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.
Hello, Dr. Sher.
I am interested in whether mini-IVF/IVF may be a viable option for us. Here is our situation:
Me (36) – no health problems, sperm analysis 3% morphology, otherwise normal.
My wife (35) – no health problems, diagnosed with DOR yesterday (02/05/18).
Follicles seen on ultrasound (01/29?, CD3?): one 11mm? (left)? and one 17mm? (right)
AFC: 1 (left)
AMH: 0.25
She had two viable pregnancies at age 20, both terminated. She is 4’11″ and 115lbs.
We have had insemination by natural intercourse every other day (or more frequently) for the past 6 months. She has had periodic anovulatory cycles but regular periods for an unknown amount of time.
Her OB prescribed 50mg of Clomid CD5-CD9, her last two cycles. Her BBT showed now thermal shift indicating ovulation either cycle.
1. How many women fit all of the following criteria:
-were treated at 35 years of age
-used their own eggs
-have diminished ovarian reserve (at 0.25 AMH or less)
-had previous viable pregnancies
-have no other health problems and normal partner
-safely underwent IVF at max level (3 embryos per attempt?)
2. How many of the above women subsequently had live births?
3. What is the data set you are using to provide these statistics? (Total in the history of the world, total in the United States last year, number of women you’ve personally treated, etc.)
We are trying to remain optimistic, but we need hard facts. Any insight would be greatly appreciated as we decide how best to move forward.
Thank you,
Mr. V
Mini-IVF is a procedure that involves ovarian stimulation using low dosage medications (often oral drugs like clomiphene and letrozole) under the premise that it is a “safer” and less expensive than conventional gonadotropin stimulation regimes while yielding comparable success. …….. Nothing could be further from the truth. The fact is that success rates per fresh mini-IVF cycle ranges between 10% and 12%s (i.e., about one third of that which reported national average for conventional IVF performed on women under 39y of age) ). And when it comes to older women and those with diminished ovarian reserve (DOR), the success rate with mini-IVF is usually much lower still.
There can be little doubt that aside from a woman’s age, the method used for ovarian stimulation represents the most important determinant of egg/embryo quality and thus of IVF outcome. There is no single stimulation protocol that is suitable for all IVF patients. It must be individualized…. especially when it comes to women who, regardless of their age have diminished ovarian reserve (DOR) and for women over >40y of age. The reason for this is that in such cases, the pituitary gland often over-produces LH which in turn causes the ovarian stroma/theca (connective tissue) to thicken (stromal hyperplasia/hyperthecosis) and over-produce male hormones (mainly testosterone). This in turn adversely influences egg and follicle growth, resulting in poor egg/embryo “competency” and compromised IVF outcome.
So let us examine the validity of the claims made in support of mini-IVF:
1.Milder stimulation using oral agents such as clomiphene, letrozole (alone or in combination with low dosage gonadotropins (Follistim/Gonal-F/Puregon/Menopur) reduces stress on the ovaries and overall risk associated with IVF. This argument while perhaps having some merit when applied to mini-IVF conducted in younger women who also have normal ovarian reserve, does not hold water for older women and those with DOR who (s stated above) often already have excessive LH-induced ovarian testosterone production. Furthermore, addition of clomiphene and letrozole by further increasing pituitary LH (and thus ovarian testosterone) only serves to add “fuel to the fire” in such cases and Menopur which contains both LH and hCG ( that both have similar effects on ovarian testosterone production), if administered in large amounts (>75U per day) can also do harm in my opionion.
2.Women with DOR will respond better to “milder stimulation” and egg quality will so be enhanced. This assertion borders on the ridiculous. It is like saying that applying less force to a heavier object will increase the likelihood of moving it”. That is simply not how FSH stimulates follicle development. You see…the cell membranes that envelop the follicular granulosa cells that line the inside surface of ovarian follicles have on their surfaces, a finite number of FSH receptors. FSH molecules attach to these receptors and mediate intracellular events that lead to granulosa cell proliferation with production of estradiol and the concurrent development of the egg (oogenesis) that is attached to the inner wall of the follicle. Once all the FSH receptors on the cell membranes are saturated, any residual FSH is discarded. This is why, when it comes to older women and women with DOR whose granulose cell membranes harbor fewer FSH receptors, it is virtually impossible to overstimulate them. Excessive FSH will simply be rejected and discarded.
