Ovulation Induction & Follicular Monitoring

Follicular Monitoring

Follicular monitoring is a timely and careful study of the follicle’s growth. It is a simple ultrasound procedure to see how and when the next egg will be released to be fertilized naturally or via assisted methods.

Follicular monitoring is a painless procedure that uses thin plastic probes attached to an ultrasound machine for transvaginal and flat probes for pelvic monitoring and is an essential part of assisted reproductive methods like IVF and IUI.

Follicular scans help in the following:

• Track the normal development of follicles, naturally as well as during medicated cycles
• Track the number of follicles
• Monitor the health and thickness of the intrauterine lining
• Adjust the dose of medication in cases of hormonal therapy
• Learn the exact timing of ovulation in the ovary so that natural conception and other procedures like IUI and IVF can be timed
• Identify and diagnose ovulation issues

It should be noted that follicular monitoring does not ensure ovulation and egg fertilization.

Who Can Benefit from Follicular Monitoring?

A follicular monitoring scan is typically prescribed by a certified obstetrician to be carried out on specific days of your menstrual cycle.

It is a helpful tool for women who:

• Cannot conceive naturally for more than one year of trying and have no defined infertility diagnosis
• Are over 35 years old and finding it difficult to get pregnant even after actively trying for 6 months
• Have PCOD/PCOS, an irregular cycle, irregular ovulation, or cycles of anovulation
• Take multiple medications for reproductive treatment like IUI and IVF
• Are unaware of when they are ovulating despite using ovulation kits
• Have experienced frequent miscarriages without any known specific cause
• Are on medicated cycles of FSH or clomiphene citrate to increase their chances of pregnancy.

Other benefits of follicular monitoring are as follows:

• It helps to rule out ovulation and follicle development issues if you are less than 35 years old and are actively trying to conceive for over a year.
• It helps to guide reproductive treatments that need ovulation-inducing medications and injections and detect complications like OHSS or luteal phase deficiency.

Follicular Monitoring Process

• Dr. Jagrati Laad will plan the follicular monitoring test depending on your menstrual cycle.
• For 24 hours until the follicular scan, the patient should not use vaginal douches, lotions, or powders and must abstain from sex too.
• Follicular monitoring typically starts on day 6 of a new menstrual cycle. It is calculated based on a typical 28-day menstrual cycle and continues until ovulation or day 21 in cases of anovulation.
• A clean transvaginal probe is inserted into the vagina to visualize the ovaries. It is preferred to be done on an empty bladder.
• Every scan takes 10–15 minutes; the first scan is known as the baseline reading. It can be mildly uncomfortable, but not painful. Understanding follicular development usually requires 5–7 scans per cycle.
• It is done every 2–3 days in the follicular phase and more frequently in medicated cycles and when nearing ovulation.
• Couples are advised to have intercourse nearing ovulation to increase the chances of pregnancy.
• Dr. Jagrati Laad may schedule artificial insemination depending on follicular scans.
• The follicular study also involves checking the endometrial lining to enable implantation and sustenance of a fertilized egg.

Interpretation of Follicular Scan Results

A follicular study helps visualize:

• Follicles that do not mature or stop growing mid-cycle
• Follicles that do not grow right from the start
• Dominant follicles that failed to rupture or over late
• If the endometrial lining is too thick or too thin
• Cysts or other structural abnormalities
• Tumors or growths

Abnormalities that can be detected in a follicular scan are:

• Low follicle count
• Tiny follicles
• Enlarged or shrunk ovaries
• Cysts and other blockages
• Thin/too-thick endometrial lining

Normal ranges for various parameters

Ovaries: Almond shape, 3–4 cm

Endometrial lining: 1–16 cm (differs every day of the cycle).

Follicle count (visible antral follicles) More than 12: High

Between 6–10: Normal

Less than 6: Low

Ovulation Induction

Ovulation issues reduce the chances of a successful pregnancy or can cause failed pregnancies. During regular ovulation, the ovary releases a mature egg to be fertilized by a sperm. It generally occurs between days 9–18 of a regular menstrual cycle. If the egg fails to fertilize, all the contents of the uterus and the unfertilized eggs get expelled from the body through menstruation. Unpredictable ovulation or ovulation after gaps of more than 35 days is termed oligoovulation. Anovulation is the absence of ovulation.

Ovulation induction is a process of assisted reproduction in which medications help ovulate the egg from the ovary after it reaches an ideal size. Ovulation induction increases the chances of a successful pregnancy by natural intercourse or during reproductive treatments like in-vitro fertilization (IVF) and intrauterine insemination (IUI).

Who May Benefit from Ovulation Induction?

