101. Follicle Ultrasounds Explained: Better Outcomes for Fertility

Have you ever wondered why we order mid-cycle follicle ultrasounds when you're trying to conceive? This episode unpacks exactly how these ultrasounds improve fertility care by:

✅ Tracking if you ovulate—and how well
✅ Adjusting your medication in real time
✅ Detecting issues like unruptured follicles
✅ Assessing uterine lining for implantation readiness

Dr. Minjeur shares Brittany’s story of moving from “just take the meds” advice to a truly personalized approach—highlighting how careful ultrasound monitoring turned confusing, frustrating cycles into confident, successful ones.

If you're tired of guesswork in your fertility journey, this episode shows how restorative reproductive medicine offers real answers, real monitoring, and real hope.

✨ Ready to work with our team? Book a free discovery call at radiantclinic.com.

Transcript

Monica: 0:01

Welcome back to Cycle Wisdom, where we empower women to restore natural menstrual cycles, to improve health and promote fertility. I'm your host, Dr. Monica Minjeur, and I am so glad you're listening today. Have you ever wondered why we order a mid cycle ultrasound when you're trying to conceive naturally or with medication support? Today on cycle wisdom, we're going to unpack exactly how follicular ultrasounds help us to assess ovulation. Not just whether or not you've ovulated, but also the quality of that ovulation. We also use these ultrasounds to monitor your response to medications, to look for problems like an unruptured follicle, and evaluate the lining of your uterus to give you the best chance at pregnancy without the guesswork. So let's get started, as always, with a patient story of mine who we'll call Brittany. Now Brittany came to us as a 29-year-old and she had been trying to conceive for the past two years. She had been appropriately diagnosed with mild PCOS or polycystic ovarian syndrome. Her OB doctor had told her to just take some letrozole and come back and see them. If that didn't work in the next three months. Now Brittany worked as a mechanical engineer and as a part of that, she was very focused on wanting to understand what interventions made, what difference, and what actually was going to help move the needle for her. She came to us saying that she was feeling very anxious and overlooked after she was told to just take the medication without any follow up. So one of the first things that she wanted when she came to our clinic was a better understanding of if this was the right medication and how to understand if it was working well for her. So as always, we got, Brittany started with charting her cycles. We continued forward with our standard baseline lab work, and in her case, we did order some mid-cycle ultrasounds to be done. Now, one of the things we found prior to starting any medication treatment was that her ultrasound showed multiple small follicles with no dominant follicle that was being formed. So this was one of the things that helped us to determine what Britney needed for medication. We carefully adjusted her dosage of her stimulation, medication cycle after cycle. Unfortunately, she also had some cycles where she had unruptured follicles, so the follicle matured and was there and just never released that egg, which also meant that she wouldn't have been able to get pregnant on those cycles. Initially on her ultrasound, we found a thin endometrial lining or the lining of the uterus, so we discussed different medications to help support, especially her estrogen levels. Over the course of the next four cycles, we started to see significant improvements, not just on her lab work, but also on the ultrasounds. We found that she developed one healthy, dominant follicle each cycle, and she no longer was having the unruptured follicles. The lining of her uterus did begin to thicken, so where she had nine to 10 millimeters every cycle, and after a few months, she was able to conceive naturally. Brittany described this level of care as feeling truly seen and confident because she knew that the interventions we were providing were making the real time changes that she needed in order to be able to conceive. So why do we even do follicle ultrasound? Tracking ovulation isn't just a calendar event or something that shows up on your fertility awareness chart. It's a biological process that we can visualize from ultrasounds. Now, as a reminder, follicles are growing typically from the start of your menstrual cycle up through the time that you actually ovulate and they grow on average, one to two millimeters per day. Typically we should find on ultrasound that there is one single dominant follicle on one ovary per cycle. So that's one of the first things that we're looking for is, is that we want to see is there a follicle isn't dominant, and do we see any other concerning features? So for example, as was in Britney's case, initially we saw multiple small follicles that were trying to compete to ovulate. But never actually getting to that mature follicle state. And this is fairly common in women that have PCOS. We also are always going to be tracking and looking for other anatomic variations, as well as the