FERTILITY AND STERILITY Vol. 40, No.

4, October 1983
Copyright © 1983 The American Fertility Society Printed in U.S.A.

Ultrasound measurement of ovarian follicles stimulated by human

gonadotropins for oocyte recovery and in vitro fertilization

Themis Mantzavinos, M.D.

Jairo E. Garcia, M.D.
Howard W. Jones, Jr., M.D. *

Department of Obstetrics and Gynecology, Eastern Virginia Medical School,

Norfolk, Virginia

Ultrasonic monitoring of ovarian follicles and estimation of serum estradiol (E2 )

were performed in 51 patients in whom oocyte aspiration for in vitro fertilization was
planned. All patients received human menopausal gonadotropin and human chorionic
gonadotropin. The daily growth rates of ovarian follicles were recorded ultrasonically
for 6 days prior to aspiration. Serum plasma E2 was determined daily during the
same period. Follicular dimensions based on the volume of aspirated fluid correlated
very well with the ultrasonic measurements. Follicular growth was correlated with
increasing peripheral blood E2 levels. The mean follicular diameter increased from
ZO.8 mm 6 days before aspiration to a maximum of 16.0 mm on the day of
presumptive ovulation in a group of patients characterized as low E2 responders. In
normal and high E2 responders, the values were from 9.7 mm and 10.5 mm to 16.9
mm and 17.6 mm, respectively. The mean sizes of the follicles by ultrasound 20 hours
before laparoscopy were 16.0 mm for the right ovary, 16.6 mm for the left ovary, and
18.5 mm in patients with only one ovary. At laparoscopy the mean diameters
calculated from the volume of the aspirated fluids were 17.5 mm, 17.4 mm, and 19.3
mm, respectively. Multiple follicles developed in all but 2 of the 51 patients.
Fertil Steril40:461, 1983

The possibility of ultrasound visualization of
preovulatory follicles has been demonstrated in a
series of articles. 1, 2
Ultrasonography has been used to monitor fol-
licular development and detect ovulation in
healthy women with regular menstrual cycles. 2
Later, the same procedure was used to monitor
ovulation induction by clomiphene citrate (CC) or
human gonadotropins in anovulatory infertility
patients. 3 -5 In recent years, ultrasound has be-
Received February 25, 1983; revised and accepted June 8,
1983.
*Reprint requests: Howard W. Jones, Jr., M.D., Department
of Obstetrics and Gynecology, Eastern Virginia Medical
School, 603 Medical Tower, Norfolk, Virginia 23507.
come a useful procedure in all in vitro fertiliza-
tion (IVF) programs. 6 , 7
This study reports experience in monitoring fol-
licular growth by ultrasound in normally cycling
women stimulated by human gonadotropins for
oocyte recovery and IVF.
MATERIALS AND METHODS
The ultrasound findings were studied in 51 pa-
tients who applied to the program for Vital Initia-
tion of Pregnancy (VIP) at the Eastern Virginia
Medical School between March 1 and May 31,
1982. Ovulation was induced with human meno-
pausal gonadotropin (hMG) (Pergonal, Serono
Laboratories, Inc., Randolph, MA) and human
chorionic gonadotropin (hCG). Two ampules of

Vol. 40, No.4, October 1983 Mantzavinos et al. Follicular size in in vitro fertilization 461
 ,..... 22 30
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.~ 8 10 12 14 16 18 20 22 24 26 28 30
o ~--~--~--~--~~--7---~--~
-5 -4 -3 -2 -1 0 1 Follicle Diameter by Ultrasound (mm)
Days
Figure 1· Figure 2
Curves of the daily average follicular growth until 1 day be- Correlation of the diameter of the largest follicle measured by
fore the aspiration in the left or the right ovary and in pa- ultrasound and by the aspirated follicular fluid at laparos-
tients with one ovary. copy.

hMG were administered daily, starting on the
third or fifth day of the menstrual cycle, in pa-
tients who had 28 ± 3- or 35 ± 3-day cycles,
respectively. The details of the ovarian stimula-
tion have been previously reported. 8 Each patient
was monitored by daily clinical evaluation of the
karyopyknotic index in a vaginal smear, the char-
acteristics of the cervical mucus, the dilatation of
the external os, and ultrasonograms of follicular
development. Daily blood samples were taken for
serum estradiol (E 2) determinations (Estradiol-
Pantex, Santa Monica, CA). The daily growth
rates of ovarian follicles were recorded ultrasoni-
cally by a real time sector scanner (ADR, Model
2140, Tempe, AZ), starting on the sixth day of the
cycle. The last ultrasonic examination in each
patient was done 1 day before laparoscopy, con-
sidered day O.
RESULTS
The ultrasonic monitoring of the patients was
started on the sixth day of the cycle, 3 days after
the start of hMG treatment. The mean diameter
of the largest follicle at this time was 8.1 mm for
the right ovary, 9.2 mm for the left ovary, and
10.7 mm for the patients with one ovary. Multiple
follicles developed in all but 2 of the 51 patients
by the time ofhCG injection. The mean number of
follicles was 2.27 for the right ovary, 2.08 for the
left ovary, and 3.2 for patients with one ovary. In
this series there were 15 patients with one ovary.
Based on the ultrasonic examination, Figure 1
shows the pattern of follicular growth for 6 con-
secutive days until 1 day before laparoscopy. The
values are summarized in Table 1. In patients
with one ovary, the follicular diameters were sig-
nificantly higher than in those with two ovaries
(P < 0.05 for the days 0, -1, - 2, and - 4, and P
< 0.01 for days - 3 and - 5).
A significant correlation (r = 0.7) was found to
exist between the follicular diameters estimated
on ultrasound and those derived from the vol-
umes offollicular fluid obtained at laparoscopy by
direct aspiration using the formula 4/31Tr3 (Fig.
2). The mean size of the largest follicle seen by
ultrasonography 1 day prior to laparoscopy was
16.2 ± 2.9 mm; and the mean diameter of the
follicles, which was calculated from the aspirated
volume of the follicular fluid, was 18.4 ± 3.2.
There was no statistical correlation between the
diameter of the largest follicle and the serum E2
level 1 day after the last hMG administration (r
0.037), but there was moderate correlation of

