSH 4.2. Estradiol 88.8.
    Day 20 progesterone 1.7
    Body weight 44 kg
    looking at the LH FSH ratio and hyper-responding/ OHSS . no doubt i have PCO.
    is ovarian drilling indicated to increase successful rate if i need 2nd ivf?
    Would it reduce hyperstimulation or improve oocyte quality?

    3) now only I know PCO causes poor oocyte quality. The surgeon said I don't have PCO based on intra op findings. So I have stopped taking metformin.
    Is metformin helpful in term of improving oocyte quality in PCO?
    If not, what can we do to improve oocyte quality in PCO patient?
    Antagonist protocol ? a protocol that I don't get so many follicle ?


    4) since i have OHSS, do I need to wait for 3 months for FET? Or can I just proceed immediately in the next cycle?
    Do i need to take any blood test (eg estradiol level) before FET? I know pregnancy can worsen OHSS but isn't estradiol good for implantation ? What parameter need to be monitor for embryo transfer or implantation?

    Looking forward to your opinion and advice.
    Thank you very much.

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    1. Hi. I am not surprised that you developed OHSS. In the U.S., we usually don't allow the estradiol to go higher than 4000 without starting some method of preventing OHSS such as Coasting.

      Laparoscopy cannot be relied upon to make the diagnosis of PCO ovaries. Some will be very cystic looking but others will look normal because the cysts are within.

      Ovarian drilling is an option to try to treat PCO, but is not needed if you plan to do an IVF cycle. It only gives you increased risks from surgery. I don't recommend it.

      In some PCOD patients, Metformin can be helpful, but that is only about 30% of PCOD patients. If you don't have an elevated insulin level, it will probably not be helpful. It will do nothing for oocyte/egg quality. The best way to approach PCOD patients is using a specific protocol to reduce the chances of over stimulating the ovaries. This will be a combination of using a low dose slow stimulation, using an antagonist protocol, using the agonist to trigger ovulation and sometimes having to Coast. Some doctors will also use Bromocriptine as well to reduce the chances of OHSS. My goal is always to try to reduce the stimulation thinking that it is better to get fewer but better eggs than get a log of bad eggs. In some cases, deferring the transfer from the stimulation cycle to a subsequent frozen cycle would be better to reduce the chances of severe OHSS.

      No. Only one month off is required between cycles. OHSS only occurs from the ovaries being stimulated. Since that does not occur in FET cycles, there is no risk of OHSS.

      Good Luck

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  13. Hi Dr Ramirez, thank you for your reply. My husband and I really appreciate your help.
    I've read your post dated 2june 2014.
    We are from another part of the world which is very far from US (24 hrs flight). If not, we would have gone to Monterey to seek treatment from you.
    Although we have never met you before but from the previous posts and your reply, we know that you are a very good doctor.
    I have posted question to another fertility specialist online.. His answer is very brief in two sentences and the next thing he did is promote his centre, asking me to visit them for further consultation and treatment.
    I have gone through your blog to understand my problem/ disease. I notice that you always give a clear explanation and the reasons behind. Some patients asked you whether to switch to other fertility centre after failed ivf. You try to figure out the possible reason of their ivf failure. For instance, a patient should consider change fertility centre after several failed ivf instead of grade 1 embryo. Another patient with grade 2/3 embryo had miscarriage at 8 weeks should give credit to the centre because she manage to get pregnant with average or low grade embryo. You told us logic behind and always give patients encouragement.
    My first consultation with a fertility dr here was pretty bad. We searched for a good fertility dr on Internet based on patients comment/ experience/ blog. He is located 150 miles away. We waited for 2 hours despite of appointment made beforehand. His clinic was so crowded with patients. We already had all the blood results and hsg. The first consultation including tvs took only 20 minutes. He wanted to finish the session fast and we couldn't ask him question. He told us to go for surgery for endometriosis and drilling for PCOS. No discussion regarding treatment option for these problems and no discussion regarding iui/ ivf. We came out from his clinic with no added information regarding our infertility problem. The consultation fees was charged to maximum.
    I think a dr who is willing to spend time explaining infertility problem and share with people all over the world is a generous and great doctor. He must be even more dedicated in his daily work. Keep it up! Patient will eventually know who is the good doctor. Those 'patient's comment' can be fake and misleading due to business competition. It is a method to attract patients but we will eventually find out how true it is. I don't believe in those comment after that experience.
    Thank you.

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    1. Hi. Thank you so much for your comments and I wish you would post them on some of the doctor review sites such as YELP, HEALTHGRADES, etc. Patients in the U.S. certainly use these review sites to choose doctor's because in reality, there is no other good way of distinguishing a good from a bad doctor. Such feedback is always appreciated to help guide patients.

      I'm sorry that you are so far away. Maybe you should consider a 2-3 week vacation to California to undergo IVF if that is what you need. Also, I do consultations via Skype from all over the world so it is another way to consult with me. Although it may take 24 hrs for you to come to California, that will only be the travel day (2 days for travel) and the rest can be devoted to your treatment. As the American saying goes, "where there is a will, there is a way", which means if you want it bad enough you can make it happen.

      Good Luck

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  14. I was on Lupride for last 19 days (Today was the second day of my menstrual cycle). Follicles observed were 18,14,10,10 (Right ovary) and 8,6,6,5 (in left ovary). E=15.9, P=1.9,LH=0.6 and FSH = 2.97

    What are the chances of a viable IVF cycle? Should I discontinue this cycle because the largest follicle is already 18mm?

    In my last IVF cycle, there was only one follicle (greater than 15mm) of 18mm after 12 days of menstrual cycle. Therefore, we discontinued the cycle.

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    1. I'm afraid that this is not an answerable question in terms of your chances of success. It is a little concerning that you have a 18 mm follicle present. It could be a cyst rather than a follicle. Since there is no hormone production (E2 15.9) then you certainly can proceed with the IVF cycle but your doctor needs to disregard this follicle in choosing when to trigger otherwise he/she will be triggering way too soon.

      In general, when doing IVF (with a competent doctor), the cycle continues until the follicles reach the appropriate size to trigger and 12 days is certainly not enough time. I don't know why the cycle was cancelled.

      Good Luck

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  15. Hi Dr. Ramirez,

    I just wanted to get your thoughts on this: I am 31 yo and a poor responder/low egg reserve. Today is day 8 of stim and I have the following follicles:
    Right ovary: 17mm, 17mm
    Left ovary: 25mm, 15mm, 12mm

    I am supposed to do the hCG trigger tonight with retrieval on June 13.

    How many good quality eggs do you think they will retrieve? My doctor thinks the 25mm follicle "egg is cooked".

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    1. Hello. This is where the "art" of IVF comes into play and the experience of your doctor is important. If you trigger tonight, you will have 3 or 4 mature follicles. The 12 mm will not be mature and so probably no egg retrieved. However, the 25 mm follicle is large and the egg within it might be over-mature. So the net might be 3 eggs. If you wait 2 days to trigger, you will lose the 25 mm, which you've probably already lost anyway, but will gain the 12 mm follicle and the 17's won't be over-mature so the net would be 4 eggs.

      I would be curious to see how strongly your doctor is stimulating you. If you were a poor responder, I would use a high dose protocol such as Follistim 450IU and Menopur 150IU (total of 600IU of FSH).

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    2. Hi Dr. Ramirez,

      I'm just updating you since you were curious about my doctor's protocol.

      I was on Gonal-F 450IU and Repronex 150 from June 4-6. Then dropped to GonalF 375 + Repronex 75 + Orgalutran from June 7-11. I had my HCG trigger June 11 and egg retrieval June 13. They only retrieved 2 eggs, 1 immature. ICSI was done on the remaining egg and it did not fertilize.

      Just a bit of background on myself: My AMH is 9 and my FSH has ranged from 3 up to 21. I'm not sure if this would explain my poor response. This was my 2nd IVF. My 1st IVF I was on the long Lupron protocol and lower doses of GonalF and got 9 eggs at retrieval, 5 mature, 3 fertilized, 2 made it to transfer.

      I am bit frustrated why my protocol was changed and the outcome much worse the 2nd time around.

