Ask Our Doctors – Archive
Our Medical Directors are outstanding physicians that you will find to be very personable and compassionate, who take care to ensure that you have the most cutting-edge fertility treatments at your disposal. This is your outlet to ask your questions to the doctors.
Hi and a big thank you for writing all the blog posts and answering questions. They are very informative! I hope you have time to answer me as well 🙂
I am 32 years old and have been trying to conceive for 1,5 years now. The first year naturally, then we went to examinations and everything seemed to be okay. Though they suspect that I might have PCO. My AMH was 11.5, my ovaries have many follicles and I have long cycles (sometimes 40 days). I have thyroid insufficiency to which I take thyroxin.
First we tried two times with clomifen, then once with letrozole. The cycle was shortened but no pregnancy. Then we tried three times with letrozole, pregnyl and insemination without success.
We just had our first IVF. They collected 40 follicles, 20 had an egg inside and 17 were mature. Those 17 fertilized, but 10 of them had two or more semen inside them (polyspermy?), so they were abnormal.
Of the remaining 7, five divided abnormally in the first two days so we lost them as well. One lasted until fourth day, but didn’t make it to blastocyst. One was frozen in Day 2 or 3. We are waiting that to be transferred in the future. We don’t have our hopes high since all the others were bad quality and we fear this will be also.
What could have caused our poor result and do you have any advise how to proceed with treatment? Do you think we still have hope for our own biological baby?
Our IVF protocol was as follows:
Gonal F 100 IU from day 2 to day 13.
Cetrotide 0,25 mg from day 7 to day 12.
Gonapeptyl 0,2 mg in day 13 at 10 pm
The operation was on day 15 at 10 am. We had to freeze all to avoid OHSS.
Before IVF, I took vitamin D, folic acid, multivitamin (A,D,E,C,B) and Donaferty (myo-inositol, d-chiro-inosito). I have now quit multivitamin since it has vitamin A in it, which I read isn’t good when trying to conceive. Also I took Donaferty only the month when preparing to IVF and I read that I should have taken it from 3 months earlier already. Do you think these might help with the egg quality and is there anything else you could recommend? CoQ10 perhaps?
Thank you a lot in advance for your reply! We really appreciate your work a lot!
Hi Siri,
While m the supplements you are taking wont do harm , I doubt they alone will impact egg/embryo quality. With PCOS, ot is all about the protocol used for ovarian stimulation and its implementation. It also about the timing and method used for triggering egg maturation prior to ER.
Polycystic ovary syndrome (PCOS) is a common hormonal system disorder among women affecting between 5% and 10% of women of reproductive age worldwide. Women with PCOS may have enlarged ovaries that contain multiple small collections of fluid (subcapsular microcysts) that are arranged like a “string of pearls” immediately below the ovarian surface (capsule).interspersed by an overgrowth of ovarian connective tissue (stroma). The condition is characterized by abnormal ovarian function (irregular or absent periods, abnormal or absent ovulation and infertility, androgenicity (increased body hair or hirsutism, acne) and increased body weight –body mass index or BMI.
Women with PCOS are at increased risk that ovarian stimulation with gonadotropins will result in the, of development of severe ovarian hyperstimulation syndrome (OHSS), a life-endangering condition that is often accompanied by a profound reduction in egg “competency” and on fertilization often yield an inordinately high percentage of “incompetent” embryos which have a reduced potential to propagate viable pregnancies.
Concern and even fear that their PCOS patients will develop of OHSS often leads the treating RE to take measures aimed at reducing the risk of this life-endangering condition. One such measures is to “trigger” egg maturation prematurely in the hope of arresting further follicular growth and the other, is to initiate the “trigger” with a reduced dosage of hCG (i.ed. 5,000U rather than the usual 10,000U of of Pregnyl/Profasi/Novarel, to use or 250mcg rather than 500mcg of Ovidrel or to supplant the hCG “trigger” with a Lupron “trigger” which causes a prompt LH surge from the woman’s pituitary gland to take place. While such measures do indeed reduce the risk of OHSS to the mother, this often comes at the expense of egg quantity and “competency”. Fewer than the anticipated number of eggs are harvested and those that are retrieved are far more likely to be “immature” and chromosomally abnormal (aneuploid”), or “immature” , thereby significantly compromising IVF outcome.
