I am 32 years old PCOD patient with primary infertility. My LMP was 10 days before. I took tablet Letrozole 2.5 mg once a day for five days from the next day of my periods. Today is my eighth day. I had a USG today. Findings are, ET 3.6 mm, right ovary follicle is 11 mm, left ovary follicle is 1.8X1.2X1.8 cm. What am I supposed to do now? Shall I take tablet Progynova to build up endometrium. Is that follicle on left ovary a cyst?
Please guide me in the further course of action. You can prescribe me medicines, I can take it, as I am a gynecologist and I need guidance from an infertility specialist.
Welcome to icliniq.com.
As you are on day 8, ET (endometrial thickness) is low for the day of the cycle. You should be starting on Progynova (Estradiol) 2 mg one tablet twice a day for the next seven days. Your follicular scan days should be on day 11, 15 and 17. The follicles are appropriate for the age in the right ovary and are developing. The left ovary may be a simple cyst or late recruited follicle from the previous cycle but needs to follow-up with scan.
At a follicular size of 20 mm, you should be opting for injection hCG 10000 IU intramuscularly for initiating ovulation. If this is a timed intercourse cycle and not an IUI cycle, then intercourse should be started daily from the day of hCG injection, else IUI to be done after 36 hours of injection hCG administration after a TVS scan (transvaginal ultrasound) to confirm rupture of follicle and also endometrial thickness (target 8 to 9 mm).
Also progesterone-like tablet Susten (Natural Micronised Progesterone) 2000 mg one tablet twice a day can be started from day 16 for the next 10 days, to support pregnancy if fertilization occurs. On day 14 post ovulation, you may get a serum beta hCG test done to check for conclusive results with regards to pregnancy.
Thank you doctor,
As left ovary follicle is 18 mm, am I supposed to take injection hCG today or wait for right ovary follicle to grow? Is that supposed to increase the size of the cyst and left ovary?
Welcome back to icliniq.com.
We cannot conclusively label it as a cyst with 18 mm size at present unless a follow-up scan shows no increase in size. This may be a developing follicle so that next follicular study would be significant. It is always best to wait till 20 to 22 mm size of the follicle to initiate an hCG injection to allow follicles to mature entirely and then subject them to rupture.
They may rupture earlier before administration, then you may not need an hCG trigger at all, but the chances of conception with a possible immature egg which ruptured early in the cycle would be low, and one would have to accept that fact. Another important factor is the endometrial thickness at present. It has to increase to allow implantation if any, and pregnancy to be facilitated in this cycle if the left ovarian follicle ruptures naturally in the next two to three days.
So my advice would be to practice timed intercourse, depending on the result of your day 11 transvaginal scan, after reaffirming the status of the developing follicles in both ovaries. Please start Progynova from today.
Thank you doctor,
I agree that it is not prudent to take injection hCG today. Will taking Progynova comprise follicle growth of right ovary if taken from today? Or injection hMG is required?
Welcome back to icliniq.com.
Letrozole cycle should not be combined with injection hMG, but it can be done with a step-up a protocol with Clomiphene. Progynova should have been started on the third day itself for next 15 days along with Letrozole especially in PCOD cases where estrogenisation is compromised. So start Progynova now before its too late, to help better endometrialisation. The further decision can be based on the day 11 follicular scan report.
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