Monday, September 16, 2013

Follicles Too Big In Clomid Ovulation Induction Cycle

I am writing from San Diego, CA.  I was on 100mg Clomid on Cycle Day 3-7, then 2mg estradiol on cd 8-12. I went in for an ultrasound to check follicles on cycle day 13.  My RE said that this was most likely a lost cycle because I had 2 dominant follicles at 26 and 31 mm.  He gave me an HCG trigger because he did not want the follicles to get bigger and become cysts.  My uterine lining was 14 mm, and my RE was happy with that.  My husband and I had intercourse the day of the trigger and the day after, then skipped a day and had intercourse one more time.  

Were the follicles too big?  Do we have any chance of conceiving this cycle?  I have also been feeling cramps since yesterday at 7 days after the trigger.  Is this normal?  

Thanks for your input. L. from San Diego

Hello L. from the U.S. (San Diego),

I don't have the ability to foresee the future, and certainly exceptions can occur, however, the follicle sizes were too big.  Usually once the follicle is greater than 24 mms, the egg within is overmature and therefore no longer viable.  Ovulation may occur but that is the main problem.  Also, it is highly likely that these follicles will turn cystic (persist) and have to be suppressed with birth control pills. You need to make sure a baseline ultrasound is done to evaluate for this at the start of your next cycle.

So, statistically and physiologically speaking, this cycle is probably a bust.  Unfortunately, your doctor missed the appropriate point by not doing the ultrasound early enough.  Next cycle he should begin looking at cycle day #9 or 10, which is what I do.  If I'm too early that's okay because nothing is lost and gives me a better idea of follicular development.  If you're too late, as in your cycle, then then cycle is lost; a big price to pay.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program

Monterey, California, U.S.A.


  1. Dear Dr Edward,

    Thank you so much for your kind services. Would be grateful if you could clarify my doubts.

    I am a 30 year old woman undergoing my 2nd ivf treatment. My husband has low sperm count and quality.

    In the first and second ivf I have had many good sized follicles but very few eggs collected. First ivf, unsure how many follicles but retrieved 5 eggs, 3 matured. Second ivf 11 follicles, retrieved 5 eggs and 4 matured. My doc told me that many of the follicles though grown had water in it and no eggs. She mentioned that being overweight might be the reason.

    Could the egg count and quality increase if I lose weight? What else can I do to help increase the number of eggs collected?

    1. Hello,
      Weight has nothing to do with this and is just an excuse for your doctor's miss. I think what is going on is that your doctor is not allowing the follicles to grow long enough. If triggered too soon, the egg within the follicle will not be mature and hence, nothing will be collected because the egg has to become mature to pinch off the sidewall of the follicle and be released into the fluid. Of course, I cannot tell you that this is what is going on without reviewing your records, but this is the most likely cause. May doctors trigger when the lead follicles are 18-20 mms (the lead follicles are the largest 2-5). I have learned over my experience that I have to balance the size of the largest follicles with the size of the smallest in order to get the largest number of mature follicles. This is where the ART of IVF and experience come into play. For that reason, sometimes I'll allow my lead follices to grow to as much as 24 mms, and in some cases larger if it means I'll get more follicles to mature size (at least 16 mms).

      Maybe it's time to look for a different clinic or doctor?

  2. Thank you so much Dr Edward, I am changing my doctor.

  3. Dear Dr. Ramirez,

    My question is what does it mean that I have produced nine large follicles (not antral) in one cycle without any medication. I am a 42 year old just starting her first round of IVF (no history of PCOS). I have a 13 year old conceived naturally. I was widowed and am trying for a baby with my new husband. (New husband’s sperm is normal.)

    I have always had 28-29 day cycles, but since I moved to Israel in June my last cycle was around 60 days. My day 4 FSH was 9.7 (lab closed on day 3), and all the other hormone levels were normal. The doctor didn’t tell me the number for the antral follicle count, but he did say that he saw lots of follicles and did not think ovarian reserve would be a problem. The doctor wants to do the long protocol.

    We are now waiting for me to finish ovulating so I can start the downregulation drugs, but every time I go for blood work and ultrasound to see if ovulation has occurred, we keep finding follicles, so this cycle is long as well. It looks like I have naturally produced 9 follicles for this cycle (see below). I have not taken any medication at all yet.

    What do you think about this; is this normal or is this a problem? Have you seen this many follicles on a natural cycle before, or someone taking so long to ovulate? The nurse says she thinks this means I will respond well to the stims, and seems happy about the number of follicles, but I’m worrying it means I will run out of eggs even faster. Could these eggs be harvested this cycle? Do I run a risk of OHSS with the long protocol? I am having IVF done at Assuta hospital in Tel Aviv.

    My results:

    Tues, Sept 3, 2013 (day 19 of the cycle)
    E2: 2011 pmol/l
    P4: 0.85 nmol/L
    Endometrium=8.3 mm
    left ovary: 13 mm follicle (new follicle #1)
    right ovary: 16 mm (new #2), 17 mm (new #3)

    Sunday, Sept. 8, 2013 (day 24)
    E2=2856 pmol/l
    P4=1.16 nmol/L
    Endometrium=8.8 mm
    left ovary= nothing
    right ovary=22 mm (#2 again)

    Thursday, Sept 12, 2013 (day 28)
    E2=760 pmol/l
    P4=1.6 nmol/L
    endometrium=8.8 mm
    left ovary=nothing
    right ovary=15 mm (new #4), 22 mm (#2 again)