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    3. Hi. From the levels of your FSH and the high protocol you were on, it sounds like you were a "poor responder" and that is why the protocol change. 450/150 is the highest protocol that I, and most IVF centers, use in patients that are poor responders or with ovarian resistance. That would also explain why there were not many eggs retrieved, but without seeing the actual medical record, I can't make any specific analysis of your cycle.

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  16. Hello doctor,
    I am 29 years old and going through my first IVF cycle. I have gonal f and pergoveris from 3 rd day onwards. Now day 11, I have 5 on left and 11 on right. The biggest is 13.5mm. Is this normal? The clinic told me I'm responding quite slow to this. Is there anything I should worry about and take note? It's quite stressful to know I am not responding well.

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    Replies
    1. Yes, this is normal. You just keep going until you can get the maximum number of mature sized follicles >15 mms. One other possibility for the slower growth is that you are not getting enough medication but you don't give the dosages you are on.

      Just to reassure you, the amount of time it takes in the first phase (follicle growth) is not important.

      Delete
  17. Hi Dr. Ramirez,
    I wanted to better understand your philosophy with IVF and triggering when follicular size is 20-24. When you trigger do the follicles that are between 20-24 stop growing? And, are those follicles that are smaller than 20 continue to grow after triggering and before egg retrieval?

    ReplyDelete
    Replies
    1. Hello,

      The follicles don't stop growing but I have not had a problem with over-maturation of the eggs within. I take follicles up to 24 mms sometimes in order to gain some of the smaller follicles (ie get them into maturity size). Basically the "art" of ART is to determine when to trigger so that you can get the maximum number of mature eggs. The eggs need to reach a minimum of 15mms. To be clear, however, once the HCG trigger is given, the follicles will continue to grow but the eggs within then begin the final maturation process. Therefore, any eggs that have not matured enough, will not go through this final process.

      Delete
  18. Hello,
    I had one IVF retrival and ended up with 5 3-day embryos during my mini IVF cycle the first time round. Had two transfers and wasnt successful. I am now with a new doctor and going through convential IVF, I dont have as many follicles as I did with the mini IVF and am a bit concerned. Isnt conventail IVF/stronger meds suppose to produce more follicles? Does a person produce differently each month?

    ReplyDelete
    Replies
    1. Hello,

      Certainly every cycle can be different because it is a completely new cycle. So, the ovaries can respond differently. However, if a higher stimulation protocol is used, then you should get more follicles.

      Good Luck

      Delete
  19. Hi Dr i am on an IVF process. This monday i had my 7 day scan and my largest follicle was 4.7mm. do you think this can grow to 18mm so that i can have my trigger shot? for how long can we wait for the follicle to grow?

    thanks

    ReplyDelete
    Replies
    1. Hello,

      The purpose of the ultrasound scanning is to determine when the follicle has reached the appropriate size for HCG trigger and retrieval. You continue following it until it reaches that point. By the way, a CD#7 scan is very early and most clinics don't do a scan at this time. In my protocol, the first scan is done at CD#9 until the Estradiol taken on D#5 is high.

      Delete
  20. Hello Dr.Ramirez,

    I am 34 years old and my husband and I have been trying to get pregnant for almost 1 year. I have a 32 day cycle and never missed a period however I am overweight. My physician has recommended I do the "timed intercourse with Clomid". I took100mg of Clomid between cycle day 2-6. I went for an ultrasound in day 11 and I had a bunch of follicles the biggest being 8mm. My MD told me it was too early and to come back on Day 14. On day 14, I had several follicles but they were still at 8mm!! Is this normal that they haven't grown in 3 days?? I am going back on day 17 to check the follicles again. My MD told me not to worry and that it might be because they suspect I may have polycystic ovaries, therefore I ovulate late. Do you think it's normal for my follies not to grow in 3 days?

    Also, today I feel pain on my pelvis like I might be ovulating. Can I ovulate with a small follicle? Can this mean I don't ovulate at all. I don't know what to believe and I am concerned. Please help!

    Thank you!

    ReplyDelete
    Replies
    1. Hi. I can't tell exactly what is going on because I'm not there to see the ultrasound but it sounds like you are not responding to this dose of Clomid. There is a chance that it will respond later and doing another ultrasound in 5-7 days would be a good idea. Follicles have to reach 18 mms in size for them to ovulate.

      Good Luck

      Delete
  21. I had my second scan today and am on my 8th day of injections. We use Gonal F in the UK and I am on a dose of 375 now which they increased from 300. I had 12 follicles on Wed, but todays scan shows 4 at 15mm, 4 at 10mm and 4 that are not really growing. Is it likely that the 10mm one will increase much before Monday's scan and could the small one still have any time left to catch up? I'm worried that the 15mm ones may grow too quick before the others have a chance. Thank you in advance.

    ReplyDelete
    Replies
    1. I think your worry is valid and there is not exact way to predict how the follicles will grow. In general, follicles grow 2 mms per day. That is what we use to estimate their growth, but they can grow slower or faster. Choosing the day to trigger is where the "art" and experience comes into play with IVF doctors. The goal is to maximize the number of mature follicles (>15 mms) in order to maximize the number of mature eggs retrieved. Immature eggs can't be fertilized. Sometimes you have to sacrifice the biggest follicles in order to allow a higher number of smaller follicles to get to the potential maturity point.

      Delete
  22. Dear Dr. Ramirez I am from India, I had Endometriosis diagnosed in Nov 2013, Had laprotomy in Jan 2014 and removed a choclate cyst from my left ovary. Had fundal metroplasticity and my F. tubes were disconnected due to hydrosphalynx in both the tube. Advised for Zoldex two months. Currently I am going through IVF cycle on day 6 Ultra sound scan I found 11 follicle in my right ovary 3 more than 13mm 2 more than 10mm and 10 less than 10 mm. My left ovary is showing only 5 follicles size less than 10. I take Gonal-f and menopure 150/75 and cetroide was started on day 4. Is this normal, please advice us from your perspective....

    ReplyDelete
    Replies
    1. The only comment I can make is that you seem to be responding well to this low protocol so I would keep going. Nothing more can be said at this point.

      Delete
    2. One additional comment I just thought if is the use of Cetrotide at this early stage. This will suppress ovarian response, so it might be a little premature, but because there are so many variations of protocols in the world, this is only for information purposes and not a criticism of this protocol. You have to presume your doctor knows what he/she is doing.

      Delete
  23. Aloha Doc,
    Thanks for all your information. My wife and I are almost ready for egg retrieval which we are very excited about. During this morning's ultrasound, we were told that that the follicle was suddenly growing much faster than expected and we were going to move the date up for the egg retrieval by two days. Our doctor said not to worry but also mentioned that the egg might not be fully matured. I have been searching online for possible outcomes in this scenario but have found very little. What does that imply for the health of the egg and could that have negative impact on health of child if we make it to a live birth? Thanks for your time. ---- Stressed Papa to be

    ReplyDelete
    Replies
    1. I presume your question is directed to the comment "might not be mature" as opposed to the follicle growing faster. An immature egg cannot be fertilized and so will not result in an embryo. Therefore, there is no impact on health of the egg or the child (because there won't be one). The goal in IVF is to get as many mature eggs as possible, since there are the only ones that can be fertilized, so that there are as many embryos to choose from as possible. Timing of the trigger is determined based on the both the size of the lead follicles, as well as, the sizes of the smaller follicles. The "art" of IVF, which is highly dependent on the experience of the doctor, is to choose the point that will yield the maximum number of mature (>15 mm) sized follicles/eggs. Once this trigger date is determine, then and only then can the retrieval be scheduled. The retrieval is, therefore, a moving target, not a set date.

      Delete
    2. Thanks Dr. Ramirez,
      Tomorrow is our retrieval day. We only have two follicles unfortunately and one of them is the previously mentioned follicle which grew too fast. I guess we will find out soon enough if there are any eggs and if they are able to be fertilized. Anyways... Thanks again

      Delete
  24. Hi, I am hoping you can help explain something that I have not been able to find a good answer for online and my doctor was not really able to explain either. During my first IVF cycle, I was slow to respond to the stim medications but eventually we did the trigger and 14 eggs were retrieved. 12 of them fertilized and more than half of the embryos were rated as very good quality. We transferred two, but the test came back negative two weeks later. Now I learn that my estradiol levels were low considering the number of eggs that were developing -- about 800 on trigger day when there were 17 follicles developing (obviously 3 of them ended up not being mature enough). What would explain having low estradiol but a high number of follicles and subsequent embryos? Is there any possibility that the embryos that we have left, while considered good quality, actually can not result in pregnancy?

