Op here - I am going to trigger tonight. My retrieval is scheduled for Sunday morning. It is with Dr. Lauren Roth. She is from SGF's office in Frederick. Apparently she is on duty this Sunday in Rockville. Anyone had experience with her?

NP here - I agree with what all the other posters have said. I'm the poster who posted about having been a patient at both GWU and SGFC in your previous thread. I will say that it sounds like you are just stressed which is exactly where almost everyone going through stims is at this point. That will not change from SGFC to GWU to any other clinic. A follicle from 15mm - 23mm might all be in play. Once you trigger, follicles do still grow and so for example, that 15mm on the day you trigger might very well be 17/18mm 36 hours later at the time of retrieval. Additionally, some patients just produce larger follicles and so while 23mm is larger than normal, that may still be in play or they may sacrifice that one because the majority of your other follies will get to the average size they are looking for if they allow you to stim another day.

Regarding your question about a cyst - it is very difficult to tell the difference between a cyst and an actually follie once stims is underway. That is something that you typically catch at your first appointment after you start stims or before at baseline, and even that can be difficult to "catch". Cysts typically are larger than 10mm so that is something also to keep in mind. For all intents and purposes on the ultrasound they look just like a follicle but they won't produce estrogen. I had a 14mm cyst on one cycle with SGFC. It was my first monitoring appointment of that particular cycle and the tech thought it was a dominant follie. Everything about it looked like it could be a follie but I begged my Dr. to monitor it as I was pretty sure it was a cyst - why - simply because on my previous IVF cycle, I got a cyst from the bcps. The only way they could be sure it wasn't a dominant was by having me come in every single day of that IVF cycle to watch it and my estrogen levels. Sure enough, we were able to establish that it wasn't a cyst around day 6/7 or so and so I did not have to start ganirelex prematurely (I was on an antagonist protocol). I credit my doctor at SGFC for being willing to listen to my concern and use the tools at her disposal to confirm what I was concerned about. That 10mm "cycst" may very well be just a new follie that popped up, which follies continue to do throughout stims. It's nothing to concern yourself with as it is not in play.

Here's what you really need to be focused on during monitoring: Your lining measurement (and note this also can change from day to day including go down towards the very end of stims depending on where they measure it); your estrogen level; your lh number; and the approximate number of follies you have that are likely to be "in play" size wise.

Anonymous wrote:There isn't a way for a follicle to shrink, as such. But it is a squishy three-dimensional object that the ultrasound is only seeing a two-dimensional slice of. So it is not unusual for the measurements to fluctuate up and down.

I can understand why you want to know whether and, if so, how much a follicle grows between the last ultrasound, the end of stimulation, and between the trigger and retrieval. I hope it isn't too frustrating to say that it doesn't really matter. This is all about the odds, and from a statistical process control perspective, what matters is (1) the last measurement, (2) the process adjustment, and (3) the ultimate success rate. In other words, the protocol is optimized based on what was seen at everyone's last ultrasounds.

There is some evidence that adding follicle measurements to total estrogen levels doesn't significantly improve the quality of the decisions about how much to stimulate and when to trigger. Generally, they will be looking for an appropriate rate of increase and a level that is consistent with the number and size of follicles seen.

Thanks so much for in depth explanation!

There isn't a way for a follicle to shrink, as such. But it is a squishy three-dimensional object that the ultrasound is only seeing a two-dimensional slice of. So it is not unusual for the measurements to fluctuate up and down.

I can understand why you want to know whether and, if so, how much a follicle grows between the last ultrasound, the end of stimulation, and between the trigger and retrieval. I hope it isn't too frustrating to say that it doesn't really matter. This is all about the odds, and from a statistical process control perspective, what matters is (1) the last measurement, (2) the process adjustment, and (3) the ultimate success rate. In other words, the protocol is optimized based on what was seen at everyone's last ultrasounds.

There is some evidence that adding follicle measurements to total estrogen levels doesn't significantly improve the quality of the decisions about how much to stimulate and when to trigger. Generally, they will be looking for an appropriate rate of increase and a level that is consistent with the number and size of follicles seen.