3. Use of fewer drugs translates into lower cost. This would be true, were it not for the fact that success rates with mini-IVF across the board are much lower than with conventional ovarian stimulation. More important is the fact that the cost of IVF should be expressed in terms of “the cost of having a baby” rather than “cost per cycle of treatment”. When this is taken into account the cost associated with mini-IVF will b be significantly higher than conventional IVF. Then there is the additional emotional cost associated with a much higher IVF failure rate with mini-IVF.
4.Mini-IVF is less technology driven, less stressful and easier to execute. This assertion is in my opinion also without merit. Aside from reduced cost of medications, the same monitoring and laboratory procedures are needed for mini-IVF as with conventional treatment.
What is the best approach? When it comes to older women and those with DOR, it is in my opinion preferable to use a long pituitary down-regulation protocol with conversion from an I.M agonist (e.g. Lupron or Buserelin) to an antagonist such as Cetrotide/Orgalutron or Ganirelix (the agonist/antagonist conversion protocol) augmented with human growth hormone (HGH) and/or estrogen priming and combing this “embryo banking” over several cycles. In such cases preimplantation genetic screening (PGS) can be incorporated to help select the most “competent” embryos for transfer.
What about younger women with normal or increased ovarian reserve? If mini-IVF has any role at all, it could be in young women who have normal or increased ovarian reserve. I do not o not advocate aggressively stimulating the ovaries of younger women who have normal or increased ovarian reserve (as assessed by basal FSH, AMH and estradiol) simply to try and access more eggs. In fact, such an approach is neither safe nor acceptable. In such women it is often wiser to use lower dosage stimulation to try and prevent the development of severe ovarian hyperstimulation syndrome (OHSS) which aside from putting the woman at severe risk of (sometimes) life-endangering complications, can also compromise egg/embryo quality. However, it is my fervent belief that in such women, the preferred approach to ovarian stimulation is through the use of low dosage FSHr-dominant gonadotropins (rather than oral agents such as clomiphene or letrozole and/or high dosage Menopur). This approach is referred to as Micro-IVF.
Here is the protocol I advise for women, <40Y who have adequate ovarian reserve.
My advice is to use a long pituitary down regulation protocol starting on a BCP, and overlapping it with Lupron 10U daily for three (3) days and then stopping the BCP but continuing on Lupron 10u daily (in my opinion 20U daily is too much) and await a period (which should ensue within 5-7 days of stopping the BCP). At that point an US examination is done along with a baseline measurement of blood estradiol to exclude a functional ovarian cyst and simultaneously, the Lupron dosage is reduced to 5U daily to be continued until the hCG (10,000u) trigger. An FSH-dominant gonadotropin such as Follistim, Puregon or Gonal-f daily is started with the period for 2 days and then the gonadotropin dosage is reduced and a small amount of menotropin (Menopur---no more than 75U daily) is added. This is continued until US and blood estradiol levels indicate that the hCG trigger be given, whereupon an ER is done 36h later. I personally would advise against using Lupron in “flare protocol” arrangement (where the Lupron commences with the onset of gonadotropin administration.
I strongly recommend that you visit https://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.
• Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas
• Should IVF Treatment Cycles be provided uninterrupted or be Conducted in 7-12 Pre-scheduled “Batches” per Year
• A personalized, stepwise approach to IVF
• “Triggering” Egg Maturation in IVF: Comparing urine-derived hCG, Recombinant DNA-hCG and GnRH-agonist:
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
Good evening. I did my ivf transfer exactly 4 weeks back. It was 5 day embryo transfer. My first, second and third HCG beta were 199, 357 and 1253. I started bleeding today sometime back – its bright red with thread like clots with light cramping but no abdomen pain. Is anything i need to worry about and take action or is it common to have?
