What are the implications of having multiple ovarian follicles?

From the Guidelines

Multiple ovarian follicles are a common finding in women with polycystic ovary syndrome (PCOS) and can be diagnosed using transvaginal ultrasound (TVUS) with a cutoff value of ≥25 follicles per ovary, as recommended by the 2014 Androgen Excess and Polycystic Ovary Syndrome Society 1. The presence of multiple follicles can be due to various factors, including hormonal imbalances, and can be a sign of conditions like PCOS or a response to fertility treatments. For women with PCOS experiencing multiple follicles, treatment often includes lifestyle modifications such as weight loss and regular exercise, combined with medications like metformin (500-2000mg daily) to improve insulin sensitivity, as supported by a systematic review and diagnostic meta-analysis published in 2024 1. Hormonal contraceptives like combined oral contraceptive pills can regulate cycles and reduce androgen levels. For those undergoing fertility treatments, medications such as clomiphene citrate (50-150mg daily for 5 days) or gonadotropins are used to stimulate follicle development, but require careful monitoring to prevent ovarian hyperstimulation syndrome, as highlighted in the acr appropriateness criteria for female infertility published in 2020 1. Regular ultrasound monitoring is essential during treatment to track follicular development and adjust medication dosages accordingly, especially during fertility treatments where the goal is controlled stimulation of multiple follicles. Key points to consider in the diagnosis and management of multiple ovarian follicles include:

• Using TVUS to diagnose PCOS, with a cutoff value of ≥25 follicles per ovary 1
• Implementing lifestyle modifications and medications like metformin to improve insulin sensitivity in women with PCOS 1
• Utilizing hormonal contraceptives to regulate cycles and reduce androgen levels
• Carefully monitoring women undergoing fertility treatments to prevent ovarian hyperstimulation syndrome 1.

From the Research

Multiple Ovarian Follicles

• Multiple ovarian follicles can be a result of ovarian stimulation, which is a common treatment for infertility 2.
• Ovarian hyperstimulation syndrome (OHSS) is a potential complication of ovarian stimulation, and it can be life-threatening 2, 3.
• The development of OHSS is associated with increased vascular permeability, which can be triggered by the administration of human chorionic gonadotropin (hCG) 3.
• The use of dopamine agonists, such as cabergoline, can help prevent OHSS by inhibiting the phosphorylation of the VEGF receptor 2 (VEGFR-2) 3.

Ovarian Stimulation and OHSS

• Ovarian stimulation with follicle-stimulating hormone (FSH) or human menopausal gonadotropin (hMG) can increase the risk of OHSS 4, 5.
• The risk of OHSS can be reduced by using recombinant FSH (rFSH) instead of hMG, although the difference in risk is not always significant 4, 5.
• Coasting, which involves withholding gonadotropin stimulation for a period of time, can also help reduce the risk of OHSS 6.

Treatment Options

• Gonadotropins, such as rFSH or hMG, are commonly used for ovulation induction in women with polycystic ovary syndrome (PCOS) 4, 5.
• The choice of gonadotropin may depend on the individual patient's needs and medical history, as well as the cost and convenience of the treatment 4.
• In vitro fertilization (IVF) is also a common treatment option for women with PCOS, and the use of hMG or rFSH can affect the outcome of the treatment 6.