A Little More About Normal Ovulation
Here is a question someone asked about the timing of hCG. It’s a good starting point for this blog.
“I am 40 and just had a failed first IVF cycle that resulted in all immature eggs (7 retrieved) after only 5 days of stims (follistim/menopur + ganirelix days 4 & 5) before the hCG shot.
The doctors were very surprised that by day 5 I had 7 follies 12 - 19 (more <10) and they said I had to trigger, my final E2 was only around 700. I had a good hCG level after the trigger.
I have never heard of anyone only stimming for 5 days. I am curious what your experience has been with people who are fast responders and what you recommend in terms of changing protocols? Do you believe that follicle size alone determines egg maturity or can a short follicular phase be a problem even with larger follicles?”
Figuring out the right time is not that difficult, but there are a few important factors that must be taken into consideration. We need to first start with a brief review of what happens in the natural menstrual cycle, then it will be easier to understand how the IVF cycle works. There are 3 important elements: the growing follicle’s schedule, estrogen levels, and the size of the follicle at ovulation.
Just a reminder: the follicle is the fluid-filled cyst that houses the egg. Each follicle has one egg. We can't see the egg on ultrasound because it's microscopic. But we can see the follicle.
The Growing Follicle’s Schedule: By the 2-3rd day of bleeding, the previous month’s follicle has disappeared and the new one, which has already been chosen, has not started to grow much. On ultrasound you may see it, but you may also see other small ones that look the same. It’s the FSH coming from the pituitary gland (the pituitary will be a blog to come) which causes the little follicle to start and continue to grow.
As the next week goes by, the chosen (or dominant) follicle gets bigger and bigger, until it ovulates somewhere usually between days 11 and 20, most often close to day 14. It’s pretty rare to ovulate before day 11, but not so rare to ovulate later. The day of ovulation is related when the follicle starts to grow, and the cycle length gives us a hint as to when this was. It takes about 2 weeks for the follicle to grow from tiny to big. That means for a 28 day cycle, the follicle grows till ovulation, usually day 14.
What if the cycles are, say, 35 days? Well it still takes the 2 weeks to grow, it just starts later. So for a 35 day cycle the early follicle sleeps for about a week, then wakes up and starts growing day 7 and ovulates day 21. We don’t know what causes these differences.
What if the cycle is 24 days? In this case the follicle probably takes less than 2 weeks to grow, so 2 weeks is not mandatory. Again, the reason for these differences are unknown.
Estrogen Levels: As the follicle grows, it makes more and more estrogen, so the blood levels of estrogen rise each day. The estrogen is not coming from the egg, it comes from the tons of little ovarian cells (the granulosa cells) that surround the egg. The estrogen is probably not important for the egg, but one of estrogen’s very important jobs is to thicken up the lining of the uterus.
Estrogen’s second job is to cause the ovulation. The pituitary gland is constantly monitoring the estrogen levels, and when they get high enough, the pituitary dumps out LH (this is what your home ovulation kit reads) and this is what causes the egg to pop out.
There is not an exact estrogen level that causes the ovulation. Most of the time it’s anywhere from 150 to 350. Why there is a difference we do not know, it may be that there are other unknown hormones that work with the estrogen to get the job done.
Follicle Size: The size of the follicle is important too. Most ovulations occur with a follicle that is 20-25 mm(about one inch), but 16 mm is close to the bare minimum and 30 mm is close to the top size.
Next time we will talk about the timing of ovulation in an IVF cycle.
Thanks for reading,
Dr. Licciardi
“I am 40 and just had a failed first IVF cycle that resulted in all immature eggs (7 retrieved) after only 5 days of stims (follistim/menopur + ganirelix days 4 & 5) before the hCG shot.
The doctors were very surprised that by day 5 I had 7 follies 12 - 19 (more <10) and they said I had to trigger, my final E2 was only around 700. I had a good hCG level after the trigger.
I have never heard of anyone only stimming for 5 days. I am curious what your experience has been with people who are fast responders and what you recommend in terms of changing protocols? Do you believe that follicle size alone determines egg maturity or can a short follicular phase be a problem even with larger follicles?”