This procedure will help women who form healthy follicles but with irregular ovulation/no ovulation due to:

• PCOS/PCOD
• AMH, LH, and FSH disturbances
• High testosterone levels
• General body disturbances like thyroid issues, diabetes, insulin resistance, eating disorders, and obesity
• Excessive workout

Ovulation induction is done along with IVF to control the number of mature eggs and their release at the right time (controlled ovarian hyperstimulation syndrome).

The Ovulation Induction Process

It uses several hormone-based medications to induce ovulation to help regulate the cycle and induce egg release.

Oral medications

• Clomiphene citrate: This medication helps in ovulation when the pituitary hormones are normal in the blood. It is popularly known as Clomid.
• Aromatase inhibitors: Popularly known as Femara or letrozole, it has a similar action as clomiphene citrate. It is generally helpful in PCOS.
• Insulin-regulating medication: Commonly known as metformin, this medication is helpful in patients who show symptoms of diabetes or prediabetes, which causes ovulation issues.

Injectables

• Gonadotropins include injectables of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), which help the egg mature correctly and ovulate on time.

It is sometimes seen that treating issues like weight gain, obesity, and thyroid problems also solves ovulation problems.

Benefits and Risks of Ovulation Induction

The benefits of ovulation induction include the following:

• It presents with high chances of egg fertilization and eventual pregnancy.
• It is the non-invasive first step to solving infertility.
• Low cost compared to IVF.
• It can be effectively used with other treatment options in cases of severe infertility.

Like with any medical treatment, ovulation induction also can cause side effects. For example, Ovarian Hyperstimulation Syndrome (OHSS). OHSS results in the formation of excess mature follicles in the ovaries, which may cause:

• Bloating
• Nausea
• Headache
• Hot flashes
• Weight gain
• Pelvic pain
• Blurry vision
• Rise in body temperature
• Swollen and bulky ovaries on sonography

In most cases, any side effects can be mild to severe but are self-clearing within a few days to a few weeks. They usually do not require any treatment. However, OHSS can lead to multiple egg releases and subsequent fertilization, especially in IUI or IVF. This means, it can result in multiple/high-risk pregnancies. Dr. Jagrati Laad will discuss this in detail during the consultation, and answer any questions you may have.

A Typical Medicated Cycle for Ovulation: Follicular Monitoring Along with Ovulation Induction

Oral medications: Depending on the medication Dr. Jagrati Laad decides, you may need to start oral medications from the fifth day of a new menstrual cycle for 3–5 days. Follicular monitoring typically starts from cycle day 9 through day 13 (every alternate day). After this, the scan is done daily from cycle days 14–18 to avoid missing the ovulation window.

Couples are advised to indulge in natural intercourse multiple times, or an IUI and IVF session is scheduled from 6 hours before expected ovulation till 48–72 hours later.

Injectables: FSH and LH injections are started from cycle day 3 or 5, every alternate day, for 6–12 days, and the follicles are monitored for growth. As injectables tend to induce faster follicle growth, the medication is tweaked as per the growing follicles.

A high dose of human chorionic gonadotropin (hCG) injection is given to induce ovulation on day 14/15 or when the desired number of mature follicles reaches the size of more than 19mm.

A follow-up scan is done to confirm ovulation.

Statistics for Follicular Monitoring and Ovulation Induction

Follicular monitoring has a generalized success rate of 10% every cycle. A study showed 17% success in the first attempt of IUI after a follicular study showed follicles more than 16mm in size. Clomiphene citrate–based ovulation induction shows success rates of almost 70–80% Aromatase inhibitors: For patients with PCOS but a BMI of under 30, Femara shows a success rate of almost 69%. Injectables have a success rate of 60–80% of ovulation, with over 50% resulting in pregnancies.

There are also several other factors that affect the chances of conception:

Age

Women under age 35 have better chances of conception.

Lifestyle Factors

• Non-smoking partners
• No drug use
• Caffeine use of fewer than 2 cups/day

Medical Conditions

• Previous pregnancies
• BMI of less than 30
• Thyroid disorder
• Cancers disrupting fallopian tube
• Non-cancerous tumors and polyps
• Fallopian tube damage and block
• Early menopause
• Pelvic adhesions
• Treatment of cancer for either male or female

Follicular monitoring can help predict the time of ovulation for assisted pregnancy when couples cannot get pregnant after months of actively trying. And ovulation induction is carried out in conjunction with the above procedure to ensure ovulation in cases of anovulation or during an IUI/IVF procedure to help a successful assisted-reproductive cycle.

For further detailed treatment plans, our gynecology and obstetric experts at Wombs Fertility & Reproductive Health Clinic, Pune are here to guide and help you in your infertility journey with the utmost care and proficiency. So contact us today!