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/

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

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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.

      Delete
  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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    Replies
    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.

    ReplyDelete
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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.

      Delete
  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?

    ReplyDelete
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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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    Replies
    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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    Replies
    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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    Replies
    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.

      Delete
  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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    Replies
    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











      Delete
  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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    Replies
    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

      Delete
  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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    Replies
    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.

    ReplyDelete
    Replies
    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".

    ReplyDelete
    Replies
    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).

      Delete
    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.

      Delete
    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.

      Delete
  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.

    ReplyDelete
    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

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