Table 1. Daily Growth of the Follicles Untill Day Before Aspiration

Day

-5 -4 -3 -2 -1 0

Right ovary 8.1 ± 0.8 8.2 ± 1.0 10.5 ± 1.5 12.9 ± 1.7 14.3 ± 2.8 16.1 ± 3.2
Left ovary 9.2 ± 0.9 9.6 ± 1.7 10.4 ± 1.8 12.5 ± 2.0 14.2 ± 2.0 16.6 ± 2.8
One ovary 10.7 ± 0.5 11.3 ± 0.8 12.7 ± 0.7 14.1 ± 1.2 15.8 ± 1.1 18.5 ± 3.8

462 Mantzavinos et al. Follicular size in in vitro fertilization Fertility and Sterility
 2500 2500
2250 2250
r =0.03
2000 2000 r = 0.5
E 1750 1750
"-
Ol
~
c. 1500 Ol
c. 1500
0
'6
~
1250
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1000 ~ 1000
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750
500
250
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18 21 27 0
0 3 6 9 12 15 24 30 0 2 3 456 7 8 9 W
Diameter of Largest Follicle (mm) Number of Follicles

Figure 3 Figure 4
Correlation of serum E2 levels and the diameter of the largest Linear progression of serum E2 levels and the number offolli-
follicle on the day of hCG injection. cles.

the E 2 levels with the number offollicles (r = 0.5) only the number and size of the follicles, but also
on the same day (Figs. 3 and 4). the side on which they are located.
The daily follicular growth and the correspond- The mean diameter of the largest preovulatory
ing E2 levels are shown in three different groups follicle in this study was 16.3 mm in patients with
of patients according to the E2 levels 1 day after both ovaries and 18.5 mm in those with one ova-
the last administration of hMG (Table 2). The ry. In normal cycles, O'Herlihy et al. lO reported
patients were classified according to E2 levels: the diameter of preovulatory follicles to be from
those with levels of 300 pg/ml and under were low 17 to 26 mm, Renaud et alY found the diameter
responders; those with levels between 301 and of the follicle the day before disappearance to be
600 pg/ml were normal responders; and those 27 ± 3 mm, and Vargyas et al. 12 reported that in
with levels> 600 pg/ml were high responders. 9 induction of ovulation with CC for IVF the mean
Among the low responders there was no signifi- follicular diameter was 22.1 ± 0.4 mm 1 day after
cant correlation (r = 0.33), in the normal re- the last dose of hMG. In induction of ovulation
sponders the correlation was moderate (r = 0.54), with gonadotropins, Sallam et al. 3 and Cabau and
and in the high responders the correlation was Bessis 5 reported preovulatory diameter of the
significant (r = 0.69) (Figs. 5 to 7). largest follicle to be 20 to 25 mm; and Y16stalo et
al.,4 15 to 22 mm. Both are somewhat lower than
those of the preovulatory follicle in the normal
DISCUSSION
cycle or in the CC-induced cycles.
The use of ultrasound has the advantage of giv- Smaller follicles were also found in this study,
ing a direct view of ovarian follicle development compared with those of normal cycles or with
in response to the administration of gonadotro- those of the cycles induced in anovulatory pa-
pins. In programs of IVF, ultrasound is particu- tients using CC or hMG/hCG. This could be relat-
larly useful because of its ability to determine not ed to the amount and the method of hMG admin-

Table 2. Daily Mean Follicular Diameter and E2 Levels Until 1 Day Before Aspiration in the Low, Normal, and High Responders
Low responders (n = 8) Normal responders (n = 31) High responders (n = 12)
Day E2 ± SD" Diameter ± SD E2 ± SD Diameter ± SD E2 ± SD Diameter ± SD
pglml mm pglml mm pglml mm