    ReplyDelete
    Replies
    1. Estradiol is produced by the cells of the growing follicle. So as the follicle grows, more estradiol is produced. If the cell stops growing or starts to die out, the estradiol level declines. Normally the amount of estradiol is an indication of the number of mature sized eggs. RE's use 200 units per egg as an indicator of the number of mature eggs, but of course, this is not the case in your experience. I am at a loss to explain how you could have a low estradiol level but lots of mature eggs. Your level should have been closer to 2400. It could be lab error. It could also indicate that the follicles were over mature and were in the process of dying out. Another possibility is if the estradiol dropped abruptly, then spontaneous ovulation could have occurred. This should not impact egg/embryo quality however. If mature eggs were retrieved and they became good looking embryos, then the chances of getting a pregnancy should not be impacted.

      Delete
  25. hi dr.ramirez im 37 yrs old my tvs scan was 12mm follicle on the right ovary and left was too small on day 19,is this possible ovulation?thanks

    ReplyDelete
    Replies
    1. It may be on its way to ovulation but it is not there yet. A follicle needs to reach 19-20 mms to ovulate. It is still going to be several days before ovulation occurs.

      Delete
  26. Hi dr Ramirez ,
    I am 42 years old...being followed by fertility clinic and looking to get first ivf this month. I am on Gonal f and Luveris. My ultrasound (day 9) had follicules at 8. Ultrasound (day12) shows follicules at 9. Doctor increased my dose of gonal f with the hopes of follicules to grow more. I am due for anther ultrasound i(day 15). Is it possible that my follicules can go from 8 to 18 in a meter of a few days ?

    ReplyDelete
  27. Hi Dr Ramirez, I just wanted to say THANK YOU for giving so freely of your time in responding to these questions on your blog. I'm having IVF at the moment, just had my first scan and was looking for some more information on what the follicle numbers mean at this stage in my cycle. Just by reading the article, along with the questions and answers above, I was able to have my questions answered. I'm from New Zealand, so unable to visit you in person; but if I was anywhere near the US, I would be at your clinic for an appointment! So, congratulations on a wonderful, giving thing you are doing - may your generosity with your extensive knowledge bring you many clients - and may they have many successful pregnancies :) :) :)

    ReplyDelete
    Replies
    1. Thank you for your positive feedback. With God's blessings, I have been able to help many patients achieve their dream of having a child. Christmas is a time that reinforces the purpose of my task when I receive wonderful cards with pictures of the children. Since I have been doing this for 20 years now, some of my children are all grown.

      Delete
  28. Hi Doctor, i have Pcos and endometrioma but this cycle my doctor gave metormin A, normoz,caberlin,and bestova tablets from day 3,

    on day 9 of my follicular study showed 2 follicles of 8,8.5mm on my right and 7 mm,6mm on my left,

    On day 11 of my follicular scan, I had 11.5,9.5mm on my left and 9 mm on my right
    On day 13 of my follicular scan, I had 13.5,12.5,9.5 mm on my left and 11.6mm on my right
    On day 15 of my follocular scan, i had 20.3,19.8,19.2,18mm on my left and two 16.5 mm on my right.
    I was given a lupride shot on my thigh on day 15 and asked to take prognova 2mg as my wall was thin about 7.2
    Doctor also gave me gestofit along with all the other tablets.

    She had asked me to do intercourse every alternate day from day 11 to day 22.

    but on day 16 and 18 he ejaculated on my vagina and could not enter in me. what are the chances of pregnancy in my case.

    Do all the follicles rupture after the lupride shot?
    I have read about 36 hours but i felt cramping on day 20 of my cycle... I am confused

    If ovulation occurs in 36 - 48 hours , what is the need of having intercourse till day 22?

    Can there be a chance of multiple pregnancy in my case iff there is a chance of pregnancy in this cycle.

    Am i on the right path?

    We have been trying for a year now.

    Can i ever concieve???

    Please help

    ReplyDelete
    Replies
    1. Hello,

      It is not an absolute that ALL follicles will rupture, but I think the timing of your trigger was appropriate. The general rule that many Ob/Gyn's follow is to do intercourse every other day, and NO, it does not need to be done for that long. However, because it cannot be absolutely known when IVF will occur, and we know that it can range from 24-52 hrs after the trigger, I advise my patients to have intercourse every day for only 4 consecutive days to cover this ovulatory period. In terms of your chances of pregnancy, that I can't answer. Only God knows the answer to that.

      Delete
  29. Hi sir I am ttc from one year but no use. This month I took fertyl and went to follicular study. Df was 15mm on cd11 and it stopped growing till in cd30. Can u plz help me what should i do to get good follicle size

    ReplyDelete
  30. Hi Dr, I have PCOS and TTC for two years. Is it okay to have HCG trigger when follicle is 14mm. The ultrasound scan shows that there is slow growth of follicles. On CD 11 it was 12mm and on CD 14 it is 14mm. After HCG shot, are there chances of follicle growth any further?

    ReplyDelete
    Replies
    1. No. Once the HCG trigger is given, the final steps in maturation occur. If the follicle is not mature size, then the follicle will undergo atresia. Anything less than 16 mms is not adequate for egg maturity. Your trigger was given way too soon and I doubt that ovulation will occur. In general, we wait until the lead follicle is at least 18 mms before giving the trigger.

      Delete
  31. Hi dr Ramirez ,
    My wife is on 11th day of stim. ultrasound revealed follicles of size 21, 17, 18, 15, 14, 13, 18, 17, 15, 12,10, 11,16 mm. her estrodil level on day 10 is around 2800. We are little worried that we will end up with only less eggs for ICSI. I had my testicular biopsy & found very rare twitching sperms but my biopsy result says active spermatogenesis sloughing in the lumen. If i have active spermatogenesis i should be have more sperms as per my understanding but my results are worrying. Please advise.

    ReplyDelete
    Replies
    1. Sorry for the delay in this response, but this blog is not a daily project. The stimulation looks adequate with good follicular sizes. I personally would probably have waited 1 or 2 more days to get the maximum number of mature eggs. Since TESA is the only way you can get sperm, which is done in conjunction with ICSI, you have no choice but to hope that you get good fertilization. So, you should not worry. It will either happen or not, but in my experience, you will get some embryos formed.

      Delete
    2. Thanks for the reply Doctor. You are doing a great job.
      We have collected 22 eggs & 19 where injected by IMSI-ICSI & 12 fertilized but at the end of day 5 we had only 3 blastocyst Grade 2 embryo & 1 early blast Grade 2 embryo which we freezed for embryo transfer in the next cycle. In the report they had mentioned 'Very rare twitching sperm with poor morphology' is this a reason for only 3 growing till blastocyst stage & others not. Will the poor morphology affect the child if we have a successful pregnancy with these embryos. Is grade two embryos good to implant & turning into successful pregnancy? Please reply.

      Delete
    3. It is possible that the poor sperm quality affected the embryo quality and the number that survived to blastocyst stage. In general, abnormal embryos will not survive to implantation (no pregnancy) but if they do, they usually will end in miscarriage. Only mild genetic abnormalities such as Down's syndrome will survive further. I recommend that you have genetic screening as should be done in pregnancy no matter how it was conceived. The grade two blastocysts certainly have the potential to implant and lead to a successful pregnancy.

      Delete
    4. Thank you very much for this information. I am currently going through follicle monitoring for pregnancy. My yesterday reading was 37 and 25 when my egg will release from ovary?

      Delete
    5. Hello Sarita,

      The follicles need to be 18-24 mms when they ovulate. Follicles that are greater than 24 mms are overmature and either have ovulated already (they refill with fluid after ovulation) or have become cystic (cysts) and will not ovulate. If you are undergoing monitoring by a doctor, then your doctor did not trigger at the correct time.

      Delete
  32. Hi.i am on aromek for 5days.along with hmg masson for 3days.then doctor ask me to come on 6day then she have done tvs and says I have small follicles.then she suggested me fertim 150iu daily 2inj.then I have done another tvs on 10day .follicle size is8mm.she ask me to inject further fertim 150iu for 2days.plz tell me either ovulation possible wid this size.my age is30.weidght is 75.i also used folic acid daily,dopergin daily,metwil xrdaily.she also says I have pcos.

