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.
I have PCOS . I am currently doing a stim cycle . I am 8 days into stims and my estrogen is around 3200 . Should I be triggering with Lupron only or Lupron and hcg . Also what should my hormone levels be at in order to do a fresh transfer ? If the estrogen is high will that affect a fresh transfer ?
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.
We transferred an embryo today. It was frozen in day 3, but we wanted to culture it to blastocyst. It didn’t reach blastocyst stage in 2 days after thawing, but we transferred it anyway. I asked about the odds for a live birth, since it’s progress had slowed and they evaluated it with a lower grade than when it was frozen.
My doctor said that everytime we get to the point that we can do an embryo transfer, the likelihood of a live birth is 35 % with women under 37 years old, not depending on whether it was a blastocyst or day 3 embryo, or other factors. This sounds crazy to me. Do you agree with my doctor?
I RESPECTFULLY DISAGREE. EMBRYOS THAT DO NOT DEVELOP INTO BLASTOCYSTS USUALLY ARE NOT VIABLE.
GEOFF SHER
Hi – I was interested in hearing your thoughts on whether it was worthwhile (forgetting the economic costs) of trying IVF with PGS under our current circumstances.
My wife is 35 and we have a 2.5 year old born naturally and delivered via emergency c-section. We have been trying for #2 since June and have had 3 consecutive miscarriages (all very early on 6.5 weeks, 4.5 weeks and 5 weeks). All of the extensive testing has come back negative for anything and the drs. believe that the miscarriages were probably chromosomal (but we never had any testing done as we werent able to get anything to test). It just seems unlikely to us that 3 miscarriages in a row were all chromosomal and there needs to be something else wrong – therefore the IVF w/ PGS would not be successful. We are at a cross roads here as we seem to get pregnant fairly easily, but are extremely worried now as we cannot find an issue or a solution and do not want to go down the IVF path if it doesnt significantly help our chances. We are also a bit anxious on timing as our daughter is 2.5 and we would have liked our family to be close in age if possible.
Thanks!
Jon
Dear Dr. Sher,
I am 41 year old and living in Germany. Has experienced many negative ICSI treatments and the only high TH1/TH2 ratio was detected. I know, that you recommends to make the K-562 target cell test, which nobody knows here in Germany. I found one lab, which did the same test.
Here is the results:
NK-Function (Staging)
NK-CD25 – 2 % NK (Normal 0 – 10)
NK-CD69 – 1 % NK (Normal 0 – 5)
NK-p44 – 14 % NK (Normal 0 – 5)
NK-Stimulation
NK CD25 stim – 3 % NK
NK CD69 stim – 29 % NK
NK-p44 stim – 16 % NK
NK-nat Cytotoxicity
NK-G2D – 99 % NK (Normal 97 – 100)
NK-p46 – 35 % NK (Normal 60 – 100)
NK-Apoptose
NK-FAS Ligand – 21 % NK (Normal >30)
I have psoriasis
Do I need Intralipid prior transfer? or better IVIG?
Many thanks in advance
Valeriya
Here is my TH1/TH2 ratio test result:
ITT (TH1,TH2) …
IL-2 (TH1, TH2) – 2392 pg/ml (Normal > 1000)
IFN (TH1) – 3671 pg/ml (Normal 500 – 3200)
IL4 (TH2) – 1,3 pg/ml (Normal 1 – 6)
Quotient (TH1,TH2) – 2823,8 (Normal 500 – 533)
The best test is the K-562 test. I am unable to adequately comment on the test results presented. I suggest you contact Reprosource in Boston, MA or Reproductive Immunology Associates in Van Nuys, CA and have the blood sent there from Germany.
Good luck!
Geoff Sher
Hi Dr Sher.
After a failed fresh transfer due to Ovarian Hyper-stimulation Syndrome I have had a 5 day frozen transfer. At 10p5dt, by HCG was only 5. I was asked to repeat bloods and I’m currently waiting for the results. Is there any chance in your opinion? People say it might have implanted late – but just how late could it have implanted? I had strong cramping 7, 8 and 9dpt but none since. I’m still taking oestrogen and progesterone. i’m hoping that it isn’t an ectopic pregnancy, but should I be hoping for rising hcg?
Sadly this is not very encouraging Renee.
Geoff Sher