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 Dr Sher,
Thank you for the valuable information you provide us on this blog.
My question for you is:
After a few failed IVF cycles, and no embryos making it to freeze, I am starting my final attempt as I have run out of money to spend on these treatments. So I want to do all I can to ensure it succeeds.
After the first failed cycle, I did immune testing with showed raised NK 12.5:1 and raised TNF-a:IL10
So for the second cycle I was treated with intralipids twice prior to embryo transfer. That cycle failed as well. Then I had a few more blood tests which showed a Protein C deficiency.
So for this cycle my Dr wants to put me on Prednisolone 20mg, Clexane 40mg, PIO and do intralipids twice before transfer and, if successful, an intralipid upon testing positive and then 2 more intralipids 4 weeks apart and stopping at 12 weeks. But since I haven’t done a full immune testing, and I have no idea about DQ alpha matches etc, isn’t it safer to just have intralipids if successful every 2 weeks during the first trimester at least, and then every 3 weeks during the 2nd trimester? If there is no harm I want to do the most out of precaution, what’s your opinion on that? Is intralipids every 2 weeks okay? or is every 3 weeks starting from the first trimester more than enough?
Your input is greatly appreciated!
Thank you
In my opinion, there is no benefit doing more IL than needed. For autoimmune implantation dysfunction a total of 2 infusions is all that is needed. The first is done 10-14 days prior to ET and the second, with the =ve beta hCG…This is combined with steroid therapy…and that is it. Fo alloimmune implantation dysfunction..the same is done only I continue infusing IL every 2 weeks after the +ve beta hCG until the 24th week. Steroids are used until the 8th week of pregnancy and then tailed off over 10-14 days. There is no need for more IL infusions in either autoimmune or alloimmune implantation dysfunction. The dosage of IL is 100cc of 20% IL mixed with 500cc of normal saline and it is infused slowly, over about 3 hours. With a partial DQ alpha match only one blastocyst is transferred per ET. With autoimmune , two.
While there is probably no harm done, there is no need for additional infusions…than the above….in my opinion.
Good luck!
Geoff Sher
Hello Dr Sher,
Does coloring hair in early stages of the cycle compromise eggs?
Not to my knowledge!
Geoff Sher
Dear Dr Sher,
Thank you for the service you are doing with this blog and your knowledge. Most ladies having success at other clinics owe it to you because they are incorporating your advice to their treatment.
My issue is that my follicles take a long time to appear. When they do, they grow. Since not much happens for about a week, is it better to start the stims later in the cycle around day 6?
My other question is if Cetrocide is administered from CD1 would it compromise follicles growing if no follicles are seen on initial ultrasound?
Hi Tanya,
I could be wrong, but it sounds as if you are launching your ovarian stimulation coming directly off a BCP or estrogen. And that is not unexpected. If you use a BCP wihout overlapping with an agonist such as Lupron/Buserelin, that is precisely what will happen in many cases.
Here is why! In natural (unstimulated) as well as in cycles stimulated with fertility drugs, the ability of follicles to properly respond to FSH stimulation is dependent on their having developed FSH-responsive receptors . Pre-antral follicles (PAF) do not have such primed FSH receptors and thus cannot respond properly to FSH stimulation with gonadotropins. The acquisition of FSH receptor responsivity requires that the pre-antral follicles be exposed to FSH, for a number of days (5-7) during which time they attain “FSH-responsivity” and are now known as antral follicles (AF). These AF’s are now able to respond properly to stimulation with administered FSH-gonadotropins. In regular menstrual cycles, the rising FSH output from the pituitary gland insures that PAPs convert tor AF’s. The BCP (as well as prolonged administration of estrogen/progesterone) suppresses FSH. This suppression needs to be countered by artificially causing blood FSH levels to rise in order to cause PAF to AF conversion prior to COS commencing, otherwise pre-antral-to –antral follicle conversion will not take place in an orderly fashion and the follicles will not readily respond to gonadotropins (FSH) , thereby delaying follicle development by up to 7 days and compromising egg quality. GnRH agonists (e.g. Lupron, Buserelin, Superfact) , cause an immediate surge in release of FSH by the pituitary gland thus causing conversion from PAF to SAF. This is why, women who take a BCP to launch a cycle of COS need to have an overlap of the BCP with an agonist.
By overlapping the BCP with an agonist for a few days prior to menstruation the early recruited follicles are able to complete their developmental drive to the AF stage and as such, be ready to respond appropriately to optimal ovarian stimulation. Using this approach, the timing of the initiation of the IVF treatment.
Please visit my new Blog on this very site, http://www.DrGeoffreySherIVF.com, find the “search bar” and 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
•Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
•Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
•The “Biological Clock” and how it should Influence the Selection and Design of Ovarian Stimulation Protocols for IVF.
•Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
•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?
•IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
•Why did my IVF Fail
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF
•How Many Embryos should be transferred: A Critical Decision in IVF.