    ReplyDelete
    Replies
    1. You are asking a protocol question and that I have to leave up to your doctor. However, in general, injectable fertility medications are slowly increased until there is evidence that the ovaries are responding. It seems to me that your ovaries are not responding at the current dosage. Does your doctor know what he/she is doing? Once the appropriate dosage is instituted, all patients will respond in a way that lead to ovulation. The main problem tends to be that in PCO patients, the ovaries over respond and so have more ovulatory sized follicles than can be safely ovulated. We don't want you to have more than 3 eggs ovulate at a time to reduce the chances of triplets or greater.

      Delete
  33. Thank you so much for sharing your knowledge Dr. You have given me more insight to the IVF process then my own FS (unfortunately). Thanks again

    ReplyDelete
  34. Hello Dr. Ramirez,

    I am on Day 9 of IVF stimming. I am on high dose of FSH (450) plus 75 of Menopur. After the appointment today I was told that I have 12 total follicles measuring: Left 21, 18, 17, 16, 11, 10 and Right 23, 21, 13, 12, 11, 9. My E2 was 1140. I was sure that they would have me trigger today, but the RE wants me to do one more day of stimming. I am concerned that the 21-23 eggs will be too mature. Based on your experience and looking at my numbers, does it seem worth it waiting one more day for the smaller ones to catch up? Thank you!

    ReplyDelete
    Replies
    1. It is possible that the 23mm follicle will have an over-mature egg but the others are not in jeopardy. I think I would agree with your doctor. Waiting another day will allow for one or two more follicles to reach maturity. But at the same time, triggering now would be okay as well since you won't gain that many more in one day.

      Delete
  35. Dear Doctor

    My follicle spread today is below, would you wait another day or trigger today?

    23, 21, 20, 19, 17, 17, 17, 16, 15, 10 mm

    Regards
    Milly

    ReplyDelete
    Replies
    1. If you are doing IVF, I would trigger today. If you are doing timed intercourse or IUI, I would not trigger, and instead, give the birth control pill to prevent you from getting spontaneously pregnant. I would also advise that you not have sex for the next 7 days. The reason is that you have 9 ovulatory sized follicles which is too many for a natural method. Your risk of a super-multiple would be too high. On the other hand, for IVF, it is an appropriate number and the sizes are adequate.

      Delete
  36. Hi pls help i have had stimulating drugs and the trigger shot but gave it to early and been told we will have to wait till june for another appointment but they said my follicles are very big and told not to have sex but want to see if I can get pregnant with the shot is this safe

    ReplyDelete
    Replies
    1. No. Follow your doctor's recommendations. Getting pregnant involves more than just a trigger shot and sex. The reproductive system is very complex and everything involved has to be correct hormonally and physiologically.

      Delete
  37. Dr. Ramirez,

    I am confused by my levels...(I have Graves disease) Cd3 levels are E2 18, P4 0.2-0.4. My levels on CD32 (a long cycle yes) were Estradiol 262, P4 0.7, FSH 25. 2 follicles in the left ovary, 18-20mm each, and 3 in the right, 14mm each (approx.). 24 hours later, E2 was 249, P4 was 0.8, follicles were 20-22 in the left and 16, 16, 15 in the right. The tech said they were all clear follicles. I triggered that night with 10k hcg (timed intercourse this cycle, IUI next cycle if we don't get pregnant). I went in for the release ultrasound approximately 60 hours post trigger. They couldn't tell if I ovulated - the left ovary now had an echoic 25mm follicle. My progesterone level was 1.18. If I had ovulated 48 hours post trigger, would my follicle and p4 level look like that 12 hours later? I am 38, almost 39, high FSH (which has amazingly come down since I quit smoking and began eating healthy and organic!).

    ReplyDelete
    Replies
    1. Post-ovulation ultrasounds are ineffective and worthless. The only way to check for ovulation would be daily ultrasounds from the day of the trigger to see if the follicles collapse. Follicles will re-inflate after ovulation and form what's known as the "corpus luteum" so ultrasounds done several days after cannot distinguish between the pre-ovulatory follicle that was there or the post-ovulatory corpus luteum. In addition, why is your doctor checking progesterones over and over? That too doesn't make any sense. Progesterone levels (P4) are usually checked on CD#21,22 or 23 to verify that ovulation occurred. Done at other times tells you nothing! Also why is he doing the FSH levels? Same reasoning as the P4 in that it is usually only done on CD#2 or 3 to check for ovarian reserve. At other times is gives no information. Are you sure you're seeing a competent doctor/specialist?

      Delete
    2. I'm seeing Dr. Jerome Check at Cooper in NJ. Everything I have heard indicates he is a top RE. I'm starting to feel hopeless though. My FSH is so high, my thyroid hormones are fluctuating...As far as the FSH/LH/E2/P4 levels throughout cycle, I think it's just they test all 4 each time. I'm on Ethinyl Estradiol to suppress my FSH level. I just started a provera induced period. Is there a different protocol you would use?

      Delete
    3. Hello. I don't know Dr. Check and don't mean to disparage him but you might want to ask him exactly why he is doing so many blood tests? The conventional protocol is a baseline FSH/LH/Prolactin/TSH in preparation for IVF to determine the ovarian reserve (ability to stimulate) and to ensure that the pituitary and thyroid are normal. After that it is not necessary. The only test that is done during IVF is estradiol, and some will do progesterones (P4) but that is usually after the transfer. Since the doctor is getting paid based on this testing, could that be a reason?

      Delete
    4. I forgot to answer your request for a protocol. I don't give specific protocol recommendations because there are so many variations and not one that is better than another. Most doctors use protocols that they were trained to use. Others, like me, will change the protocol over time with experience, but mine are not necessarily better than another's. However, given that pregnancy success rates vary between doctors and clinics, I'm sure that this can make a difference.

      Delete
  38. I just finished my first round of Clomid. Thanks to the Clomid, I have produced 9 mature follicles (3 reaching 18mm). My doctor will not administer the trigger shot due to the danger of having multiples (more than 3). I want to know what the chances of me conceiving on my own are without the shot since I do have that many follicles. Any advice would be appreciated.

    ReplyDelete
    Replies
    1. I do not recommend trying for pregnancy if you have more than 3 ovulatory sized follicles (>15 mm)! I can't give you a statistic on what your pregnancy chances are, but your chances of a super-multiple would be significantlly higher. In order to prevent my patients for doing what you are thinking of doing, I will usually place my patient on a birth control pill at that point in an emergency contraception type protocol.

      Delete
  39. Hello Dr Ramirez- I ovulated pre maturely in my last cycle. I has two follicles @ 18 and 19 going into the trigger, which was 36.5 hours prior to my scheduled retrieval. How can this be avoided in the future?

    ReplyDelete
    Replies
    1. Hello Kelly,
      It may be that you were not suppressed enough by the Lupron or Ganerelix prior to retrieval, or that your retrieval was scheduled too late. I prefer to schedule the retrieval for 35-36 hours. These are things that your doctor needs to evaluate; not you. That is what you are paying for.

      Now even I have cases of premature ovulation, that I could not have prevented. The body is not an absolutely perfectly predictable thing. Fortunately, I rarely see it happen twice so no changes are required.

      Delete
  40. Hi doctor. Im on clomid and went for a scan today(day 10) to see how my follicles develope. On my right ovary I had a 12mm and two 11mm and on my left ovary I had one 11mm. I would like to know if all of the follicles will mature? Thank you

    ReplyDelete
    Replies
    1. At this point they are medium follicles and hopefully they will continue to grow to maturity size (>16 mms). Hopefully they will not stop growing and there is no way to predict that, but in most ovaries, they continue to grow.

      Delete
  41. Dr. Ramirez.... Would you trigger me tonight with following info - follicle sizes 20, 18.5, 17.5, 17.5, 15, 12, 9.5, 8, 3?

    ReplyDelete
    Replies
    1. YES. Definitely, if you are undergoing an natural treatment options such as IUI or Ovulation induction. If you are doing IVF, I would wait one or two extra days to let some of the smaller ones develop.

