Follicles Too Big In Clomid Ovulation Induction Cycle

Hello,
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

Answer:

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
www.montereybayivf.com

Monterey, California, U.S.A.

Young IVF Patient Fails Two IVF Cycles: Empty Follicles

Question:

Dear Dr. Ramirez, I am 31 years old, have never been pregnant. My husband and I haver been trying to conceive for about 3 years, tried 5-6 cylces of Femara.

I had three failed IUI's and two failed IVF cycles. The first IVF cycle there was one egg but it disintergrated before it could fertilize. The second IVF cycle there were no eggs. Each cycle had 14-16 follicles 8-10 of them being mature. My AMH level is 2.19. My husband has been tested and is fine. I have a left blocked tube, which they say could be a spasm reaction from the dye. During the IVF I was on Bravelle, Menopur and Ganerelix injections, along with the trigger shot. It is emotionally and financially draining. Any thoughts? Thanks, H. from New York

Answer:

Hello H. from the U.S. (New York),

There is a finding called "empty follicle syndrome" where no eggs are within the follicles. But this occurs in a single cycle and those patients generally have eggs when retrieved in subsequent cycles. I have had young patients, and many older ones, with no eggs retrieved. In older patients, many of the follicles don't have eggs i.e. they have run out of eggs, so it is fairly common. But, this is not common in young women.

In most cases when eggs are not retrieved in a young woman, it is often because either (1) the HCG trigger was not adequate, or (2) the follicles sizes were not mature enough and therefore the eggs were not mature. I am suspicious that you fit into the latter category based on your first cycle. It is possible that you are being triggered too soon. In terms of the HCG not being adequate, when I previously encountered empty follicles in my young patients, I came to the conclusion that either the HCG had a manufacturing defect, was not stored properly or not given properly. I used to use generic HCG. I have now switched to the brand HCG, Ovidrel, and have not had a repeat of that problem.

I also worried that in more obese patients, the depth of the injection was not adequate to get the HCG into the tissues so I have my obese patients given the HCG injection into the back of there arm where the fatty tissue is less, rather in the abdomen where the fatty tissue is thicker.

Finally, if it is that the follicles were not allowed to grow sufficiently, that is a procedural problem. So you either can ask your doctor to wait a little longer to trigger you (I have found in my experience that I have to wait until the lead follicles are 21-22 mms rather than the 18 mms that most doctors will trigger at) or you can try a different clinic/center because each doctor and clinic are different and the outcome can be different.The bottom line is not to give up.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
Monterey, California, U.S.A.

Wondering About Follicle Size And Ovidrel Shot

Question:

Hi, I am on Gonal-f and my US (ultra-sound) yesterday showed I had 2 follicles measuring at 17mm and 14mm, my doctor told me to take one more shot of 75ui Gonal-f last night and to trigger with ovidrel tonight.

Do you think my eggs will be mature enough to ovulate???
Thanks! N. from the U.S.

Answer:

Hello N. from the U.S.,

If the follicles grow normally, they should increase by 2 mms each day. That means that they will be 19 and 16 mms the next day. I NEVER trigger without knowing the follicle size for sure. That is sloppy care. In addition, I would want you to be able to ovulate both follicles so I would probably wait one extra day and use the gonal-f another day. That way the follicle sizes should be 21 and 18 mms, so that both would be ovulatory size. Since follicles don't always follow the expected growth rate, I feel you have to look each day to know for sure.

In terms of your question, if the follicles grow to 19 mms and 16 mms the next day, then the 19 mm follicle definitely should ovulate and the 16 mm follicle may or may not.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
Monterey, California, U.S.A.

Was My IUI Triggered Prematurely?

Question:

Hello, I just had my first IUI (intra uterine insemination) this past Tuesday and although the doctor was not happy with my follicles after Gonal f, he decided that I should trigger anyway with Ovidrel. The ultrasound the day of the trigger showed follicles 16.5mm, 16mm, 15.5mm and also some 13's, 12's and 10's. Were my follicles sufficient enough in size to produce a viable egg or two? :(( also do they continue to grow after Ovidrel? I had my IUI 34 hours after the Ovidrel injection.

I so desperately want a child and am not sure whether I even have a chance with this IUI! Please help. V. From the U.S.A.

Answer:

Hello V. from the U.S., I have to admit I don't understand at all why your doctor triggered you at this point? Why not wait for the follicles to grow bigger? Were they not responding to max stimulation? If you weren't on max stimulation then why not increase the dosage and wait?