Figuring out the right time is not that difficult, but there are a few important factors that must be taken into consideration. We need to first start with a brief review of what happens in the natural menstrual cycle, then it will be easier to understand how the IVF cycle works. There are 3 important elements: the growing follicle’s schedule, estrogen levels, and the size of the follicle at ovulation.
Just a reminder: the follicle is the fluid-filled cyst that houses the egg. Each follicle has one egg. We can't see the egg on ultrasound because it's microscopic. But we can see the follicle.
The Growing Follicle’s Schedule: By the 2-3rd day of bleeding, the previous month’s follicle has disappeared and the new one, which has already been chosen, has not started to grow much. On ultrasound you may see it, but you may also see other small ones that look the same. It’s the FSH coming from the pituitary gland (the pituitary will be a blog to come) which causes the little follicle to start and continue to grow.
As the next week goes by, the chosen (or dominant) follicle gets bigger and bigger, until it ovulates somewhere usually between days 11 and 20, most often close to day 14. It’s pretty rare to ovulate before day 11, but not so rare to ovulate later. The day of ovulation is related when the follicle starts to grow, and the cycle length gives us a hint as to when this was. It takes about 2 weeks for the follicle to grow from tiny to big. That means for a 28 day cycle, the follicle grows till ovulation, usually day 14.
What if the cycles are, say, 35 days? Well it still takes the 2 weeks to grow, it just starts later. So for a 35 day cycle the early follicle sleeps for about a week, then wakes up and starts growing day 7 and ovulates day 21. We don’t know what causes these differences.
What if the cycle is 24 days? In this case the follicle probably takes less than 2 weeks to grow, so 2 weeks is not mandatory. Again, the reason for these differences are unknown.
Estrogen Levels: As the follicle grows, it makes more and more estrogen, so the blood levels of estrogen rise each day. The estrogen is not coming from the egg, it comes from the tons of little ovarian cells (the granulosa cells) that surround the egg. The estrogen is probably not important for the egg, but one of estrogen’s very important jobs is to thicken up the lining of the uterus.
Estrogen’s second job is to cause the ovulation. The pituitary gland is constantly monitoring the estrogen levels, and when they get high enough, the pituitary dumps out LH (this is what your home ovulation kit reads) and this is what causes the egg to pop out.
There is not an exact estrogen level that causes the ovulation. Most of the time it’s anywhere from 150 to 350. Why there is a difference we do not know, it may be that there are other unknown hormones that work with the estrogen to get the job done.
Follicle Size: The size of the follicle is important too. Most ovulations occur with a follicle that is 20-25 mm(about one inch), but 16 mm is close to the bare minimum and 30 mm is close to the top size.
Next time we will talk about the timing of ovulation in an IVF cycle.
Thanks for reading,
Dr. Licciardi
posted by Dr. Licciardi at 8:04 AM
18 Comments:
Thank you so much for posting this description. I am very curious about what you mentioned about a 35-day cycle. Is it still possible to ovulate during a 55+ day cycle? I get the impression from what I've read that a cycle of that length is assumed to be anovulatory.
I've had two successful IVF rounds. One which resulted in my son, and now I'm pregnant again. First stim was 5 days, then a few days of coasting. Three years later the next stim was 13 days, I think. A LOT more days, different meds. I had worse OHSS the second time. I think I had better and more eggs with the 5 day stim, but then again I was three years younger.
Do you have any thoughts about ovulating very early on an unmedicated cycle? I used to have regular 28-31 day cycles until about 3 years ago. Then I started having amenorrhea and was diagnosed with PCOS. We've conceived twins once with clomid (and had a late miscarriage). Since the miscarriage, we have not been able to conceive despite me responding well to oral medications.
We decided to try an monitored unmedicated cycle. By cd 11 I had a lining of 8.7mm but no dominant follicle. I suspected ovulating around cd6-8 because of ovulation pain. The did a progesterone test to humor me and it came back positive.
My RE's office then suggested AMH testing because of the early ovulation. But I thought low AMH and ovarian reserve was inconsistent with PCOS.
Again thanks for this very informative blog!
I recently came across your blog and have been reading along. I thought I would leave my first comment. I don't know what to say except that I have enjoyed reading. Nice blog. I will keep visiting this blog very often.
I'm with Mad Hatter. Is there something wrong if my cycle days are 60 to 70 days long? And how can I track ovulation?