Vaginal bleeding occurs in about 25% of all pregnancies. When it happens, it almost invariably raises the concern of pregnancy loss (miscarriage). Bleeding can also be a sign of a tubal (ectopic) pregnancy, and in cases where the distended Fallopian tube ruptures it can precipitate a life-threatening crises. However, a small amount of painless vaginal bleeding can also be the result of normal embryo implantation (i.e. implantation bleeding) or it can result a local erosion of the vagina or cervix and/or trauma during intercourse.
Notwithstanding, in virtually all cases the occurrence of early pregnancy vaginal bleeding congers concerns or even alarm regarding the possibility of miscarriage. And when this happens to women who conceived following infertility treatment, the alarm often turns into panic. However, the truth is that in most such cases the bleeding soon stops and the pregnancy proceeds unabated to the birth of a healthy baby. However, because some do progress and end in miscarriage, and in most cases, only time will tell how things will ultimately turn out, we use the term “threatened miscarriage” to describe such early bleeding. The term “inevitable miscarriage” is used once symptoms and signs confirm a miscarriage is in progress. The term “complete miscarriage” is used if all products of conception are passed, leaving the uterus “empty”. An “incomplete miscarriage” refers to cases where some products remain retained in the uterus.
Geoff Sher
I am a case of multiple abdominal sugeries. Not a single laproscopy but all wide open cuts. First was done when i was 14 to take out Appendix. In the same month i had another surgery to remove congential Jacsonian Membrane around my large intestine filled with fluid. At the age of 28 years i was trying for pregnancy but wasnt successful. Got myself checked and was told i have the same membrance appeared back and filled with fluid. They removed it. The surgeon did manage to rightly position my tubes and ovaries which were burried under adhesions and scar tissues. After 9 years of trying naturally with combination of IVF i get to know that my tubes are filled with fluid and are hampering embryo transplant. The same became base of my latest surgery where 1 tube was cut and other was tied as that was not in a position to be cut( burried under adhesions).My recovery was slow and i developed anxiety and gut issues. As a routine ultrasound today i was told that my tied tube is all filled with fluid again and is pretty swollen. I am devastated. I cant afford any surgery whether laproscopy(due to tons of adhesions its impossible) or wide cut open. I have pain in my lower pelvic area on one side(not constantly). For the past 4 months my periods are extremly heavy for 1st 3 days and then just spotting for 2 days and cycle ends. I get really heavy blood clots too during first 3 days. Never missed my periods date though. Is this all due to post tubal ligation?. I am too tensed and worried. Have developed stomach acidity issues due to all this. Can i take some oral drugs for this swollen tube which is tied and is presumably not leaking into uterus(is this due to post tubal ligation)?. I did all this to attempt IVF but cant as this new development has happened. I am 37 at the moment.
Hi Sanaa, Obviously the hydrosalpinx involves the ligated tube. Thus since that tube is blocked as it leaves the uterus, the fluid from the hydrosalpinx cannot drain back into the uterus. Thus it is of no consequence and will not impede your ability to conceive with IVF.
Good luck!
Geoff Sher
We went through 2nd egg retrieval using donor sperm per the doctors recommendations per our results and failed outcome in the previous ivf round.
1st Egg Retrival
16 eggs received
Total : 4 embroyos with 1 normal after PGS (grade 5AA normal male)
Miscarried at 7 weeks
2nd egg retrieval (using donor sperm)
16 eggs retrieved
day 1 : 14 fertilized ICSI
day 3 , 11 hatched
day 5 : 7 embroyos for pgs .
PGS results : 3 mosiac, 4 abnormal
What advice would you give us by these results? Doctor is ok to transfer the mosiac embroyos but there are risks involved as of genetic diseases and higher risk of miscarriage.
Should we transfer the mosiac embroyos as this is our only transferable embroyo?
Is this an egg or sperm issue?
I can send my detailed PGS report as well
Please advise.
I would recommend you do the transfer.
Geoff Sher
Hi Dr. Sher, I was wondering if going in a hot tub or steam room is harmful in any way before starting an IVF cycle (ovarian stimulation) and/or during an IVF cycle?
I do not think so as long as you drink lots of water and keep well hydrated.
Geoff Sher