In general, in order to achieve maturity, we will wait until the leading follicles are at least 18 mms. It is known, however, that if the follicles reach 16 mms then there is a chance that they will be mature at aspiration (retrieval) during IVF. But, I do think that the trigger was premature with your IUI. Yes, you might get three mature eggs, but all the follicles that are less than 16 mms will be immature. With an intra uterine insemination as opposed to in vitro fertilization, the picture is different. If the follicle does not reach 18-20 mms, it is unlikely that the follicle will ovulate despite HCG (Ovidrel). They do continue to grow a little, but the follicle has not reached ovulatory size.

I hate to burst your hopes, there is always a chance that a pregnancy can occur, but in general, I would not expect you to achieve pregnancy with this cycle because the trigger was premature thereby lessening the chance that ovulation will occur. I think you need to have a serious talk with your doctor and ask why he triggered so early! Was it a scheduling issue i.e. you would have reached maturity on the weekend and he would not have been able to do the IUI? Real infertility doctors work the weekends as necessary. I know that one of the local Ob/Gyn's in my area does not work the weekends. He cancels the cycle or turns it into a timed intercourse cycle if it falls on the weekend. If this is the case, I think you need to consider whether you want to continue to expend time and money on this doctor.

Good Luck,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.comMonterey, California, U.S.A.

HCG Trigger Shot Must Be Timed With Ultrasound Surveillance NOT With Calendar Dating When Doing IUI

Question:

I am writing from Hawaii with several questions. We will be undergoing our first IUI soon. The background is the following: I am 36 years old with no fertility factors. We decided to seek out fertility help because my husband, also 36, has an ejaculatory issue. I have been using Follistim AQ for the past 10 days and have two more days to go. My doctor instructed me to use my hCg shot at 11pm the night before my IUI. My first question is this, with only a 13 hour window between my hCg shot and IUI is this optimal? I have read that 36 hours is best.

Also, my normal cycle length is 26-27 days, I will be inseminated on day 16, will I still follow my normal cycle and expect to see my period on day 26? Should I ask my specialist for Progesterone supplements? I had 5 decent sized follicles 5 days ago, all between 10 and 12mm. Today during my ultrasound only 2 follicles were visible, one at 14mm and one at 15mm. I have been using a ClearBlue Easy fertility monitor, which said 3 days ago I was reaching peak fertility. Is it possible I already ovulated one or more egg? Thank you so much for your time. My doctor is a good doctor, but very busy and I often don't formulate my questions until after I have left the office. Mahalo! H. from Hawaii

Answer:

Hello H. from Hawaii,

First, let me say that I am a little skeptical of your doctor, based on your questions.

The optimal size for a follicle at ovulation is 18-20 mms. Using Follistim, your cycle should not be timed based on a calendar, but on the growth and size of your folllicles. In addition, at your age, the maximum number of ovulatory follicles should be no more than 3 because of the significant increased risk of a super-multiple if there is more than 3. So, the proper way to do this is daily ultrasound, if necessary, as your follicles reach closer to the 18 mm point. Once the follicle is 18 mm (my personal preference is 20mms), then the HCG shot is given and the IUI is done at 36 hours if only one IUI is done or at 24 and 48 hrs if two are done (My preference is the two IUI protocol).

The times don't have to be exact. The sperm just needs to be there reasonably close to ovulation and precede ovulation. Since it cannot be known exactly when ovulation occurs and it is know that it can take up to 12 hours for the egg to find and enter the tube, exact timing cannot be done. In general, follicles grow at 2mms per day but this can vary as well. That is why close ultrasound surveillance needs to be done as you get closer. If your doctor solely uses a calendar date, such as cycle day #16, there is a possibility of missing ovulation, which essentially dooms this cycle. In any case, based on a 27 day cycle (and counting backwards), you would ovulate at around cycle day #13 not #16.

I ALWAYS supplement with progesterone. It is an easy thing to do and there is no downside risks. If you have inadequate stimulation of progesterone in the luteal phase, you risk non-implantation and/or early miscarriage. I hate to take that chance when I can cover the risk by adding a little progesterone. I have written extensively regarding timing and doing IUI's in my blog. I would recommend you review that material and discuss your concerns with your physician.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Monterey, California, U.S.A.

Ovarian Follicle Size Is Key When Planning For Trigger Shot

Question:

Dear Doctor Ramirez,

I had 3 follicles when I received the trigger shot. 30mm 24mm and not sure what size the 3rd one was. Is the 30mm follicle a good size to have a mature egg to be released?

Thanks, G. from the U.S.

Answer:

Hello G. from the U.S.,

I'm sorry to say but those follicle sizes are way too big. The trigger should be given when the follicle is between 18-23 mms. Once larger than that, the egg becomes over mature and non-viable. In some cases the follicle will not ovulate and be retained as a retained physiologic cyst. This type of situation generally occurs when patients are seeing the wrong type of doctor. I would advise that you consider seeking out a specialist in infertility or at least an ob/gyn who knows how to monitor your cycle properly so that you trigger at the correct time.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com