Against this background, It is my considered opinion that when it comes to performing IVF in women with PCOS, the most important consideration must be the selection and proper implementation of an individualized or customized ovarian stimulation protocol. Thereupon, rather than prematurely initiating the “trigger” to arrest further follicle growth, administering a reduced dosage of hCG or “triggering with a GnRH agonist (e.g. Lupron/Buserelin) that can compromise egg “competency”….. use of one of the following techniques will often markedly reduce the risk of OHSS while at the same time protecting egg quality:
1. PROLONGED COASTING…my preferred approach: My preferred approach is to use a long pituitary down-regulation protocol coming off the BCP which during the last 3 days is overlapped with the agonist, Lupron/Buserelin/Superfact. The BCP is intended to lower LH and thereby reduce stromal activation (hyperthecosis) in the hope of controlling LH-induced ovarian androgen (predominantly, testosterone) production and release. I then stimulate my PCOS patients using a low dosage of recombinant FSH-(FSHr) such as Follistim/Gonal-F/Puregon. On the 3rd day of such stimulation a smidgeon of LH/hCG (Luveris/Menopur) is added. Thereupon, starting on day 7 of ovarian stimulation, I perform serial blood estradiol (E2) and ultrasound follicle assessments, watching for the number and size of the follicles and the blood estradiol concentration [E2]. I keep stimulating (regardless of the [E2] until 50% of all follicles reach 14mm. At this point, provided the [E2] reaches at least >2,500pg/ml, I stop the agonist as well as gonadotropin stimulation and track the blood E2 concentration daily. The [E2] will almost invariably increase for a few days. I closely monitor the [E2] as it rises, plateaus and then begins to decline. As soon as the [E2] drops below 2500pg/ml (and not before then), I administer a “trigger” shot of 10,000U Profasi/ Novarel/Pregnyl or 500mcg Ovidrel/Ovitrel. This is followed by an egg retrieval, performed 36 hours later. Fertilization is accomplished using intracytoplasmic sperm injection (ICSI) because “coasted” eggs usually have little or no cumulus oophoris enveloping them and eggs without a cumulus will not readily fertilize naturally. Moreover, they also tend to have a “hardened” envelopment (zona pellucida), making spontaneous fertilization problematic in many cases. All fertilized eggs are cultured to the blastocyst stage (up to day 5- 6 days) and thereupon are either vitrified and preserved for subsequent transfer in later hormone replacement cycles or (up to 2) blastocysts are transferred to the uterus, transvaginally under transabdominal ultrasound guidance. The success of this approach depends on precise timing of the initiation and conclusion of “prolonged coasting”. If started too early, follicle growth will arrest and the cycle will be lost. If commenced too late, too many follicles will be post-mature/cystic (>22mm) and as such will usually harbor abnormal or dysmature eggs. Use of “Coasting” almost always prevents the development of severe OHSS, optimizes egg/embryo quality and avoids unnecessary cycle cancellation. If correctly implemented, the worst you will encounter is moderate OHSS and this too is relatively uncommon.
2. EMBRYO FREEZING AND DEFERMENT OF EMBRYO TRANSFEDR (ET): OHSS is always a self-limiting condition. In the absence of continued exposure to hCG, symptoms and signs as well as the risk of severe complications will ultimately abate. Thus, in the absence of pregnancy, all symptoms, signs and risks associated with OHSS will disappear within about 10-14 days of the hCG trigger. Conversely, since early pregnancy is always accompanied by a rapid and progressive rise in hCG , the severity of OHSS will increase until about the 9th or tenth gestational week whereupon a transition from ovarian to placental hormonal dominance occurs, the severity of OHSS rapidly diminishes and the patient will be out of risk. Accordingly, in cases where in spite of best effort to prevent OHSS, the woman develops symptoms and signs of progressive overstimulation prior to planned ET, all the blastocysts should be vitrified and cryostored for FET in a subsequent hormone replacement cycle. In this way women with OHSS can be spared the risk of the condition spiraling out of control.
