After a year and a half of trying, I have just learned that each of my ovaries produces approximately 10 follicles, but all are very small (1-2mm, the largest being 5mm). I understand that the normal size of a follicle just before ovulation is about 20mm. Does this mean I am not ovulating? Progesterone, FSH and LH surge are all normal. Will Clomid help?

Jackie

Each ovary has hundreds of thousands of eggs. Each egg is surrounded by a group of cells called the cumulus cells. Together, the egg and these cells are called a follicle. The cumulus cells maintain the egg in a state of suspended animation until such time that the follicle receives a signal (as yet, we do not understand this signal) to resume growth, ultimately leading to ovulation.

Each month, hundreds of eggs start to grow. Luckily for us, only one or two typically make it to ovulation; the rest of the egg/follicle combinations stop growing. If they didn't, octuplets would not be such a rare occurrence. In some women, the follicles stop growing before they completely develop, anywhere from 2-6mm in size. This is a hallmark of polycystic ovary syndrome (PCOS). These partially developed follicles surround the outer margins of the ovary; on ultrasound, they produce what is called the "necklace sign," because the small dark follicles look somewhat like the beads in a necklace. The condition is often associated with an excess production of male hormones and irregular menses. Hormonal analysis is important before making a diagnosis to make sure other medical conditions that mimic PCOS are not present.

Recent studies have identified an association between PCOS and insulin resistance, a mild pre-diabetic condition. While clomiphene is often initially prescribed, depending on testing, other medications may be prescribed to lower insulin levels. If these approaches fail, either laparoscopic ovarian drilling (draining the small fluid-filled ovarian follicles) or injectable ovulation induction medications should be considered.

For more information about PCOS, see my many other columns on this subject, or check the website for the Polycystic Ovarian Syndrome Association.