      Delete
  42. Dear Dr. Ramirez....I'm anxious to have my trigger shot tonight. Would you trigger me tonight given the following stats? Follicles 20, 18.5, 17.5, 17.5, 15, 12 (small 9.5, 8, 3)? I was worried about losing the lead in favor of the 12?

    ReplyDelete
    Replies
    1. I think you asked the same question twice.

      Delete
  43. Hello Dr. Ramirez,

    Your article was very informative.

    I am 38 year old with history of 4 first trimester miscarriages. All tests normal except a subseptum which was resected.

    We are now pursuing IVF - done 3 cycles so far (with 450units of Menopur and Orgalutran). On an IVF cycle we see 7-8 follicles on Day 8 - is this normal for my age?

    And we also think there is uneven follicle growth. Last cycle I took HGH but it was still uneven: 19, 17, 16, 15, 14, 13, 7, 5. How to avoid this? We want to have one more cycle and would appreciate any advice.

    Thank you,
    Amie from Australia.

    ReplyDelete
    Replies
    1. There is a little too little information here for me to give you specific answers to your questions, but suffice it to say, follicle growth is often uneven. That is a normal fact. We try to get as many mature sized follicles as we can and so timing of the trigger shot (HCG) is critical in that regard. There is no way to make the follicles grow evenly, but sometimes giving more medications will stimulate them to grow a little closer together.

      Delete
  44. Dear Dr. Ramirez,
    I’m an intended father (IF) working with a 22 years old egg donor. I chose to work with her because she had a great first cycle in January 2015 with another IF: 35 eggs, 29 mature, 29 fertilized ICSI, 15 embryos frozen at day 5, 10 normal by PGD. She has AFC 43, AMH 5.0, and regular periods. With my cycle now in May 2015 we started following the same protocol, but on day 8 of stimulation we are seeing 11 follicles above 10 mm and E2 1086. During the previous cycle at day 8 she had 21 follicles above 10 mm and E2 1400. The IVF doctor is now increasing her medications. It seems to me there is a discrepancy between cycles. What is your opinion about cycle reproducibility? Would you expect a 22 years old to perform similarly within 4 months? Why would she progress slower during the second cycle? Could she develop “resistance” to medications and just not respond as well second time around? Should we have waited longer in between cycles? Would you expect the quality of the eggs to be consistent? Will a more aggressive protocol decrease the quality of the eggs?
    Thank you!

    ReplyDelete
    Replies
    1. Yes, the ovaries can stimulate differently each time. Ovaries have a mind of their own. I would expect a same stimulation but lack of it does not mean anything is wrong. In my opinion, the donor was stimulated too hard the previous time. I always worry about OHSS in patients that have more than 20 follicles. Patients do not develop "resistance" to these medications. I don't think waiting longer between cycles will make any changes (each cycle is different), I would expect the quality of the eggs to be good in the majority and I do think that over-stimulation leads to poorer quality eggs and embryos (studies have shown this in PCO type patients).

      Delete
  45. Dear Dr. Ramirez,
    I have had a short protocol IVF treatment but it was cancelled on Cycle Day 12 due to poor response, however I did have two follicles that were 12mm and was told to try naturally but I was told that it could still not happen, well I am trying naturally. I have decided that since it looked like my follicles were growing at 1mm a day (on Meds) then I could predict my follicle growth going forward. If I follow this logic then my Follicles would be 2.5mm Cycle Day 25 (Today - 11 June 2015)
    I have been using OPK sticks (Clear blue dual hormone) However, yesterday and today I have only shown High fertility and no peak yet. I am trying to guess when to take my Trigger Shot (Pregnly) as I have paid for it and if I use it I will ovulate with 36 hrs. Do I do it now or do I do it when I get a Peak (LH Surge) The meds really supressed my ovaries but I also do not want my follicles to be so big that they are not viable anymore. any advise would be great, I am 41 with no children and been trying for 7 years, Long Protocol cancelled same reason as above, Natural Pregnancy but m/c at 7 weeks, Natural cycle no egg, short Protocol above. Help.

    ReplyDelete
    Replies
    1. Hello.
      Follicles usually grow at 2 mms per day. An OPK would be a good way to time your intercourse since you've switched to a natural cycle. You would start intercourse the day after the OPK turns positive and have intercourse once per day each day for four consecutive days. There is no way to know exactly when the egg will be released (ovulation). Without looking at the size of the follicle, there is no way to predict when to give the HCG, but you could certainly give it on the day the OPK is positive, although this would be redundant. HCG is given in lieu of the LH surge and the OPK is detecting the LH surge. If you have the surge, HCG is probably not necessary. Why don't you just ask your clinic to continue to monitor you until the trigger?

      Overall, you need to know that your chances of success are decreased due to your age. In addition, it sounds like your ovaries are not responding very well to stimulation. In this case, I would not cancel your cycles but try with each cycle despite a low number of follicles. You never know if one of those follicles carries that special perfect egg, and IVF will give you a higher chance than trying naturally because it gets you much closer to implantation.

      Good Luck. I offer a subscription based email consultation/advisory service, where patients can ask unlimited questions while they are going through the infertility journey. Through this service I can explains things in more detail and give some recommendations. I can't care for you however. If this is something you are interested in, please contact me at info@montereybayivf.com and specify that you want to subscribe to the email consultation service.

      Delete
  46. Hello

    I am currently undergoing my second ivf cycle. In my first, I triggered after 11 days of gonal f dose 100 and got 19 eggs. This cycle, I am on day 13 of gonal f 125 (first 8 days 100) and my follicles are still only 15, 16 and 17 (most around 15) and they have frustratingly only grown 1mm per day in the last 3 days. Is it possible they can stop growing at 17mm for no reason? My lining was 7.5mm yesterday and 6.5 today which I am also upset about and do not understand. Any advice would be appreciated

    ReplyDelete
    Replies
    1. They will not stop growing. You need to continue with the medication until the follicles reach the appropriate size even if it takes several days longer. Your doctor might want to increase the medication a little bit if he feels that the follicles are not growing but that is probably not necessary. It just take a little time and the increased time may actually be good for the egg quality.

      Delete
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    ReplyDelete
  48. Hello Doctor ,

    I am going through my first IUI cycle after trying for natural pregnancy for more than a year . In my case , there is a mild male factor involved . My husband's sperm count and motility are quite low and I was suggested IUI

    Today was my day 12 ultrasound and blood work There are four follicles : Left measuring : 16.5 mm, 11.7 mm and 11.2 mm . Right measuring : 17.5 mm . Endometrium thickness 11.62 mm

    My nurse is yet to call and confirm blood work reports and direct me about next steps .

    As per the information i provided , pleade let me know when is right time to take ovidrel and right time for IUI .

    My doc would call me but I need your expert opinion . Do you see any issues with my measurements for iui


    Thanks

    ReplyDelete
    Replies
    1. Your doctor will determine when he wants to trigger, and each doctor will have different points. My personal preference is to try to get as many of the follicles to maturity as possible without losing any. 16 mms is the minimum size needed for maturity. So in your case I would probably trigger when the three largest follicles reach 20-22 mms so that the 11 mm follicle might have time to get to mature size.

      Delete
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  50. Hello Doctor... I am 26 years old.. I had my first IUI on 15th June 2015... to brief my history I was diagonised with thyroid and pcod... had my last LMP on 25 may 2015... I was put on glycomet. Siphene 50 mg, loprin, follivate and bcrip medication... Also I have taken HMG and folligraf injections... on day 20 I had my HCG trigger shot with 24 mm on RO and 16& 13 mm on LO. .. on day 22 i had my IUI process done with follicle on RO is ruptured and left with 16 and 15 mm and endometrium 14mm t line.... currently I am taking progesterone vaginal inserts and advised to take pregnency test after 15 days.... from day 2 after my IUI I am experiencing mild cramps which is on and off... I would like to know your view on my IUI process... I'm longing for this cycle turned out to be positive... any suggestions /advice to make things positive in this cycle

    ReplyDelete
    Replies
    1. In IUI cycles, my goal is to try to get 2-3 follicles to ovulate. In your case, it looks like you got only one in this cycle, and the IUI was late as manifest by the lack of the right follicle at the time of the IUI. But, your doctor is following normal convention and one option for doing IUI is only one IUI at around 36 hours after HCG. We'll have to see how this cycle turns out. Good Luck.

