What is the management plan for a dominant ovarian follicle on the left?

From the Guidelines

The management plan for a dominant ovarian follicle on the left should prioritize minimizing the risk of multiple gestations and ovarian hyperstimulation syndrome (OHSS) while optimizing pregnancy rates, as evidenced by the most recent and highest quality studies 1.

Key Considerations

• For patients undergoing fertility treatment with gonadotrophins, regimens with 75 IU or lower should be used to minimize multiple pregnancy rates while maintaining similar pregnancy rates 1.
• Human chorionic gonadotropin (hCG) injection may be administered when the follicle reaches 18-24mm to trigger ovulation, with timed intercourse or intrauterine insemination scheduled 24-36 hours later.
• In cases where more than two dominant follicles >15 mm or more than five follicles >10 mm are present at the time of HCG injection or LH surge, IUI should be withheld to prevent high rates of multiple gestation pregnancies 1.

Clinical Approach

• Monitoring follicle growth and development through ultrasound is crucial to determine the optimal timing for intervention.
• The decision to intervene should be based on the patient's reproductive goals, the presence of symptoms, and the risk of complications such as OHSS.
• Clomiphene citrate or tamoxifen may be considered as alternatives to low-dose gonadotrophins for reducing multiple birth rates and costs, although they may result in lower live birth rates 1.

Patient-Specific Factors

• The management approach should take into account the patient's individual characteristics, such as age, medical history, and reproductive history.
• Patients with a history of OHSS or multiple gestations should be closely monitored and managed to minimize the risk of recurrence.
• The patient's preferences and values should be considered when making decisions about treatment options and interventions.

From the Research

Management Plan for Dominant Ovarian Follicle on the Left

The management plan for a dominant ovarian follicle on the left involves several considerations, including the size of the follicle, the thickness of the endometrium, and the timing of ovulation induction.

• The size of the dominant follicle is an important factor in determining the management plan. Studies have shown that follicles with a diameter of 18-19.9 mm are less likely to result in luteinized unruptured follicle (LUF) syndrome compared to those with a diameter of ≥22 mm 2.
• The thickness of the endometrium is also an important factor, with thicker endometrium being associated with higher pregnancy rates 2.
• The timing of ovulation induction is critical, with human chorionic gonadotropin (hCG) typically administered when the dominant follicle reaches a diameter of 18-23 mm 2, 3.
• The use of letrozole or clomiphene citrate in combination with gonadotropins may also be considered, with letrozole being associated with lower incidences of LUF syndrome and higher pregnancy rates 2, 3.

Monitoring Follicular Growth

Monitoring follicular growth using transvaginal ultrasound is an essential part of the management plan.

• This allows for the tracking of follicular size and the timing of ovulation induction 4, 5.
• The use of vaginal sonography may be less valid for the left ovary compared to the right, due to the presence of the sigma, and therefore requires careful consideration 5.

Pharmacological Management

Pharmacological management of the dominant ovarian follicle may involve the use of gonadotropins, such as human menopausal gonadotropin (hMG) or recombinant follicle-stimulating hormone (FSH), in combination with letrozole or clomiphene citrate.

• The dose and duration of gonadotropin therapy will depend on the individual patient's response and the size of the dominant follicle 2, 3.
• The use of letrozole or clomiphene citrate may help to reduce the incidence of LUF syndrome and improve pregnancy rates 2, 3.