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Dr. Eric Daiter

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Dr Eric Daiter has served Monmouth and Middlesex Counties of New Jersey as an infertility expert for the past 20 years. Dr. Daiter is happy to offer second opinions (at the office or over the telephone) or new patient appointments. It is easy, just call us at 908 226 0250 to set up an appointment (leave a message with your name and number if we are unable to get to the phone and someone will call you back).


"I always try to be available for my patients since I do understand the pain and frustration associated with fertility problems or endometriosis."


"I understand that the economy is very tough and insurance companies do not cover a lot of the services that might help you. I always try to minimize your out of pocket cost while encouraging the most successful and effective treatments available."

NJ Center for Fertility and Reproductive Medicine - Infertility Tutorials

Mechanics of Ovulation (in Detail and Clinical Correlations)
A normal menstrual cycle requires a precisely timed series of events that interrelate to allow for regular ovulation. These events are important to understand since they allow physicians to manage your fertility care. They include:

* (1) development of a monthly pool of recruitable follicles.

Only the recruited follicles will respond to the signal to mature, which is a hormone named follicle stimulating hormone (FSH). Research suggests that this small group of recruitable follicles present at the onset of a cycle has actually been prepared specifically for the cycle over a 3-6 month period of time.

No recruited follicle will enter more than one cycle of maturation, so that if a follicle begins to mature with FSH stimulation the follicle will either ovulate or will degenerate during that month.

Clinical importance

Fertility medications called human menopausal gonadotropins (menotropins) have FSH as their active ingredient stimulating egg maturation. In the presence of excess amounts of FSH all recruitable follicles may develop simultaneously. At the time of maturation in cycles using fertility medication, there may be more than 10-25 mature eggs in the ovaries as compared to only one mature egg in the usual natural cycle.

The goal of menotropin therapy generally is to mature as many eggs as possible. Since only that month's recruited follicles can respond to FSH and develop you are not using eggs that would ever enter another cycle. Therefore, you will not have early menopause due to menotropin therapy.

* (2) FSH concentration increases a few days prior to the onset of menstrual flow.

Circulating FSH concentration changes throughout the cycle such that only one mature egg is usually produced at ovulation. FSH concentration increases prior to the onset of menstrual flow which rescues some of the eggs within that month's recruitable pool of follicles from degeneration. These eggs begin to mature.

Within the first 5-7 days of the cycle one of the developing follicles out competes the others for available FSH. This becomes the "dominant follicle" that normally goes on to ovulate.

It is uncommon for 2 eggs to mature simultaneously in a cycle, with the twinning rate for natural cycles in the USA about 1 in 80 to 1 in 90 pregnancies.

Circulating FSH concentration decreases as ovulation approaches to enhance atresia (degeneration) of the maturing nondominant follicles

Clinical importance

Fertility medications used to increase the number of fully matured eggs during a given cycle should be initiated prior to the selection of the dominant follicle. This will enhance the yield of fully mature eggs.

* (3) the growth rate and hormonal function of the dominant follicle changes during the cycle

A sudden rapid increase in both the follicular diameter (size) and the circulating estrogen concentration (function) occurs just prior to complete egg maturation. The increase in diameter is identifiable by ultrasound. The increase in estrogen level is identifiable with close monitoring of blood estradiol concentrations.

Clinical importance

Monitoring findings from ultrasounds and the woman's bloodwork allows the infertility specialist to interpret changes in egg development and adjust therapy.

* (4) circulating leutinizing hormone (LH) concentration increases dramatically about 36 hours (one and a half days) prior to ovulation

This sudden increase in LH concentration, the "LH surge," is the trigger for both "the egg" to undergo its final maturational step and for "the ovary" to undergo the final changes required to release the mature egg into the pelvis.

Clinical importance

Injections of hCG (Profasi) when the egg(s) is mature can mimic the LH surge since the hCG and LH molecules are very similar. Actually hCG and LH occupy the same cellular receptors to accomplish their biologic response. The hCG injection triggers ovulation about one and a half days later.

Detection of the LH surge (as LH excreted in urine) is the basis for the commercially available ovulation predictor kits (purchased in the pharmacy).

* (5) the follicular cyst rapidly changes following ovulation under the influence of increased LH to become a "corpus luteum" cyst.

