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Infertility/Fertility/Large number of follicles but very low estradiol


Hi, I am from Huntington Beach, CA. After taking birth control pills consistently (without blanks) after my son was born eight years ago, my body never went back to a normal cycle, and I was diagnosed as hypothalmic hypogonadism.  The only way I can get a period is by using injectable estradiol and then provera.  I started my first IUI cycle of Follistim injections, but after taking 75 per night for 12 days, I had approximately 8-10 follicles in each ovary (sizes ranging from 7-23) but my estroidol level was only 340.  My doctor advised me to cut the dose of Follistim in half (37.5) so I could take it for 5 more days.  My doctor said the larger follicles will probably die off in the meantime, but is it possible that I could ovulate only the larger follicles before returning next week and deciding whether to trigger with HCG?  My doctor also said it's possible that none of my eggs would be good in this first cycle anyway, and if my estradiol doesn't rise significantly, the cycle would be cancelled and I would be put on birth control pills before restarting Follistim.  My doctor hasn't been testing any other hormone levels (LH, progesterone, etc). My husband has a morphology issue (4%) so do you believe we should skip IUI and go directly to IVF?  What do you recommend next?

Hello Lisa,

"Hypogonadotropic hypogonadism" is a condition whereby the hypothalamus does not function correctly and therefore does not stimulate the pituitary to produce FSH and LH.  Since both are required, the appropriate treatment is to provide both FSH and LH either as a single medication (Menopur) or two Medications (eg Follistim (FHS) and Luveris (LH)).  Follistim alone does not tend to be sufficient.

In your case, you mentioned that you have 8-10 follicles but the size ranges are from 7-23.  Only the follicles over 16 mms are relevant and have the potential to ovulate.  The fact that your estradiol is low means that there are NOT than many follicles that are growing to maturity (estradiol levels tend to reflect the number of maturing follicles), which means that most of those follicles are not doing anything.  The 23mm follicle has actually reached maturity size and should have been triggered to ovulate.  It is likely that it would be the only one to do so (ovulatory size is 17mms - 24mms).

Based on 2010 WHO parameters, the minimum percentage required for normal Morphology is 3%.  So, that means that your husband's morphology is normal.

You don't mention your age,which could be relevant in the strategic planning for your treatment, but at this point, I don't see why IUI would not be appropriate, given that you are seeing the correct doctor who knows what he/she is doing.

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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