Anonymous wrote:I'm sorry you are frustrated and that you don't seem to be getting clear information from the clinical team. What they're trying to do is to maximize the number of mature (but not too mature) eggs on the retrieval date. There's a certain window of follicle sizes--say, from 14mm to 19mm--that are statistically most likely to contain such eggs; the lower and upper limits change depending on the protocol and other factors (agonist suppression generally means the follicles will be bigger). Smaller ones might contain mature eggs and larger ones might still be fine. There might also be independent reasons to trigger early, say if E2 is getting too high and they're worried about PCOS or if the P:O ratio is skewing. Because the follicles are growing, and at varying rates, different sets of them will be passing through this window at any point in time. Each day is a snapshot and they're trying to project how many follicles will be in the optimal range for the retrieval.

So really they've been telling you incomplete, but not inaccurate or inconsistent things. An 18mm follicle is likely to contain a mature egg; a 15-16mm one less so. A 13mm might not be that likely now, but could grow and move into the optimal window of sizes with more stimulation. And once the biggest follicle reaches 21mm, that might be a good time to trigger if it turns out that all of other ones, though smaller, are in that window.

Thank you so much for shedding some light on this question. I am absolutely unsure about every single follicle I have due to conflicting findings each day.
Can you please tell me if follicles actually grow more after the trigger?
My dominant on the right ovary is 20.3 as of today. If I have 48 more hours off stimulation plus a trigger, will it get out of the range and become unusable?
What about estrogen - is there a number range it has to be before trigger?
Can follicles shrink?

I'm sorry you are frustrated and that you don't seem to be getting clear information from the clinical team. What they're trying to do is to maximize the number of mature (but not too mature) eggs on the retrieval date. There's a certain window of follicle sizes--say, from 14mm to 19mm--that are statistically most likely to contain such eggs; the lower and upper limits change depending on the protocol and other factors (agonist suppression generally means the follicles will be bigger). Smaller ones might contain mature eggs and larger ones might still be fine. There might also be independent reasons to trigger early, say if E2 is getting too high and they're worried about PCOS or if the P:O ratio is skewing. Because the follicles are growing, and at varying rates, different sets of them will be passing through this window at any point in time. Each day is a snapshot and they're trying to project how many follicles will be in the optimal range for the retrieval.

So really they've been telling you incomplete, but not inaccurate or inconsistent things. An 18mm follicle is likely to contain a mature egg; a 15-16mm one less so. A 13mm might not be that likely now, but could grow and move into the optimal window of sizes with more stimulation. And once the biggest follicle reaches 21mm, that might be a good time to trigger if it turns out that all of other ones, though smaller, are in that window.

OP here - I have few more days of stimulation and I am getting tired of the sono team. Today, two of my follicles "shrunk" significantly compared to all previous days (not sure how is something like that biologically possible) and one was found to be a 10 mm cyst even though it was called a follicle all through out monitoring (13 days in and 5 monitoring appointments).
I hear different takes on follicles from everyone: one tech said that at least 3 need to be 18mm for trigger, another said that 16 and 15mm ones could also be fertilized but at a lower success rate, one said that even a 13mm has a chance to catch up, while my nurse says that 21mm is needed for trigger.
I am fed up. I want clear answers as to what kind of follicles are needed for trigger and why. I also want consistency between one appointment to another. I guess I am not going to get that at SGF.
I understand that lots of people are satisfied with the clinic. I guess they had better experience than me and I am glad for that.

I just finished my first retrieval cycle at SG, and from my experience, the time that the techs spent tracking down and measuring each follicle dramatically increased as I approached the end of my stims. My ovaries love to hide, so my counts were all over the place during my first few ultrasounds. (And I completely understand your worry -- I went on an emotional dive the day that I suddenly "lost" 8 follicles -- but then at my next appointment, they found them again!)

Once I got close to "triggering size," the techs were routinely referring to the previous day's count and trying to make sure they were all accounted for, so I would give it a few more days and see if your tech's counts don't get more specific the closer you get to triggering.