A major difference between the follicular cyst (prior to ovulation) and the corpus luteum cyst (following ovulation) is hormone production. The predominant sex steroid produced by the follicular cyst is estrogen and that of the corpus luteum cyst is progesterone.

Granulosa cells are cells that line the inside of both of these cysts and are capable of producing either estrogen or progesterone. Cholesterol is the starting material for either of these hormones and cholesterol's molecular structure is changed using proteins called enzymes. The activity of the enzymes that change cholesterol into either estrogen or progesterone can be enhanced or suppressed within these granulosa cells.

Under conditions present prior to ovulation the granulosa cells produce mostly estrogen and under the conditions present following ovulation these cells produce mostly progesterone.

Prior to ovulation, the high circulating estrogen concentrations act on the endometrium (uterine lining) to stimulate growth that results in an increased endometrial thickness. Following ovulation, the high circulating concentration of progesterone acts on the endometrium to stabilize it and prepare it for the implantation of an embryo.

Clinical importance

Inadequate progesterone effect during the luteal phase of the menstrual cycle (a "luteal phase defect") can be treated with supplemental progesterone (oral micronized progesterone, vaginal suppositories, vaginal gel applicator, or by injection in an oil base). Supplemental hCG can be given as injections every few days following ovulation to enhance the ovary's own progesterone production. Clomiphene citrate in the follicular (preovulatory) phase may increase the final size of the follicle prior to ovulation so that there are more granulosa cells to then produce progesterone in the luteal phase.

Supplemental progesterone for a luteal phase deficiency is usually continued until about 10-12 weeks gestation (8-10 weeks from fertilization). The placenta takes over progesterone production from the ovarian corpus luteum during this time, so that further supplementation is not necessary.

* (6) the "window of uterine receptivity" is a short period of time during which embryos may implant into the uterus

During this period of uterine receptivity the endometrial lining is ideally prepared to allow for embryo implantation. In most cases embryos will only implant and grow normally if present in the cavity during this window of receptivity.

Progesterone is believed to be the major determinant of the window of receptivity, however, many other candidate hormones and protein messengers are also being considered as the research on molecular mechanisms of implantation continues to grow

The duration of the window of uterine receptivity in humans is thought to be about 3 days

Clinical importance

During cycles of In Vitro Fertilization (including frozen embryo transfer cycles and donor egg cycles involving egg recipients) the success rate (in terms of implantation or pregnancy) relates to the hormonal preparation of the endometrium (uterine lining).

If progesterone production, or the uterine response to the progesterone produced, is not adequate then the lining of the uterus may be inadequate for embryo implantation. This situation can lead to either infertility if the lining does not become receptive or recurrent pregnancy loss if the lining is receptive for implantation but the embryo cannot develop normally.

* (7) menses occur if a pregnancy is not achieved

LH stimulates the enzymes within the corpus luteum cyst to produce progesterone for only about 2 weeks following ovulation. If the woman becomes pregnant the placental cells that grow into the uterine lining and establish contact with the maternal circulation produce a hormone called human chorionic gonadotropin (hCG). The hCG molecule produced by placental cells (syncytiotrophoblast cells) is structurally similar to LH and shares the same receptors on the ovary to produce similar biologic responses.

In a pregnancy cycle, the maternal circulation begins to have a detectable hCG concentration about 7 to 8 days after fertilization (fertilization occurs within a day or so of ovulation). This hCG then takes over (by acting like LH) the stimulation of progesterone production by the corpus luteum cyst.

If the woman does not become pregnant, then there is no hCG to take over the role of LH in the support of the corpus luteum cyst. Thus, the corpus luteum cyst deteriorates, the progesterone concentration supporting the uterine lining declines and the uterine lining that has grown in preparation for pregnancy is shed (as the menstrual flow).

Clinical importance

Menstrual flow sometimes becomes a monthly reminder associated with the pain and frustration often felt by couples with an infertility problem.

More information on the events involved in Ovulation are available here.

More information on the causes and treatments of miscarriages is available here.


| About this web page | Basic Infertility | Ovulation | The Sperm | Pelvic Factor |

Eric Daiter, M.D. - Edison, NJ - E-Mail: - Phone: (908)226-0250

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