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Infertility/Fertility/Follicle not getting ruptred

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Hi, its Isha from Saudia again. Thank u so very much for your answer. I am sorry for this much long detail, but I thought I should tell you.
Well actually, the dr. I am going to, always refused to do to do ultrasound after clomid and  giving me hcg shot. She just do TVS on mine 10th and 12th day of cycle to see that mine follicle is ready around 20mm to give me hcg shot. Whenever I requested her to do it later to, she says it obviously getting rupture because if its not then it should be there in the form of a cyst in next cycle.
So I thought to try another dr, she also did TVS upto the time to give me hcg shot after taking clomid, on mine request she did once later too on I think mine 14th day of cycle and said you were having 2 follicles one of 16mm and other one of 25mm, now after hcg shot one of 16mm is reduced to 14mm and other one got bigger of 31mm..she said may be 16mm one have been ruptured but there is very less chance of it, then she asked me have LH and FSH test on mine 2nd day of next cycle.
I had it..and then go to mine dr. again..she said  these results confirmed that you did’t ovulate and your’s follicle did’t ruptured. Because there is always a difference between both values and they are almost close as 1:1.
Here are mine FSH result 4.470mIU/ml and LH result 5.640mIU/ml
She asked me to double the dose of mine clomid..50 to 100mg and also double the hcg to 5000 to 10,000 in next cycle. She said by taking 100mg clomid  I will have more follicles and from where ovary wall would be thin, follicle would rupture and ova could release. She said If it did’t work to rupture the follicle then you need to have laparoscopy . She also said in TVS your’s ovaries did’t look like too much polycystic to me..looks close to normal.
I got scared of laparoscopy , and gone back to mine previous dr, i did take double dose, on which she was angry that why I take double,I was responding good on 50mg..so she did’t allow me to take 10,000 hcg shot…when I told her what the other dr said…she said just leave it..there is nothing like that.
In that cycle I had 4 follicles…2 were up than 10mm something and 2 were 17 and of 16mm respectively.it was mine 10th day and she said to take hcg shot of 5000 on 11th day..which I take.
I had ultrasound from some outside clinic on mine 13th day as mine dr. refused to do as usual. They were become smaller to 14 and 15mm.
Now I don’t know exactly I ovulated or not 
Mine dr. said to have one month rest…no medicine or injection.. and come to me after 1 month on your 2nd day of cycle for IUI, when u will come I will have your’s ultrasound to confirm you that you don’t have any follicle of last cycle which means you ovulated.
So I am on rest these days.
You said 50 mg of Clomid is not sufficient to induce ovulation..  So if I do ovulated on 50 mg, maybe i don't have PCOS. Well for this I will say last summer suddenly mine periods got delayed for 2 weeks…I gained weight from 58 to 65kg. I start to have more hair growth on mine body since that time, I had an ultrasound and dr. says you are having polycystic ovaries.
Mine dr. asked me to lose weight, for that I have been doing dieting, no sweets, & bakery products at all. Now I have 56 kg…trying to lose more…I should or not? I am 25 year old and of 5.4 height.
I have one more question…when follicle rupture, does follicle disappears or shrink immediately or it take some days…if it does take some days then how many?
All mine other tests are completely ok.

Answer
Hello Again,

I think your second doctor was closer the telling you correct information than the first doctor, who doesn't seem to know anything about reproduction.  However, neither doctor are infertility specialists.

1.  Just to help you with some knowledge let me share this information.  Clomid dosages range from 50 mg to 250 mg and the goal is to determine the appropriate dose to induce ovulation and increase the number of ovulatory follicles to three.  It is your doctor's job to determine the optimal dosage and that can only be done if ultrasound is used to see how you respond.

2.  Follicles must reach a minimum size of 16 mm in order to become mature and ovulate.  The generally accepted preference is for the follicle to be 18-20 mm at the time of HCG injection.

3.  If you are trying to verify ovulation after an ovulation induction cycle, there are only two ways to do this: (1) follow the follicles for 2-4 days after HCG to see the follicle(s) disappear.  Ovulation can occur between 24-52 hrs so only 1 or 2 days of surveillance may not be adequate.  If followed closely, the follicles will be there one day and gone the next to indicate ovulation. (2) A progesterone done on cycle day #21 or 22 will be an indirect measure that ovulation occurred.

4.  PCO is a clinical diagnosis and patients must have at least 2 of the PCO criteria to have the disease.  These include at least irregular menses and then either an elevated LH/FSH ration (LH 2 times or higher than FSH), elevated testosterone level, obesity, elevated insulin, PCO type ovaries on ultrasound.

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.

for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on twitter with me at @montereybayivf and facebook @montereybayivf.  Skype and internet comprehensive consultations now available via my website for those who want a more extensive evaluation that this site can accommodate

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Edward Joseph Ramirez, MD, FACOG

Expertise

I am a specialist in infertility and advanced gynecological care. I can answer questions about infertility, gynecology related ills, menopause...virtually anything that affects women's health. PLEASE tell me where you are writing from as I am always interested.

Experience

I have been practicing as an Ob/Gyn and Infertility Specialist for over 23 years. Gynecology, advanced laparoscopic surgery, basic infertility, IUI's, IVF, reproductive surgery, and ovulation induction are all areas of my expertise. I am Board Certified. I have been doing In Vitro Fertilization in my clinic for 19 years.

Organizations
American College of OB/GYN, American Board of Obstetrics and Gynecology, American Society of Reproductive Medicine, Society of Assisted Reproductive Technology, American Association of Gynecologic Laparoscopists, Fellow of The American College of Obstetricians & Gynecologists,Resolve-National Chapter, Open Path - Northern California, Board of Directors Monterey Medical Society

Publications
American Journal of Obstetrics and Gynecology, Wall Street Journal, Monterey Herald, SERMO, Women's Health and Fertility Blog

Education/Credentials
Medical Degree from Stanford University, Residency at Tripler Army Medical Center, Reproductive Training at Pacific Fertility Center, San Francisco

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