lining of the uterus, which we'll talk about in a little bit here. In restorative reproductive medicine, we don't just assume ovulation has occurred because we see an LH shift or a temperature shift or a mucus observation. We want to document that that has happened with those ultrasound findings and to optimize it when necessary. So what are the things that we can do to help optimize this ovulation? Now, if you want to know more about some of these medications, go back a few episodes. Episode number 94, I talked about ovulation induction. Without the guesswork, and this is where we talk about some of these medications that can really help us to understand, is this improving ovulation or is this the right medication that we need? So follicle ultrasound scanning tracking is what we utilize in order to monitor our response to these ovulation medications like Letrozole or Clomophine. And these medications are not a one size fits all, so we need to be able to adjust the dosages on these medications, determine if this is the right fit, and most importantly, we want to make sure that it is the right fit for you. When we monitor, not based on just our lab findings, but also on the ultrasounds, it helps us to avoid an under response. So for example, if we don't have a dominant follicle, then we're not able to conceive on that cycle. It also allows us to make dosage adjustments either in the middle of that cycle or in following cycles. And most importantly, it helps us to prevent ovarian hyperstimulation, which can be a very serious condition where we give too much stimulation to the ovaries, and all of a sudden are producing multiple, multiple follicles each cycle. This also allows us to work towards maintaining a healthy singleton pregnancy. Now, lots of our patients would be very excited to have twins, but again, we know that a singleton pregnancy typically has fewer complications for both mom and baby. So ideally, we're wanting to utilize these medications for a single pregnancy at a time. When we are looking at these scans, we're looking at a few different things. So typically we try and time those scans, the first one to be done a couple of days before ovulation. Now, there's a lot of different ways that different restorative reproductive medicine physicians do this. Some of them will do an ultrasound scan every other day until ovulation. Some of them will try and limit the number of scans that are needed to be had. But in our practice, we typically try and aim for about two to three days prior to ovulation. What I'm looking for at that time is to track the number of follicles, how many dominant follicles do we have, and generally we know if it's a dominant follicle based on its size in relationship to others as well as individually. Ideally, we're also looking at this time to see what's the lining of the uterus and make sure that we don't have other multiple follicles growing on the other ovary. This allows us to track and monitor. What do we predict that the size of that follicle will be when it is supposed to rupture? So for example, if I scan you today, and I've got you on five tablets of Letrozole, and we say, okay, that scan shows that you have a dominant follicle and it is 19 millimeters in. And I find out that you ovulated based on your other biomarkers about three days later. I can estimate that if you were 19 millimeters on the day of your ultrasound three days later, that follicle was probably around 21 to 24 millimeters in size, which is a very normal size for ovulation. That tells me that our dosage of letrozole is appropriate, and if it was a single follicle, that means we're on the right track. On the other hand, if we do that scan and we say that you actually ovulated three days later, but initially that follicle was only 12 millimeters, then probably the very largest that follicle could have been would be around 16 to 17 millimeters. Probably a little smaller than that, and that's a little bit on the low side as far as a dominant follicle. So it may help us to decide we need to have more letrozole. So that's the first scan, and then we repeat the second scan again after ovulation. And ideally, we wanna look around two days after ovulation because that's going to show us if that follicle has ruptured or released the egg that's there. Again, we want to see that that follicle is starting to decrease in size because the fluid around that egg has been released, and we should see that that follicle is starting to shrink down. Now, different doctors will look at different numbers, but ideally we're looking for a decrease in size of around five millimeters from its largest size. So again, if I am estimating that that follicle got up to 25 millimeters, when I follow it up on ultrasound a couple of days after ovulation, I should see that that dominant follicle is somewhere closer down to 20 millimeters or less in order to prove that it has actually ruptured or released that egg. The other thing I'm looking for when I check an ultrasound scan after ovulation is going to be the lining of the endometrium, and that's going to give us a good idea of is everything optimal in order to allow implantation to occur? So what's the optimal lining that