I tried IVF and ended up having a stroke!
Read about it here:
www.dreampregnancy.blogspot.com
Thank you for this blog. With so many fertility blogs out there, it's nice to see something informative and reliable.
I hate to add to the millions of questions you get, but if this sounds at all interesting to address, I'd love to hear what you think. I have PCO, and have been using clomid for six months. My son was conceived with clomid—tenth cycle!—after four early miscarriages (5 weeks...). Since starting to try again, I've had two more very early miscarriages. No doctor has seemed interested in exploring the miscarriage issue—chalking it up to chance.
Is there a better option than clomid, that's not as intense/expensive as IVF? I ovulate with clomid, and I even conceive. So what now...?
Mine is the last comment—I probably should have mentioned I'm only 28 years old.
Thank you for the valuable information! I’m doing a research on trying to get pregnant without success, and possible solutions.
I've managed to find much better care for my own issues after finding your blog and website. I cannot express enough thanks for letting me see how much better care I could find. You mentioned awhile back that you were going to blog on AMH testing, and I'm very interested in hearing your thoughts on this tool. I'm 36 with normal FSH levels with low normal AMH. Family history is early menopause (39 onward) and I'm wondering when the biological alarm clock will go from a beep to a howl. Months? Years?
Dear Dr.:
Thank you so much for your posting. It helps to know so much about the science of conceiving. I have had 3 IUI cycles with one Ectopic and 2 miscarriages. I had to have my right tube removed and on HSG have found a 0.5mm polyp in the left tube, but my dr. feels it is not a cause of problems. I am having all my karyotype testing and remainder of the tests done now. Does this make sense and will I ever conceive again?
This post has been removed by the author.
I just started reading your blog a couple of months ago Dr. Licciardi and you have very helpful information. I am 33 years old and have been trying to conceive for 3.5 yr. I just completed IVF #3 and is on two week week. My RE did a 2 day transfer this time which makes me nervous. 4 eggs were retrieved but 3 arrested and I have one embryo left that is 3 cell grade 1.5 (1 being the best and 5 the worst) . My RE thinks the embryo has more chances of surviving it the natural environment. What are your thoughts on this? My lining is 11.2 for this cycle. I am poor responder with diminished ovarian reserve and my FSH for this cycle is 9.1.
I am very curious about your comments re: ovulation and longer cycles. I tend to ovulate late (around CD21-32) and although I conceive easily (first try every time!) we have had 5 consecutive miscarriages. My husband and I have had tons of testing done and aside from Factor V Leiden heterozygous and possible lupus anticoagulant (negative and positive test results) we have nothing wrong health wise. We are both 30 and have been trying to conceive for 2 years. I'm drained from having 5 failed pregnancies, and I have always felt that there must be a link between my late ovulation and my miscarriages. Would the uterine lining be of poorer quality with a late ovulation? Could egg quality also be diminished, even though you mention that the egg "sleeps" until a bit later in the cycle?
Just curious what your thoughts on later ovulation are... My luteal phase seems to be of normal length.
I'm 31 and my husband is 38 now, this is the 4th year of our marriage. my first pregnancy was in last december and was ectopic. after that suffering infertility.
I have PCOS. now I'm under treatment, took clomid, 150 mg per day and now on Merional Injection,today is the 12 th day of my cycle. Today the follicle size is 13 mm. and we are going to do IUI in this month. [last two months I have good follicles, we expected twins , but nothing happened.HSG is normal for me. for my husband there is puzzle in the semen sample(we didn't understand)]we are so confused to take IUI (as with good follicles I failed with normal intercourse, , can you please explain what is IUI , and its success rate.
thank u doctor in advance, and your blog is very informative
A menstrual cycle evaluation may consist of many different components. You may need all or just some of the testing...Cialis Online
Dear Dr.
I'm 37 yr old with a 2 yr old son (conceived with IUI). Since then have had 6 failed IUIs and 2 failed IVFs...issue appears to be fertilization. The eggs are not fertilizing or activating (to form 2 pronuclei). Normal sperm counts and morphology. They told us to try again and they want to use Ca ionosphore with ICSI tx. I also seem to have a short stimulation i.e. only 7 days on microdose flare protocol. Should we try this or is it time to explore donor eggs?
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