Infertility/Fertility/immature follicles


Hi Dr. Ramirez:
I have had a problem with immature follicles in the past during all my IVFs. I had one cycle where no eggs were retrieved with 5 follicles above 18 and estrodial at 1950. The next 2 IVF's ended in the retrieval of 3 eggs with 6 follicles above 18 and estrodial at 2000. The last 2 IVF's we used 10,000 HCG and a Lupron trigger to retrieve eggs. Between both these cycles we have frozen a total of 4 Grade A 3 day 8 cell, 10 cell, 12 cell, 14 cell with 10% fragmentation embryos. With this information, I am wondering if it would be worth trying an IUI or TI with a double trigger and letrozole. I usually get 2 mature follicles on Letrozole. I am thinking the problem is immature eggs and obviously I have low AMH.  Orginally thought it was egg quality. What are your thoughts? I am 41 with severe endometriosis. We have done no transfers yet.

Hello Mary from the U.S. (Colorado),

I can't give you an exact analysis of your cycles without review of the medical records but can give some general feedback.

Certainly based on the number of mature eggs retrieved versus number of follicles your follicle maturity rate is not too good.  In my practice it would be below threshold as I measure the number of eggs retrieved/total follicles and expect 50%.  This could be because you are not being stimulated strongly enough (not enough medication) or our doctor is not waiting long enough before trigger.  The "ART" in IVF is to determine when to trigger, which takes into account the number of mature size (>15 mms) versus immature follicles with the goal to have the largest number of mature sized follicles as possible.  Sometimes I will sacrifice my larger follicles to get more of the smaller ones to grow.  Certainly your peak E2 levels have been adequate, but my goal is a peak E2 of 2000-4000.

In addition, in my practice, I culture my embryos to blastocyst stage (D#5) before freezing.  The newest literature/studies show this to be the optimal time for cryopreservation.

Also, I don't think it is an HCG or Lupron problem because you have mature eggs at retrieval.

Again, without review your records I can't make any specific recommendations.  Certainly at 41 years old, egg quality is a major problem, even if you have mature eggs retrieved.  Will IUI be better? Some experts think so in older poor responder patients and some studies have shown that, but I personally don't think so.  If you go through IUI, your body has to go through 7 of the 10 reproductive steps on its own and despite a good egg, it may fail at some other point in the process.  Whereas, with IVF 7 of the steps are accomplished for you and only 3 steps left to natural processes.  For that reason I think IVF is more efficient and effective.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program

Monterey, California, U.S.A.

for additional information check out my blog at 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.  I also now provide an Email Concierge Advisory Service with a 1 year subscription for patients that want easy access to me to answer questions along their journey (women's health, infertility, pregnancy).  Contact me at if you are interested in continuous access to me.


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Edward Joseph Ramirez, MD, FACOG


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.


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.

American College of OB/GYN, American Board of Obstetrics and Gynecology, American Society of Reproductive Medicine, California Medical Association, American Association of Gynecologic Laparoscopists, Fellow of The American College of Obstetricians & Gynecologists

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

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

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