Follicle Friday!

So this morning was the big scan to see if the drugs were working and see if we were ready for the next phase! This included an internal ultrasound scan to see if the gonal-f injections had worked and I was producing eggs.

Normally you produce one egg a month from one-side (we all know that) - these drugs are aiming to produce as many eggs as possible (safetly) from both sides. Going into the clinic I felt sick anyway but also nervous - as I reported yesterday I was sure there was going to be nothing there. Dr Bond reassured me saying ‘thin girls are normally ready earliest’.

The scan was painless and to our delight showed approx 13 lovely follicles. Nine on one side and the rest on the left side. They have to be 20mm in length for them to consider the next move. Mine were all between 8 and 15mm so had a little way to go. To this end I am being left to cook them a little bit longer over the weekend to try and get more of a 20mm size to use.

This explains the follicle stimulation phase:

Ovarian Stimulation Protocols for IVF

In order to maximize success rates with in vitro fertilization we want a good number of high quality eggs from the woman. We generally want to get about 8-15 eggs at the egg retrieval procedure.

IVF success rates correlate with the number of eggs retrieved with IVF.

There are several ovarian stimulation medication protocols that are used to “pump up” the ovaries to make sufficient follicles and eggs. Without stimulating medications, the ovaries will only produce one follicle and mature egg per menstrual cycle (month).

Follicles in 3D ultrasound view from stimulated ovary
3D ultrasound view of multiple follicles in an ovary stimulated for IVF
A computer in our 3D ultrasound machine calculates accurate follicle sizes
A larger version of this image is shown below

All of the commonly used IVF regimens include injections of a medication containing follicle stimulating hormone - FSH. Injectable FSH products are sometimes referred to as “gonadotropins”, or Human Menopausal Gonadotropins, HMG.

The most commonly used ovarian stimulation protocols for IVF are:

Luteal Lupron protocol also called “long Lupron”, or agonist “down regulation”
Antagonist protocols that involve use of of the GnRH antagonist medications
Flare and micro-flare protocols, also called short Lupron protocols, or short protocols are used for patients expected to have a low response to ovarian stimulation

IVF stimulation protocols in the US generally involve the use of 3 types of drugs:

A medication to suppress the LH surge and ovulation until the follicles are mature.
There are 2 classes of drug used for this:
- GnRH-agonist (gonadotropin releasing hormone agonist) such as Lupron
- GnRH-antagonist such as Ganirelix or Cetrotide
FSH product (follicle stimulating hormone) to stimulate development of multiple follicles
- Follistim, Gonal-F, Bravelle, Menopur
HCG (human chorionic gonadotropin) to cause final maturation of the eggs

The woman is stimulated with the injectable FSH medications for about 8-12 days until multiple mature size follicles have developed.

What is the goal of a good IVF ovarian stimulation?

With ovarian stimulation for in vitro fertilization, the goal is to produce approximately 8 to 15 follicles that will give quality eggs at the egg retrieval procedure.

We do not want to have overstimulation of the ovaries which can lead to significant discomfort for the woman and in rare cases can result in ovarian hyperstimulation syndrome, OHSS.

We also do not want the ovarian stimulation to be insufficient and only give us a few eggs if we might have been able to obtain more by using higher medication doses, etc.

IVF can be successful with a very low number of eggs retrieved, but success rates are substantially higher when more than a few eggs are recovered.

Learn more about the number of eggs at retrieval and IVF success rates

With the ovarian stimulation, the job of the infertility specialist doctor is to:

Select a proper medication protocol and dosing regimen

Monitor the patient’s stimulation progress so that medication doses can be adjusted properly

Trigger with hCG at the ideal time. Triggering to early or too late reduces success and can sometimes increase the risk for ovaian hyperstimulation (if triggerred late).

Stimulated ovary for ivf
Ultrasound of multiple follicles (black areas) in a stimulated ovary
Yellow cursors outline a 15 mm diameter follicle
Most mature sized follicles (about 15-20 mm diameter) will give mature eggs at retrieval

Using the latest 3D ultrasound technology to obtain precise follicle measurements

Quality control throughout the entire process is very important with in vitro fertilization. One of the ways that we have improved quality control in our program is by using highly specialized ultrasound equipment.

We use a GE Voluson E8 ultrasound machine with a computer built-in that can outline and accurately measure the developing follicles.

We have found that this method is more precise and reliable as compared to the traditional method - which is usually manual measurements in two dimensions.