      Delete
  51. On Sunday am I had two 15mm folicals on the right and one 20mm folical on the left. Estradiol was 535 and progesterone .05. Gonal f 225iu given Sunday night. Trigger shot (ovidrel) given Monday morning at 8am. IUIs scheduled for Tuesday and Wednesday morning (24 and 48 hours post trigger). Questions: 1. Have you see a benefit to doing 2 iuis 2. Have I run the risk of losing the 20 mm folical (growing to big) by waiting to trigger 3. Are the two 15 mm likely to be mature enough. Thanks!

    ReplyDelete
    Replies
    1. Hello.

      1. I am a believer in doing two IUI's like your doctor did, at 24 and 48 hrs.
      2. I probably would have triggered on the day that the 20 mm follicle was seen because, yes there is a risk that ovulatation could have occurred, that would ruin the cycle. But that is not always the case and you would have to hope that didn't happen. When you had your IUI, did your Dr. look with the US after to see if the follicles were still there or had ovulated yet?
      3. The minimum size for ovulation is 15 mms but they don't always ovulate. Because you had a 20 mm follicle, you had to trigger on that date. The chances are that the 15 mms did not ovulate.

      Good Luck

      Delete
  52. Hello Doctor, We are set for our trigger shot (HCG) tonight at 10:00 pm. Our ER is scheduled for Friday at 10 am (exactly 36 hours after trigger shot). This will be our 2nd round of IVF. My concern is; my wife ovulated early the last time we went in for ER and lost a lot of the eggs. I've heard that ovulating before ER is very rare. How can we prevent this from happening again? We are very uneasy that our timing is set for exactly 36 hours. Can we do the shot an hour or so later? We are just looking for a little peace of mind. Any thoughts? Thank you in advance.

    ReplyDelete
    Replies
    1. Hi,

      I know that this answer is late (and this blog is not meant to be an immediate question and answer site. That is available as an email subscription service), but in a patient such as you that ovulated before the 36 hour mark, I will usually plan the next retrieval at 35 hours (HCG taken 1 hour later).

      Good Luck

      Delete
  53. Hi,

    I got my follicle analysis report and it says RO- no DF and LO F1-12x8mm. endometric thickness 8.8mm on 14th day. Is there a possiblity of getting pregnent.

    ReplyDelete
    Replies
    1. The information you provide is insufficient to draw any conclusions or state any statistical chabnces. The one follicle you have is not sufficient to ovulate yet, but once it is, there is always a chance for pregnancy. The majority of women in the world get pregnant ovulating only one egg at a time.

      Delete
  54. Dear Doctor. ..today is my 14th day and I have done a scanning and it shows that my left follicle is 25mm and it got ovulated. ..is there is a good chance of becoming pregnant with 25mm?

    ReplyDelete
    Replies
    1. There is always a chance, but in general, if the follicle is over 24 mms (based on IVF data), the egg will often be over-mature and non-viable, but that is not always the case. All you can do at this point is hope for the best.

      Delete
  55. Dr. Ramirez,

    I'm concerned I don't shed my lining completely. Prior to starting provera to induce my period, my lining was 14mm. On CD3 it was 9mm. I am 38, high FSH, on Ethinyl Estradiol to suppress FSH. My CD3 blood work was good, FSH 5.3 and E2 21. My doctor is optimistic about this cycle. But I'm worried about my lining...it was 9mm on Monday, and today (Wednesday) my period is pretty light. We are hoping to have an IUI this cycle. Should I be concerned?

    ReplyDelete
  56. Hello Dr Ramirez,

    I'd like to ask your opinion please. I am 34 with a history of moderate-severe endometriosis (no endometriomas) and a low ovarian reserve demostrated through a very poor response to two IVF high dose stimulation cycles which retrieved one and two eggs respectively. My FSH is around 9 and my AMH is 11.5 (UK measures) but my day 3 E2 is often high 200-330 p/mol. My antral follicle count is regularly 7 in total.

    I am now having natural modified IVF but on day 4 I already have one follicle at 13mm (endometrial lining of 6.7, E2 was 368 UK measure). This seems very large at this early stage. I also have 5 follicles at around 6-7mm and 1 at 10mm. I have taken 40mg of Tamoxifen since day 2, but have not added any other low dose stimulation yet.

    This is very similar to the follicle growth pattern when I am taking high dose stimulation. One follicle always grows big, quickly. My question (sorry it's taken a while to get to it..) is how much is my egg quality compromised by this fast follicle development? I am only aiming for one egg but I wonder if it's better to cancel this cycle and wait to see if I have a smaller day 4 lead follicle on a different cycle. I wonder how an egg can be mature enough with such quick growth. I expect I'd have to trigger on day 9. I'd be interested in your thoughts. That said, this is the third time this has happened and there's no way of slowing it down from what I've read so perhaps I should stick with this cycle. Sensibly, my consultant says we need to see what's happening on day 6, when in theory I should start adding 150 iu Gonal F.

    There seems to be very little literature about high E2 levels and ovarian reserve and quality issues - and even less about effective treatments.

    Thanks very much.
    Lisa

    ReplyDelete
    Replies
    1. Hello. The reason for doing the FSH/LH on cycle day #2 or 3 is so that we can see what these levels are at the LOWEST part of the cycle. Estradiol is measured to make sure that it is in fact at the lowest level. If the estradiol is over 100, then the FSH/LH is not valid because that indicates that it is not at the lowest level (estradiol is being made).

      However, the experience of stimulation is probably the best gauge of ovarian reserve (stimulation potential) and since you've done that, you've shown that you have decreased ovarian reserve.

      As you've pointed out, having a 13 mm follicle early is a problem because the 13 will be of maturity size before the rest of the smaller follicles have a chance to reach maturity. However, sometimes I'll not go by the largest follicle and sacrifice it so that I can get more eggs from the smaller ones. Also, egg quality tends to be better when the follicles grow at a slower pace.

      So, I'd recommend that you discuss that strategy with your doctor i.e. going less with the larger follicle (sacrificing it) and going more with the bulk of the smaller follicles.

      Delete
  57. Dear Dr, i had my first gonal f at 187.5iu on the 18/7/2015. I went in for my first U/S on the 21/7/2015 where the follicles size were ranging between 6-9mm. However, today 23/7/2015 as i went for my second U/S, some or most of my follicles (at least those that is measurable) are range between 13-16mm. i saw was of the follicle actually reaches 20mm. My doctor was surprised to see this as he then said my follicles doesnt look good as they have grown too fast. He ordered a 150iu of gonal f for today, day 6th. And took my blood to test the estrogen, progestrone and LH level in my blood. I wil back to his clinic for another U/S and the blood result To decide if we should continue with this cycle. My doctor told me that he supposed to retrieve the follicles on the 27/7/2015.
    What could be the cause of the fast growing of my follicles? If my follicles grows 2mm/day like you said, mine will be more than 24mm. Do you think i should abandone the IVF treatment for this cycle? Or do you think it is safe to continue with it?
    Thanks in advance.

    ReplyDelete
    Replies
    1. Hello. I can't tell you why follicles grow at different paces, but inadequate stimulation will sometimes cause only a few follicles to grow and not the rest. Think of it as only having enough feed for one bird where there are several so that only one or two of the birds get the majority of the food and grow and the others stay small and skinny. In IUI cycles, we purposely give low doses for that very reason. We want only one to three follicles to reach maturity size.

      You have three choices at this point since you have a 20 mm follicle: (1) you can proceed with the retrieval for this one follicle, (2) you can abandon the cycle and use a larger amount of stim in the next cycle or (3) you can disregard and sacrifice the 20 mm folilcle and proceed when the smaller ones reach the appropriate size.

      Delete
  58. Hi Dr. Ramirez

    I'm on day 8 of stimulation & had an ultrasound done & some of my follicles measured 14 mm. My Dr had me on 225 ui of Merional for 6 days & on day 7 he added Cetrotide .25 MG & today he upped my dose to 300 UI of Merional with Cetrotide .25 MG for today & tomorrow. My question is do you think I will be ready to trigger on the July 30th?

    ReplyDelete
    Replies
    1. Hello. I'm afraid I can't give you a prediction, especially without seeing how all your lead follicles are doing. Certainly, the 14 mm follicles would be ready but that is not the only criteria used to determine when to do the retrieval. My goal is always to try to get the majority of follicles to maturity size, NOT to trigger when the largest are maturity size.