0 218.3 ± 120.8 16.0 ± 1.1 512.6 ± 191.8 16.9 ± 2.4 898.6 ± 250.2 17.6 ± 1.5
-1 183.6 ± 68.5 14.8 ± 1.2 436.8 ± 77.7 15.3 ± 1.8 810.6 ± 241.0 16.4 ± 1.5
-2 213.6 ± 120.2 14.2 ± 1.1 371.7 ± 95.3 13.8 ± 1.4 529.4 ± 114.5 15.0 ± 1.7
-3 194.8 ± 73.1 13.0 ± 1.0 251.9 ± 61.4 12".0 ± 1.6 340.5 ± 91.7 13.5 ± 1.4
-4 151.0 ± 60.1 11.4 ± 0.4 175.9 ± 60.0 10.7 ± 1.2 210.0 ± 66.4 11.6 ± 0.9
-5 121.0 ± 42.5 10.8 ± 0.4 126.7 ± 44.2 9.7 ± 0.9 125.2 ± 39.8 10.5 ± 0.6

aStandard deviation.

Vol. 40, No.4, October 1983 Mantzavinos et ai. Follicular size in in vitro fertilization 463
r·
.

900,
I
I
I _ Diameter
900,
I
I
I

~
800-1 " 0.33 800-1
I 0---0 Estradiol I
I I
I
700-1I mm 700-/ mm r·O.56
18 I 18
I I
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...... I
E
...... 800~I
~ I Cl
a.
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16

:g 500i (5
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0
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2
3001
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.
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II.
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r--,'f''''
I
_ Diameter
I
I I 8
I I 0---0 Estradiol
100-' 100-1
I I
I I
I I
I I I I ,
-5 -4 -3 -2 -1 o 1 -5 -4 -3 -2 -1 0 1
Days Days
Figure 5 Figure 6
The relationship of serum E2 levels and follicular growth The relationship of serum E2 levels and follicular growth
every day until ! day before aspiration in the low responders. every day until! day before aspiration in the normal respond-
ers.

istration or to the normal feedback mechanisms in this study, and the relation becomes more clear
in the normally ovulating women who comprised in the low responder and high responder groups.
our serIes. The use ofa real-time sector ultrasonograph for
In the type of hMG stimulation used in this monitoring follicular growth proved valuable, es-
study, endogenous gonadotropins, luteinizing pecially in those patients who had one available
hormone and follicle-stimulating hormone, are ovary and in patients who had had conization of
inhibited when the ovaries are exposed to a fixed the cervix or other procedures, making cervical
amount of follicle-stimulating hormone and lu- mucus unavailable, thereby precluding the abil-
teinizing hormone. 13 Because more follicles de- ity to maintain the patient's clinical estrogen re-
velop and all are responding to a fixed amount of sponse. However, the examination proved diffi-
gonadotropins, the growth of anyone may be lim-
ited. .
The ovarian follicles become visible on ultra- 900,
I
sound scan after 3 days of treatment with hMG, I
I
800-1
on the average. The initial mean follicular diame- I
I
ter was 8.6 mm for patients with both ovaries and 700-1
I
mm r· 0.69
10.7 mm for patients with one ovary. I
I

Follicular size calculated by the volume of aspi- E 600~

...... I
16
rated follicular fluid in most of our patients ex- ~ . I
5OO~
ceeded by a small margin the ultrasonic mea- (5 : 14
...
surements. This probably is because the last ul- ~ 400~I II.
o
U
II
trasonic examination was 1 day before laparos-
copy.
8j
300 1
: .2
"-
II
I ..J
I
In our study there was no statistical correlation

~
200-1
I _ Diameter
between the diameter of the largest follicle and I
I 0---0 Estradiol
100-1
the level of serum E2 1 day after the last dose of I
I
hMG. On the contrary, there was a moderate cor- I
I ! ,

relation between the number of follicles and the -5 -4 -3 -2 -1 o

E2 level. Days
Kerin et al. 14 reported that the rate of daily
Figure 7
follicular growth was best correlated with in- The relationship of serum E2 levels and follicular growth
creasing serum E2 levels. The results are similar every day until! day before aspiration in the high responders.

464 Mantzavinos et al. Follicular size in in vitro fertilization Fertility and Sterility
cult in some patients with dense adhesions from
previous surgery, in obese patients, or in patients
where gaseous bowel distention was present. In
all patients, ultrasound was used as a comple-
mentary method with daily serum E2 levels and
the daily evaluation of vaginal smears and cer-
vical mucus.
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WP, Campbell S: Ultrasound scanning of ovaries to detect
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2. Fleischer AC, Daniell JF, Rodier J, Lindsay AM, James
AE: Sonographic monitoring of ovarian follicular devel-
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3. Sallam HN, Marinho AO, Collins WP, Rodeck CH, Camp-
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ultrasonic scanning of ovarian follicles. Br J Obstet Gy-
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4. Ylostalo P, Lindgren PG, Nillius SJ: Ultrasonic mea-
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during induction of ovulation with human gonadotropins.
Acta Endocrinol (Copenh) 98:592, 1981
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1981
6. de Crespigny LJCh, O'Herlihy C, Hoult IJ, Robinson HP:
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Mantzavinos et al. Follicular size in in vitro fertilization 465