I strongly recommend that you visit http://www.DrGeoffreySherIVF.com . Then go to my Blog and access the “search bar”. Type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.
·The IVF Journey: The importance of “Planning the Trip” Before Taking the Ride”
·Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
·IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
·The Fundamental Requirements For Achieving Optimal IVF Success
·Use of GnRH Antagonists (Ganirelix/Cetrotide/Orgalutron) in IVF-Ovarian Stimulation Protocols.
·Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
·Egg Maturation in IVF: How Egg “Immaturity”, “Post-maturity” and “Dysmaturity” Influence IVF Outcome:
·Commonly Asked Question in IVF: “Why Did so Few of my Eggs Fertilize and, so Many Fail to Reach Blastocyst?”
·Human Growth Hormone Administration in IVF: Does it Enhances Egg/Embryo Quality and Outcome?
·The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
·Taking A Fresh Look at Ovarian Hyperstimulation Syndrome (OHSS), its Presentation, Prevention and Management
·Preventing Severe Ovarian Hyperstimulation Syndrome (OHSS) with “Prolonged Coasting”
·Understanding Polycystic Ovarian Syndrome (PCOS) and the Need to Customize Ovarian Stimulation Protocols.
·“Triggering” Egg Maturation in IVF: Comparing urine-derived hCG, Recombinant DNA-hCG and GnRH-agonist:
·The “Lupron Trigger” to Prevent Severe OHSS: What are the Pro’s and Con’s?
•.Frozen Embryo Transfer (FET) versus “Fresh” ET: How to Make the Decision
•Frozen Embryo Transfer (FET): A Rational Approach to Hormonal Preparation and How new Methodology is Impacting IVF.
•Implications of “Empty Follicle Syndrome and “Premature Luteinization”
•Premature Luteinization (“the premature LH surge): Why it happens and how it can be prevented.
•Preventing Severe Ovarian Hyperstimulation Syndrome (OHSS) with “Prolonged Coasting”
If you are interested in seeking my advice or services, I urge you to contact my concierge, Julie Dahan ASAP to set up a Skype or an in-person consultation with me. You can also contact Julie by phone or via email at 702-533-2691/ Julied@sherivf.com You can also apply online at http://www.SherIVF.com .
*FYI
The 4th edition of my newest book ,”In Vitro Fertilization, the ART of Making Babies” is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoffrey Sher MD
hi doctor
i am pco with 15.4 amh my Uterus cavity and endometrium is normal. my husband has sperm issues rapid progressive(a)= 2 , progressive (b)=18, total progressive=50, non motile=50. and sperm count 50 million. morphology is 2.
does my spouse need to do SDFA (DNA fragmentation index (DFI)) SPERM TEST FOR ivf ? i have had no pregnancy for 14 months. i took 5 cycles of letrozol.
It could be beneficial.
Geoff Sher
I have read alot of reveiws and some woman said they would have a neg hcg until almost 8 weeks pregnant is that possible or no
impossible!
Geoff Sher
We would like to discuss to doctor Sher about our final prognosis, after 2 miscarriages (from natural conception) and 1 IVF cycle (7 stims which provided around 43 matures eggs but only 10 bad qualities blastos, which were under PGS, resulting 1 euploid embryo (FET performed but bfn); 3 mosaics (they are now frozen for further reflexion) and 6 aneuploids embryos out of those previous 10. Nowadays, we put our former infertility clinic,in Helsinki, in stand by about the transfer of the mosaics and we moved, then, into a renowned clinic in Spain. First thing in the new clinic: they analyzed DH’s sperm in a molecular level by TUNNEL and FISH. No SDF was found. Despite that, they still think the infertility is a male factor once the fragmentation and embryos arrest were always seen from day 3/4 from those previos stims. In resume, according to the first clinic (finnish clinic) the infertility issue is a female factor, advising for a egg donation. On the other hand, the new clinic are going to try one stim. to check the lab factor, otherwise they advise for sperm donation!!! it means: 2 clinics, 2 completly opposite diagnosis. what Dr. Sher shall add?
How did a gestation sac get into my uterus if the only tube i have left showed blocked in 2012
If indeed there is a gestational sac then at least one tube must have a small opening. W
Geoff Sher