      Delete
  59. hello Ramirez sir
    my age is 29 yrs nd m trying since 3 year. my both tube are patent fsh is in normal limit nd amh is low i.e. 1
    dis cycle my gyni prescribed me femilon for downregulation as on day 2 right ovary has multiple small follicles nd left ovary has 1of size 8*9mm nd 2 small follicles seen. on day 8 seen ight ovary msf nd left ovary 12*17*13. i had not taken femilon as previously whenever i had takn hormones med my cycle get fully disturbed. is dat ocp taking is essential in my case?? can my rt ovary follicled does not help me to get pregnant as left one mature before time??

    ReplyDelete
    Replies
    1. Hi. this is a repeat question of the one I just answered for you.

      Delete
  60. hello ramirez sir

    29year old trying since 3 years.
    both tubes are patent fsh in normal limit and amh is low 1.
    my gyni is planing iui before dat she wants down regulation as my day 2 scan shows right ovary multiple follicles nd left ovary has 1 follicle of size 8*9mm nd 2small follicles. in previous cycle on day 7 rt ovary has msf nd left ovary has 17*12 mm.
    in every cycle left ovary follicle grow before tim nd dan stopd. day 13 scan showd rt ovary 19*15 mm nd 20*20 from lef day 15 rt has ruptured follicle nd left has same 20*20.

    my quest is is femilon necessary?? i had bad experiance of ocp as it disturb my cycle. can my rt ovary follicle cant be use as it is normal?? kindly help

    ReplyDelete
    Replies
    1. The birth control pill is not necessary for IUI cycles but the strategy your doctor is using to try to even the ovaries before stimulation is a good one. The birth control pill down regulates the ovary, kind of putting it to sleep, and then the stimulation will cause the follicles to grow. Hopefully, it will be a more even growth pattern. However, in IUI cycles you don't want to have more than 3 follicles ovulate.

      Delete
  61. I m a44 years old ..I was given hmg 300iu starting on 3d day of menses ..decaptyl0.1 ..on 8 day ..LH 15...E2 2679 ..follicles 10 11 12 9 8 7 9 8 10 8.. .Each ovary...should I continue same dose or change..

    ReplyDelete
    Replies
    1. Hello. This is what you pay your doctor for. He/she needs to direct your care. You cannot get it from me via the internet. One comment I do have is that you have a lot of small follicles and your Estradiol is already high. I would presume that you are a high responder and if the estradiol goes over 4000, which it probably will before the follicles reach maturity size, then you are at risk for hyperstimulation syndrome. I hope your doctor is taking this into consideration. The good thing is despite being older at 44 years old, your ovaries are stimulating well on a low dose protocol so that should give you lots of eggs. Lots of eggs is good in older patients because that increases the chances of finding a good egg.

      Good Luck.

      Delete
  62. Hi doctor edward
    please excuse my english
    I had 3 times ivf incomplete because of my unmacutre eggs all of them always stopped on m1 stage I took medicine DHEA and other vitamins for 6 monthes .
    my doctor told me its a hopless case maybe you have a ginatik problem
    the only way to have childen is egg donation.
    Please advise

    ReplyDelete
    Replies
    1. The M1 stage is an internal development and may indicate that your doctor is triggering and retrieving too soon. Usually the egg does not change to M2 stage until it is fully mature, meaning the follicle has to be at least 16 mms, preferably 20 mms, and the HCG trigger is given, and retrieval is not for at least 35 hours from the trigger shot. It is possible that egg donation may be your only option if you are older and the ovaries are not stimulating well, but I would need a lot more information to review to draw that conclusion.

      Delete
  63. This comment has been removed by the author.

    ReplyDelete
  64. Dear Dr. Ramirez,

    I just came across you blog and after going through it have to commend you for the amazing work you are doing. There are not many doctors who are willing to give advise without monetary compensation. Thank you for making a difference in the lives of many individuals.
    I would like to present my case and hope to get your expertise to help me out. I have PCOS and infertility issues. Two years ago, with the help of a fertility clinic I was able to conceive by taking fermara, puregon injections (50 units) and the trigger shot. This time I am having some difficulty. My first cycle was cancelled because my follicles were not responding and were at the resting stage at 10mm. I took fermara days 3-7, and puregon I started at 33 units and went up in increments until I reached 66 units. Even with the increase, the follicles were not getting stimulated.
    I am on day 30 and ready to begin my next cycle, I will be taking prometrium to bring on my period. Dr. Ramirez, would you suggest I do anything differently this cycle? Also, should I take metformin, would it help my body better respond to the medication?

    Thank you once again for your assistance. A special prayer for you and many blessings

    ReplyDelete
    Replies
    1. Hello,

      Metformin is indicated if you are insulin resistant so a fasting insulin level should be done to check.

      In the next cycle, I would skip the Femara and go directly to injectables. With injectables, the dose needs to be slowly increased if there is no clear response, until there is a response. I have never seen a PCO patient NOT respond to injectables. In fact, the main problem is that they tend to over-respond. These are complicated issues so make sure that you are seeing a doctor that is competent with this type of treatment. Not all Ob/gyn's can do it.

      Good Luck

      Delete
  65. Hello Dr Ramirez

    I am 38 years old and have been TTC for 1year. My FSH has ranged from 22 to 8.7, AMH .8 and HSG shows blockage to Rt Tube. My RE recommended we try IUI with injectables. My first IUI was last month. I was on 100iu Gonal for 3 days and US showed 2 follies on the RT 10, 10.5 one on the LT 7 . They decrease my dose to 75iu, on day 8 Rt follies measure 15.7, 14,5 but the left did not grow so IUI was cancelled. This month on my 2nd IUI attempt I have 3 follies on the LT measuring 5 baseline and none on the RT. dose of 150, after 3 days LT follies measuring 9, 8.4,7 but RE said my estrogen is too high so they decreased my Gonal f dose to 112.5. Do you think I will successfully ovulate a mature egg this month? Do you recommend iVF if this Cycle does not work. We are paying out of pocket and want to make smart decisions so that we don't get into severe debt. We appreciate any and all advice.

    ReplyDelete
    Replies
    1. Hello,

      First, I am unable to predict the future so can't answer your question about ovulation.
      Second, in my opinion based on your age, elevated FSH and decreased AMH, I think you need to not be wasting your time on very low probability treatments like IUI. I think you should be going to IVF. It is the only treatment that will give you the highest chances of success. Time is working against you.

      Delete
  66. Dear Dr Ramirez,
    Thank you so much for your wonderful website. I'm so grateful that you take time to help women trying to conceive. I have questions for you and I'd really appreciate your expert opinions.

    I'm going through my third IUI cycles with 3 vials of Bravelle every night starting CD 3. At the scan on CD 12, I had five follicles (17, 15, 15, 13.6, 13). Dr had me take 3 more vials of Bravelle that night and instructed me to trigger on the night of CD13.
    I'm concerned that I triggered too early.
    What's your option on this?

    Also, do you think I am not responding too well to Bravelle? I was hoping to have at least 5 mature eggs. Looks like I have only 3.
    I'm 41 year old with one child I conceived naturally at the age of 39 after 5 cycles of trying. My Second IUI ended in miscarriage.

    Thank you again for taking time to read my questions.

    ReplyDelete
    Replies
    1. Hello,

      If the lead follicles grew at their normal rate, 2 mm per day, then you would have had a 19/17/17/16/15 mms follicles the day of the trigger. Any follicle that is 15 mm or greater has the possibility of ovulating. At least the 19 mm follicle will have ovulated for sure, but the 19/17/17 are definitely ovulatory size.

      If you were trying for all the follicles, he should have probably waited another 2 days to trigger.

      Good Luck

      Delete
  67. Hi Dr Ramirez,

    Thank you for taking the time to share yourself with us. You are providing an invaluable service.

    Im 37 soon to be 38 in Jan, recently got married and was about to start TTC with husband. I had been having night sweats around my periods for about a year now. I went to the gyno. And she reported I had significantly low AMH 0.04 numbers and to see an R E asap if I want children. This was in August of this year, I am now on CD9 of IVF. My day 3 FSH was 7.

    Since we have never tried to conceive naturally, my first question is was IVF absolutely necessary. This is what we've been led to believe. Also. I currently have just 4 follicles that seem to be progressing well according to RE. My E2 is 969. What are my chances of success?