    Tuesday, Sept 17, 2013 (day 33)
    E2=854.8 pmol/l
    P4=<0.9 nmol/L
    endometrium=9.0 mm
    left ovary=18 mm (new #5)
    right ovary=17 mm (#4 again), 26 mm (#2 again)

    Monday, Sept 23, 2013 (day 39)
    E2=435.8 pmol/l
    P4=<0.9 nmol/L
    endometrium=8.0 mm
    left ovary=12 mm (new #6), 14 mm (new #7)
    right ovary=10 mm (new #8), 21.5 mm (#4 again)

    Friday, Sept 27, 2013 (day 43)
    E2=930.9 pmol/l
    P4=<0.9 nmol/L
    endometrium=9.0 mm
    left ovary=12 mm (#6 again), 14 mm (#7 again)
    right ovary=12 mm (#8 again), 21.5 mm (#4 again)

    Tuesday, October 1, 2013 (day 47)
    E2=1685.7 pmol/l
    P4=2.9 nmol/L
    endometrium=9.6 mm
    left ovary=12 mm (new #9), 19 mm (#6 again), 21 mm (#7 again)
    right ovary=10 mm (#8 again?), 19 mm (#4 again?)

    In case this is relevant, my mother had regular menstrual cycles till she was 60 years old (she got her first period when she was 9). After age 60 she started getting irregular cycles and symptoms like hot flashes. She continued to get a period until she was 74. She was repeatedly checked for things like ovarian cancer and she is fine, we were never given an explanation for the bleeding. Is this relevant to my IVF and the multiple follicles? Have you ever seen someone bleed until such a late age? Does her late menopause mean I might have a late one as well?

    Thank you so much for your time and your amazing blog!

    Best regards,

    Note that Israel uses different units of measurement for E2 and P4 than are used in the States--pmol/l instead of pg/ml for E2, and nmol/L instead of mg/ml for P4.

    Normal lab levels here for Estradiol (E2): 
    FOLLICULAR PHASE:  72-530 pmol/l
    MIDCYCLE PEAK: 235-1310 pmol/l
    LUTEAL PHASE:  250-786 pmol/l
    POSTMENOPAUSAL:  <118 pmol/l

    Normal lab levels here for Progesterone (P4): 
    FOLLICULAR PHASE:  <3 nmol/L
    LUTEAL PHASE: 8-68 nmol/L
    POSTMENOPAUSAL:  <1.3 nmol/L

    1. Hello. I would love to help you but you are not asking a simple question, rather, you're asking for a full consultation. I can't do that in this forum. If you want one, we can do it via email, skype or telephone, and I'll review all the medical records that you provide. Please visit my website for contact information. It is fee for service.

      One thing you have to keep in mind is that you are now 42 years old. Your chances of pregnancy, even with IVF, is signficantly reduced.

  4. This comment has been removed by a blog administrator.

  5. My doctor had me come in last week to check my progesterone level. He gave me the trigger shot Sunday then told me and my husband what to do. I swear I got two positive LH surges the next day. I went in Friday and today the nurse told me that my progesterone was 2.9. Could I have still ovulated? My progesterone last cycle was 5.4 and ovulation was confirmed then with an ultrasound. Last cycle I had 2 mature follicles. This cycle I only had one. I just want to know if even with a progesterone of 2.9 is ovulation still possible? I'm getting really discouraged by everything. I'm going on my 6th month on clomid. I'm now taking 150mg along the the trigger shots of HCG and I was encouraged last month when I did ovulate.

    1. I'm sorry to hear things are not going well with your treatments. In general, a mid-luteal phase progesterone of 10 or greater (cycle day #20,21,22) indicates that ovulation occurred. The other method is to use the ultrasound to see if the preovulatory follicle is present and then gone. So, in your case, where the progesterone does not indicate ovulation but you state that the ultrasound did, I'm not sure what is going on.

      Do not get discouraged. If the Clomid does not work, which is the lowest treatment option, then you move to the next higher level of treatment. Of course, this all assumes that you have had a complete evaluation to find the source of your infertility and ovulation is the only problem. If there are any other problems, then Clomid alone will not work.

      Good Luck

  6. hey dr
    i have normal ovulution. i am 25 years old.after trying three months i havent conceive and i got a typical symptoms of pregnancy before periods. dr advised me fertility treatmemt clomid 2.5 mg after 2 to 6 day of my cycle 2 tablets daily.locyst vitamin for whole month.
    folistim injection from 6 day of cycle on every alternative days three injection was recommended. on day thirteen ultrasound was done.mature follicles was found in both ovaries. 21 and 23 mm follicle in right ovrie. dr said 100 percent pregnnacy occur according to ultrasound. and my endometrial linning was 7 mm.dr give me prestege 1000 iu injection for breaking follicle.
    yesterday i had done pregnancy test before ten days of my due period and it was negative.and now i have no symptom of pregnancy.
    i am so stressed due to this thing

  7. I have a 17mm in left ovary and 29mm in right. Had the trigger shot. Can I still fall pregnant with both folicule?
    Thank you

  8. Hi,
    I’m 42 now and been trying to conceive for over 2 years. I went to a fertility clinic and they confirmed I was insulin resistant due to PCOS. However, I don’t any other symptoms as I have regular cycles and ovulate on my own every month.
    My eggs reserve is decent for my age (AMH = 2.13)
    Something we found out thru monitoring was that my follicles were growing but I was ovulating when the follicles were over matured (over 24mm).
    I was prescribed Metformin for the insulting resistance.
    Why Is ovulation is happening once the follicle are over grown? How can this be improved or managed?



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