The computer in the machine traces the borders of the follicles (in three dimensions). It then calculates a volume for each follicle. From the volume it calculates an average diameter for each follicle - as if the follicle was a sphere.

This technology gives us more accurate and reliable measurements of the follicles than we had in the past.

2D and 3D ultrasound pictures with all 3 planes in stimulated ovary
Ultrasound picture shows the three planes in a volume of data from one ovary
This patient is near the end of IVF stimulation - numerous follicles seen in the ovary
Upper left = sagittal plane, upper right = transverse plane, lower left = coronal plane
At lower right is a 3-D view of the follicles (generated by the computer)
See below for close up views of the same images

Stimulated follicles with outlines
Close-up view of the transverse plane (from the same image above)
Computer generated tracings of follicles are different colors

Rendered 3D view of ovary stimulated for IVF
Close-up of the 3D view of the follicles (from the same image above)
The computer in the machine created this “rendered” image from a captured volume of data

How is the monitoring of the IVF stimulation done?

We try to stimulate the woman to get at least 4 follicles with sizes of 14-20mm diameter.

Ideally, there would be at least 8 follicles between 13-20 mm for IVF.

The goal is to get a good number (about 8-15) of quality eggs

Blood hormone levels and developing follicle sizes are monitored.

Ultrasound is used to measure the follicles (discussed above on this page)

Estrogen hormone blood levels are important. Estrogen (actually estradiol) levels are usually under 60 pg/ml at cycle baseline and rise significantly as multiple follicles develop.

Peak estradiol levels in IVF at the time of HCG are usually between 1000 and 4000 pg/ml.

The stimulating process usually takes about 8-10 days

Estrogen hormone levels in IVF cycle
Graph showing estrogen hormone levels during an IVF stimulation
Estradiol starts low and rises to 1000 to 4000 pg/ml by the time of the HCG injection

The HCG injection is given when the estrogen level and the follicle measurements look best for successful IVF outcome. The HCG shot is needed to induce final egg maturation.

The egg retrieval is planned for 34-35 hours after HCG injection - shortly before the woman’s body might start to release the eggs (ovulate).

See a sample calendar that shows timing of office visits and IVF procedures

How many follicles do you need in order to get pregnant with IVF?

Usually, it is not difficult to get enough follicles to develop. However, sometimes the response of the ovaries is poor - and a low number of growing follicles are seen. The ability of the ovaries to stimulate well and make numerous follicles can be predicted fairly well by an ultrasound test - the antral follicle count.

The minimum number of follicles needed to proceed with IVF treatment depends on several factors, including follicle sizes, age of the woman, results of previous IVF stimulations and the willingness of the couple (and the doctor) to proceed with egg retrieval when there will be a low number of eggs obtained.

In our experience, IVF success rates are very low with less than 3 mature follicles.

Some IVF doctors will say that you should have at least 5 follicles of 14mm or greater while others might do the egg retrieval with only one follicle. Most IVF programs in the US want a minimum of about 3-4 mature (or close to mature) follicles.

Women that are more likely to be low responders to ovarian stimulation would be those that have low antral follicle counts, those women who are older than about 37, women with elevated FSH levels, and women with other signs of reduced ovarian reserve.

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Hope that helps explain what I am doing. I am currently growing 13 eggs to try and get the best result.

If on Monday they say I am ready to go - it will mean that they will be taken out on Wednesday next week. This is both good and bad. Of course I will be excited to get going on actually making our baby but it looks like it might come at a price.

The embryo will be put back in on either Friday, Saturday or Monday. This clashes with one of my best friends wedding. I am going to ask on Monday if they can make sure I can have very early appointments so that it doesnt interfere as I am supposed to be doing her hair and make-up. I feel so stressed and feel that everything is going to go wrong. My friend will end up hating me if I am not there for the whole weekend and then I might not get a baby anyway. I am so sad that this is all coming at the same time.

I am worrying about everything - what if I get ill next week too and add that into the equation. I am trying to stay away from anyone ill but people dont understand when you say you need to stay away. I always feel like I am fighting against everything and I dont know how much fight i have left. Do I believe in fate - as all the signs are saying this is the wrong time.

BUT I am thrilled obviously with my follies as it looks like I have a lot to work with.

I have done this early as I have had horrendous nausea all day and am going to bed. Trying to look after myself as much as possible.

Night all

xxx

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