Also, I had a great tech who understood my worries and told me that since you are sedated during retrieval, they will actually be much more aggressive with the pressure they use while doing the ultrasound during your retrieval so they can make sure they get every last follicle.

Good luck and don't be shy about asking for details. Everyone's information comfort level is a little different and chances are, if your team knows you need more info to feel confident, they will start giving it to you.
Good luck!!!

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:OP, I don't know what your insurance or financial situation is, but if this cycle doesn't work out, I'd recommend a consult with Cornell. They, like GW, only have doctors do the monitoring. In fact, they get a bit touchy if you do local monitoring in DC too far into a stim cycle as they prefer to do it themselves - and the blood draws - in order to make changes to protocol. They've tweaked DW's stims very specifically (she's done 4 cycles there) in the past, and they do the same with the trigger.

As for your endo, having a cyst on your ovary could very well affect the quality of the eggs your produce. This was Dr. Braverman's theory when my wife started working with him for immune issues (while continuing IVF with Cornell), and she subsequently got a lap under his advisement. They found endo on ovaries, and a few other places as well. The thing is, they often can't tell how extensive endo is until they get in there, take a look, and, in many cases, excise it. Whether it was the laparoscopy, the immune meds, or just luck, DW did get pregnant after all of that is now about 30 weeks.

FWIW, we left SG because DW was a more difficult case and we got kind of tired of doing so much advocating for ourselves. It became exhausting, and quite honestly working with Dr. Davis at Cornell was a breath of fresh air after that.

OP here - thanks so much for this. I've been told my several REs as well as a regular gynecologist that removing the cysts would cause endo particles not visible to naked eye to spread all around uterus and ovaries and cause growth of new endo. Apparently endo and its particles are "alive". If you are grossed out by this picture believe me I was too. It sound like something from a Frankenstein movie. Another reason why all these people were opposed to me having lap is that that would remove any nascent antral follicles from the ovary, since the cyst is kind of embedded within the ovary. Another point that they all made is that the cyst would probably shrink during pregnancy, however that endo would come back with vengeance after pregnancy. So, who knows. I am definitely open to immune meds and I am planning to explore this option too. I am also trying to get an appointment with a gynecologist who specializes in endo to get a different opinion about laproscopy. I feel that no matter what I do endo is there as a factor to worry about. So far, SGF has not made any comments about the cyst being problematic and after trying to talk to them several times about it they kind of dismissed it. Not sure what to think about that.

OP - were you the one who posted about the endometriosis a few days ago? Yes, it will shrink once you get pregnant and will disappear completely as well. I had an endometrioma when I started the process and it went away. In fact, I am going through another cycle now with another endometrioma.

Thanks, yes it was me. So, you opted for no laparoscopy also? Did it affect your pregnancy outcome (pre-term labor, preclampsia, etc.?) What are they telling you in terms of egg quality and an active endometrioma being there? Are you doing any immune protocols? Endometriosis is so elusive and there are two different schools of thought (pro and against laproscopy).

As I said in the other thread, I did do a laparoscopy to remove 4 endometriomas from one ovary. It wasn't so much for fertility reason as it was for pain. A few months later, I started the IVF cycle and I had another endometrioma that grew on the same left ovary. It didn't affect my pregnancy outcome. Everything was fine. My RE wasn't concerned about the quality but the number of eggs. I had 18 eggs retrieved in total.

What a great outcome! It's comforting to know that one can get pregnant and give birth despite endometriomas.

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:OP, I don't know what your insurance or financial situation is, but if this cycle doesn't work out, I'd recommend a consult with Cornell. They, like GW, only have doctors do the monitoring. In fact, they get a bit touchy if you do local monitoring in DC too far into a stim cycle as they prefer to do it themselves - and the blood draws - in order to make changes to protocol. They've tweaked DW's stims very specifically (she's done 4 cycles there) in the past, and they do the same with the trigger.

As for your endo, having a cyst on your ovary could very well affect the quality of the eggs your produce. This was Dr. Braverman's theory when my wife started working with him for immune issues (while continuing IVF with Cornell), and she subsequently got a lap under his advisement. They found endo on ovaries, and a few other places as well. The thing is, they often can't tell how extensive endo is until they get in there, take a look, and, in many cases, excise it. Whether it was the laparoscopy, the immune meds, or just luck, DW did get pregnant after all of that is now about 30 weeks.