•The Role of Nutritional Supplements in Preparing for IVF
•Measuring and Interpreting Blood hCG to Assess Pregnancy Viability Following ART Treatments.
I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoff Sher
I have a sister who is 17 yrs old and she turns 18 by November, can she be my egg donor
Potentially…yes!
Please visit my new Blog on this very site, http://www.DrGeoffreySherIVF.com, find the “search bar” and 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
•Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF
•How Many Embryos should be transferred: A Critical Decision in IVF.
•The Role of Nutritional Supplements in Preparing for IVF
•Measuring and Interpreting Blood hCG to Assess Pregnancy Viability Following ART Treatments.
•IVF Egg Donation: A Comprehensive Overview
I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoff Sher
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Hi Dr. Sher,
I was wondering if you could give your opinion on rapidly rising estrogen during IVF. I have PCO (I’m on metformin) and I’m on the antagonist protocol. My E2 was 30 at baseline on Monday. After 2 days of Follistim 150 units, my E2 was 200. Today, which is after 4 days of stims, my E2 is already at 700! I have about 10 or so follicles between 10-13mm, a handful between 6-9mm and a bunch more too small to measure. In your opinion, is my E2 rising too rapidly? Does this fast rise just reflect the large number of small follicles, or does it mean the larger follicles that are growing are of poor quality? I am worried that this fast rise reflects poor egg quality. Thank you!
This response is typical of what one sees with PCOS. I suspect that you probably have many more follicles and that your E2 will start rising cery rapidly soon.
My approach to ovarian stimulation in such cases is consistently to have my patients who are at risk of developing OHSS, launch their ovarian stimulation, coming off a monophasic birth control pill (BCP). The last few days on the BCP is accompanied by the addition of Lupron. Thereupon the BCP is stopped and Lupron therapy is continued. After 3-7 days menstruation usually ensues, at which point the dosage of Lupron is reduced and low dosage FSHr (Follistim/Gonal-F/Puregon) -dominant ovarian stimulation is commenced. Lupron and gonadotropins are then continued together. This approach is referred to as the “Long Pituitary Down-regulation protocol” Use of the BCP is intended to lower LH and thereby reduce stromal activation (hyperthecosis) in the hope of controlling ovarian androgen (mainly testosterone) release (too much ovarian testosterone is harmful to egg development). Seventy five (75) units of LH/hCG (Luveris/Menopur) is added from the 3rd day of gonadotropin stimulation. Starting on the 7th day of ovarian stimulation with gonadotropins, I start watching daily for the # and size of follicles developing and for the rise in blood [E2]. If there are > 25 follicles, the patient becomes a candidate for “prolonged coasting” I keep stimulating with gonadotropins (regardless of the [E2]) until: a) 50% of all follicles reach 14mm and b) the [E2] reaches 2500pg/ml. At that point, gonadotropin stimulation is discontinued abruptly while daily Lupron injections continue. Thereupon I follow the daily blood [E2] without doing further US examinations. The [E2] will almost invariably continue to rise. I carefully plot the rise in [E2] (regardless of how high it goes). Usually, within 1-3 days it will plateau and then start to decline. As soon as the [E2] drops below 2500pg/ml (and not before then), I administer the 10,000U hCGu (Novarel/Pregnyl/Profasi) “trigger” or 500mcg of hCGr (Ovidrel) and then schedule an egg retrieval for 36h later. ICSI is a MUST because “coasted” eggs usually have few or no surrounding cumulus cells and eggs without a cumulus layer will not readily fertilize on their own. All fertilized eggs are cultured to the blastocyst (up to 6 days) whereupon I transfer up to two into the uterus, or vitrify all expanded blastocysts for subsequent dispensation at the directive of the patient. In some cases the embryos are biopsied for PGS testing prior to being cryostored. Subsequent frozen embryo transfers are conducted as per the wishes of the patients.
It is important to point out that the success of this “prolonged coasting” approach depends on precise timing of the initiation and the conclusion of “prolonged coasting”. If you start too early, follicle growth will stop and the cycle will be lost. If you start too late, you will encounter too many post-mature/cystic follicles (>22mm) that usually harbor abnormally developed eggs.
Use of the above approach avoids unnecessary cycle cancellation, severe OHSS, and optimizes egg/embryo quality. The worst you will encounter is mild to moderate OHSS and this too is uncommon.
Please visit my new Blog on this very site, http://www.DrGeoffreySherIVF.com, find the “search bar” and 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
•Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•The “Biological Clock” and how it should Influence the Selection and Design of Ovarian Stimulation Protocols for IVF.
•The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF
•How Many Embryos should be transferred: A Critical Decision in IVF.
•The Role of Nutritional Supplements in Preparing for IVF
•Measuring and Interpreting Blood hCG to Assess Pregnancy Viability Following ART Treatments.
I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoff Sher
I suspect I have many more hiding in there too- yikes! Thank you 🙂