we're looking for of that endometrium? So in general, our goal should be at least eight to 12 millimeters and have what we call a trilaminar appearance. Which means we've got three different layers that are creating that nice, fluffy bed in order for implantation to be able to occur. If we have a thin lining that's seen, so if your lining of your uterus is less than seven millimeters, it reduces your chances of implantation. This can sometimes be secondary to estrogen deficiency or sometimes from the effects of the other medications we are utilizing. For example, ch Clomid or c clomophine can actually thin the lining of the uterus, even if it's stimulating the ovaries. Now Letrozole typically has less impact on this, but it's still worth evaluating because we do have cases sometimes where Letrozole creates too thin of a lining. Checking for how thick that uterine wall is helps us to determine and make sure that we've got the appropriate amount of support for estrogen levels. We are adequately dosing any ovulation stimulation medications, and it allows us to make sure that we are complimenting everything we're doing with lifestyle and nutrition-based goals. So, for example, with Brittany, we started off with having a very thin lining and she was on Clate initially. After that point in time, we switched her over to Letrozole plus some estrogen support during her luteal phase and in the follow-up ultrasound, she was able to get that nine millimeter lining. Which is much more appropriate, and that's actually the cycle that she conceived. So really important that we take this into account is not enough just to say, do the lab numbers look okay? Have I ovulated? Does it look like the biomarkers are there? But we really wanna be able to back it up with the proof from those ultrasound findings that we are seeing, what we expect to see. So this is one of the big benefits of the comprehensive approach that we have within restorative reproductive medicine. It is not just a visit where we say, well, hopefully this'll work out. Take this medication, see you later. Come back if it's not working in the next three months. Instead, we're combining multiple modalities, including what we see on our fertility awareness method, charting our basal body temperature, our mucus observations, sometimes the urinary LH metabolites. We combine that with our hormone labs, again, typically checking a luteal phase, estrogen and progesterone levels. And then combine it and top it off with getting those serial ultrasounds to make sure that not only are the things we're expecting to see happen, but also making sure that we are optimizing all of our treatment courses. This approach allows us to have a personalized, ongoing evaluation of what's happening with each patient cycle. It allows us to adjust the medications appropriately to make sure we are not under-treating or over-treating, and it also allows us the opportunity to pair together with our patients in order to have a better understanding day by day of what's going on with their ovulation each cycle. We find that this approach over time helps to build patient confidence when they're able to see that yes, indeed you did ovulate and it confirms what we see on your charting. It helps to reduce those anxiety levels. As was the case with Brittany having this very objective data saying, this is how large the follicle is, this is how thick the endometrial lining is. All of those things helped us to work together and work forwards in order to be able to track what was going on and give real time adjustments when they were needed. So if you've been feeling lost in the fertility maze or told to just take your medications without monitoring them or confused about if you're even ovulating properly, please know that there is a better way forward. At Radiant Clinic, we believe your care should be personalized, thorough, and focused on restoring your natural fertility health. Imagine having a team that tracks your progress with you, adjusts your plan in real time, and helps you to understand every step of the way. If you are ready to feel empowered on your journey towards working through fertility, check us out. I would love to help you start finding answers together. If you're ready to work with our elite team of healthcare professionals, go to our website, radiant clinic.com to schedule a free discovery call and learn more about our package based pricing for comprehensive care. We are currently able to see people for in-person appointments in our Cedar Rapids, Iowa Clinic, or can arrange for a telehealth visit if you live in many different states across the us. Check out our website for current states that we can serve medical clients and let us know if your state is not listed to see if we can still cover you there as we are constantly expanding our reach, please note that our fertility educators are able to take care of clients no matter where they live. Thank you so much for listening to this episode. Please share this podcast with someone in your life who would benefit from our services. Remember to subscribe to this podcast for more empowering content that I look forward to sharing with you on our next episode of Cycle Wisdom.