FWIW, we left SG because DW was a more difficult case and we got kind of tired of doing so much advocating for ourselves. It became exhausting, and quite honestly working with Dr. Davis at Cornell was a breath of fresh air after that.

OP here - thanks so much for this. I've been told my several REs as well as a regular gynecologist that removing the cysts would cause endo particles not visible to naked eye to spread all around uterus and ovaries and cause growth of new endo. Apparently endo and its particles are "alive". If you are grossed out by this picture believe me I was too. It sound like something from a Frankenstein movie. Another reason why all these people were opposed to me having lap is that that would remove any nascent antral follicles from the ovary, since the cyst is kind of embedded within the ovary. Another point that they all made is that the cyst would probably shrink during pregnancy, however that endo would come back with vengeance after pregnancy. So, who knows. I am definitely open to immune meds and I am planning to explore this option too. I am also trying to get an appointment with a gynecologist who specializes in endo to get a different opinion about laproscopy. I feel that no matter what I do endo is there as a factor to worry about. So far, SGF has not made any comments about the cyst being problematic and after trying to talk to them several times about it they kind of dismissed it. Not sure what to think about that.

OP - were you the one who posted about the endometriosis a few days ago? Yes, it will shrink once you get pregnant and will disappear completely as well. I had an endometrioma when I started the process and it went away. In fact, I am going through another cycle now with another endometrioma.

Thanks, yes it was me. So, you opted for no laparoscopy also? Did it affect your pregnancy outcome (pre-term labor, preclampsia, etc.?) What are they telling you in terms of egg quality and an active endometrioma being there? Are you doing any immune protocols? Endometriosis is so elusive and there are two different schools of thought (pro and against laproscopy).

As I said in the other thread, I did do a laparoscopy to remove 4 endometriomas from one ovary. It wasn't so much for fertility reason as it was for pain. A few months later, I started the IVF cycle and I had another endometrioma that grew on the same left ovary. It didn't affect my pregnancy outcome. Everything was fine. My RE wasn't concerned about the quality but the number of eggs. I had 18 eggs retrieved in total.

Anonymous wrote:You will encounter this issue at any clinic you go to. Technicians don't count follicles below a certain size during stimming. This causes variability in what counts as a follicle, especially since they are eye-balling the sizes.

They most definitely are not eyeballing. They're taking length/width measurements in a two-dimensional plane (or, in some cases, using semi-automatic 3D volumetric counting).

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:OP, I don't know what your insurance or financial situation is, but if this cycle doesn't work out, I'd recommend a consult with Cornell. They, like GW, only have doctors do the monitoring. In fact, they get a bit touchy if you do local monitoring in DC too far into a stim cycle as they prefer to do it themselves - and the blood draws - in order to make changes to protocol. They've tweaked DW's stims very specifically (she's done 4 cycles there) in the past, and they do the same with the trigger.

As for your endo, having a cyst on your ovary could very well affect the quality of the eggs your produce. This was Dr. Braverman's theory when my wife started working with him for immune issues (while continuing IVF with Cornell), and she subsequently got a lap under his advisement. They found endo on ovaries, and a few other places as well. The thing is, they often can't tell how extensive endo is until they get in there, take a look, and, in many cases, excise it. Whether it was the laparoscopy, the immune meds, or just luck, DW did get pregnant after all of that is now about 30 weeks.

FWIW, we left SG because DW was a more difficult case and we got kind of tired of doing so much advocating for ourselves. It became exhausting, and quite honestly working with Dr. Davis at Cornell was a breath of fresh air after that.