    ReplyDelete
  68. Hi Dr. Ramirez,

    I am 46 years old and had my first baby by natural conception May 2010. I had another pregnancy by natural conception July 2012 and had miscarriage at 12 weeks. My menstrual cycle is still regular which is normally 28 days cycle every month.

    At the moment I am under stimulation for ivf which started on my day 2 of my cycle having dose of 300iu of menopur and 300iu of Gonal f and oral tablet Letara (Letrozole 2.5mg) 2x a day. Apart from these I am also taking dehydroepiangesterone 50mg 2 x a day and Bio-Q (Co enzyme Q10 as Ubiquinol 2 capsules 2x a day. I got a very low amh result of 0.43ng/ml. I had my scan at day 5 and only seen 3 follicles growing on my left ovary. I've given another 2 days dose of Gonal f and Menopur and scheduled for scan again on day 7 again.
    I am thinking of backing out and not going through the egg retrieval stage if I got only 3 follicles. I know my chance is less if I got few ovarian reserves. My question... is what is the danger of discontinuation of the treatment at this stage? Also will I have the danger of OHSS having a high doses? Another thing can we have intercourse while stimulation and right after I discontinue the treatment?
    Thanks

    ReplyDelete
  69. I am 25.Married for the past 1.5 years.Doctor suugested to do a follicular study..The measurements on day 13 were:
    Lt - 33X31 mm, Rt - 25X23,22X22 Endo - 9.63 mm..
    Is this normal for day 13?

    ReplyDelete
  70. Hi Doctor,

    I am trying to conceive from past 6 months. My cycle is of 27days. My AMH count is 2.47 ng/ml and FSH count is 3.87 mIU/ml. My follicle scan on day 12 is having DF of 13.5*10.5(right ovary) and 12.3*11.2. (Left ovary). My doctor has asked me to scan again on day 15 and till then she has asked me to avoid intercourse. Shall I wait for day 15 for follicles to mature or shall I intercourse in between.
    Please let me know.

    ReplyDelete
  71. Hello Dr Ramirez,
    I love your blog, and have read every entry to date. I am 43, with AMH. My RE says my situation is guarded, I know I have less than 5% chance of conceiving at all, additionally my husband is 42, and has low sperm count at 2%, but not low quality. He will also have a recount since recovering from a procedure to correct stage 3 Varicocele 4 weeks ago. My history is this: we are mid-stage fertility cycle for the second month in a row. I'm prescribed Menopūr 150iu subq qd. I'm using an app called 'fertility friend' to help me monitor CD's, fertile days, etc. I also know that Menopur contains LH. So if I am OPK testing at home, my LH surge levels will be positive, even if I am not ovulating. Today is 11/15/15. My last RE appt was 11/13/15. After US, I had 3 follicles on the Right at 7-8mm, and 3 follicles on the Left at 6-7mm. (Last month my follicles were 18mm on CD 19, so I triggered on CD 20). This month my RE said 'stop treatment, and restart BC', to which I thought was pre-mature in his decision. Knowing that follicles mature 1-2mm daily, and it was CD 13. So now I am self-monitoring and predicting my own follicle size based on my knowledge of probable growth. I am also continuing on Menopur 150iu Injectables daily, to promote the growth size, hopefully to >/=15mm, then I plan to trigger. I'm not a doctor, but I am a nurse. Can you please advise me on several items? 1). Should I listen to my RE, and stop? 2). Am I in any danger continuing w/o MD or US (ultrasound) monitoring? 3). Is there any risk of over-stim issues (my opinion is leaning towards No)? 4). How can I know when I am truly ovulating, if my home OPK tests are concluding as positive, due to the LH which is an ingredient within the Menopur? We are BDing qod, are our chancing of conceiving still good or within ok allotment? ... Now you are probably shaking your finger at me, b/c I should know better than to attempt treating myself. But I thought to go ahead, because we are seeking a 2nd opinion for our next appt. As we are not happy with our current RE. So I thought what is the harm, I'm going to be done with this cycle soon anyway. Appreciate all your thoughts, any concerns, and any advice. Thank you ahead of time!
    - Jenna

    ReplyDelete
  72. I have been taking fertility pills and finally got pregnant. My last period was 9-23 which makes me about 8weeks now. But vaginal ultrasound shows im 7 weeks (shows a 4 day difference). I had sex on 9-26 still on period and every other day after that. Oct 5 I did a vaginal ultrasound and follicles measured about 9-11mm and uterus did not show sign of pregnancy. My question is could I have gotten pregnant on my period? And based on the vaginal ultrasound my due date 7-3-16 on based on lmp my due date is 6-29-2016? Or did I get pregnant after my oct 5 ultrasound?

    ReplyDelete
  73. Hi. dr. It is my first ivf cycle. With the protocol
    As suggested 22 eggs were retrived, my e2 one day before retrieval was 1790 had 23 follicles . Suggest abt the no of embryos may be there after fertilization... Follicles were b/w 21(6) 20(6) 19(6)....

    ReplyDelete
    Replies
    1. I'm not sure what your question is. If you are asking how many of the eggs will be mature, I cannot predict that. Unfortunately, I do not have the ability to predict the future.

      Delete
  74. Hi! Dr Ramirez

    I have a question;i started my periodes on jan 28 2016 than i was put on clomidon Feb.1 2016 for five days. I had an ultrasound done on the wednesday and my follicles size where at 16mm,14mm and 10mm my dr told me to use the ovidel om thursday morning. all this is good but my concern his that if the follicles grow 2-3mm a day they will be 24mm,20mm,16mm they will be to mature and that could be a risk that it would not work right? the egg is at risk that it wouldn't be good right?

    ReplyDelete
  75. This comment has been removed by the author.

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  76. Hi Doctor Ramirez, I have just started my first ever IVF, I am 38 yrs old and have a low Amh of 1.18 , we will be doing ICSI, my doctor has put me on gonal F 450 along with Luveris 150, starting from cycle day 3, he has also given me cetrotide on cycle day 8 and called me in for a scan on cycle day 9 . Can you tell me what protocol this is and if it seems alright .
    Thanks Karin

    ReplyDelete
  77. Hello Dr Ramiez...I am going to give my wife the trigger shot in an hour, for a retrieval on March 18 at noon.

    How do these numbers look;

    The 3 biggest ones on the left are 19,18,17 (with 4 smaller ones)

    The 3 biggest on the right are 20,18,20 with 5 smaller ones.

    Wife did 375 of Gonal, as she was deemed a poor responder, which was determined after our first failed IVF attempt.

    We fear that they maybe over-ripe... Is my doctor a good artist? The nurses said its very good that that are all around the same numbers, unlike the first attempt.

    I need this to work doc.. So nervous...I found this very helpful site whilst trying to start awake and prep the trigger.


    ReplyDelete
  78. Forgot to say thanks

    ReplyDelete
  79. Hello Doctor. I had miscarriage in February 2015, and since then my menstruation has not been consistent. It shows up when it feels like coming. I am 96 days late today. I had my period on December 8 and ever since I haven't had my period although my husband was not around so pregnancy is out. I've taken about 3 different scan and they all seem there is nothing wrong with me.
    I had my last scan April 7, 2016 which states: uterus is anteverted measuring (78.1x44.3x55.3)mm with normal endometrial stripe thickness. No fluid collection in the Pouch of Douglas. Both ovaries measure right 38.1mm and left 40.2mm in diameter respectively. Both ovariescontain multiple periphery located small sized folicles with some measuring about 6.4, 5.1, 6.5, 6.9, 5.5 mm e, t, c.

    Pls my question is, how long will it take me to ovulate if possible and also want to find out if I can naturally be pregnant since period has not showed up for four months now. What are your advice. Thank you.

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  80. Hello Dr. I'm currently on my second cycle. The first time in Jan I was scheduled for egg retrival but ovulated. Since then I've been taking fertil pro 6 pills a day, Dhea 3 pills a day. Started my current cycle 9 days ago. I'm taking 600 ui of repronex and. 05 ml of superfact per day. Ony day 9 scan only three tiny follicles. The left side 3,4 mm and right side one at 5mm. Doesn't this seems really really small considering all the medication in on? Thank you so much for your time

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