OP here - thanks so much for this. I've been told my several REs as well as a regular gynecologist that removing the cysts would cause endo particles not visible to naked eye to spread all around uterus and ovaries and cause growth of new endo. Apparently endo and its particles are "alive". If you are grossed out by this picture believe me I was too. It sound like something from a Frankenstein movie. Another reason why all these people were opposed to me having lap is that that would remove any nascent antral follicles from the ovary, since the cyst is kind of embedded within the ovary. Another point that they all made is that the cyst would probably shrink during pregnancy, however that endo would come back with vengeance after pregnancy. So, who knows. I am definitely open to immune meds and I am planning to explore this option too. I am also trying to get an appointment with a gynecologist who specializes in endo to get a different opinion about laproscopy. I feel that no matter what I do endo is there as a factor to worry about. So far, SGF has not made any comments about the cyst being problematic and after trying to talk to them several times about it they kind of dismissed it. Not sure what to think about that.

OP - were you the one who posted about the endometriosis a few days ago? Yes, it will shrink once you get pregnant and will disappear completely as well. I had an endometrioma when I started the process and it went away. In fact, I am going through another cycle now with another endometrioma.

Thanks, yes it was me. So, you opted for no laparoscopy also? Did it affect your pregnancy outcome (pre-term labor, preclampsia, etc.?) What are they telling you in terms of egg quality and an active endometrioma being there? Are you doing any immune protocols? Endometriosis is so elusive and there are two different schools of thought (pro and against laproscopy).

Anonymous wrote:

Anonymous wrote:OP, I don't know what your insurance or financial situation is, but if this cycle doesn't work out, I'd recommend a consult with Cornell. They, like GW, only have doctors do the monitoring. In fact, they get a bit touchy if you do local monitoring in DC too far into a stim cycle as they prefer to do it themselves - and the blood draws - in order to make changes to protocol. They've tweaked DW's stims very specifically (she's done 4 cycles there) in the past, and they do the same with the trigger.

As for your endo, having a cyst on your ovary could very well affect the quality of the eggs your produce. This was Dr. Braverman's theory when my wife started working with him for immune issues (while continuing IVF with Cornell), and she subsequently got a lap under his advisement. They found endo on ovaries, and a few other places as well. The thing is, they often can't tell how extensive endo is until they get in there, take a look, and, in many cases, excise it. Whether it was the laparoscopy, the immune meds, or just luck, DW did get pregnant after all of that is now about 30 weeks.

FWIW, we left SG because DW was a more difficult case and we got kind of tired of doing so much advocating for ourselves. It became exhausting, and quite honestly working with Dr. Davis at Cornell was a breath of fresh air after that.

OP here - thanks so much for this. I've been told my several REs as well as a regular gynecologist that removing the cysts would cause endo particles not visible to naked eye to spread all around uterus and ovaries and cause growth of new endo. Apparently endo and its particles are "alive". If you are grossed out by this picture believe me I was too. It sound like something from a Frankenstein movie. Another reason why all these people were opposed to me having lap is that that would remove any nascent antral follicles from the ovary, since the cyst is kind of embedded within the ovary. Another point that they all made is that the cyst would probably shrink during pregnancy, however that endo would come back with vengeance after pregnancy. So, who knows. I am definitely open to immune meds and I am planning to explore this option too. I am also trying to get an appointment with a gynecologist who specializes in endo to get a different opinion about laproscopy. I feel that no matter what I do endo is there as a factor to worry about. So far, SGF has not made any comments about the cyst being problematic and after trying to talk to them several times about it they kind of dismissed it. Not sure what to think about that.

OP - were you the one who posted about the endometriosis a few days ago? Yes, it will shrink once you get pregnant and will disappear completely as well. I had an endometrioma when I started the process and it went away. In fact, I am going through another cycle now with another endometrioma.

You will encounter this issue at any clinic you go to. Technicians don't count follicles below a certain size during stimming. This causes variability in what counts as a follicle, especially since they are eye-balling the sizes.

Anonymous wrote:
I am concerned about disparity form one monitoring to another and as you put it well between technicians' skills and those of doctors on the retrieval day. There seem to be many cooks in the kitchen. One may be better than the other.

The technicians do thousands of these scans every year; they're just as good as the doctors at making reliable measurements. Moreover, at any reputable institution, and that includes SGF, there's going to be a re-read/retrospective image review quality control process. Just as with blast grading by embryologists, they are keeping a very close eye on outliers.