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 read your article on MK who had successful IVF with you by doing an antagonist long pituitary down regulation protocol, after prior unsuccessful cycles at other clinics that yielded so-called “empty follicle syndrome.” I have had three of those EFS cycles. I am 40 with high FSH (19) and low AMH (0.04). My uterus is healthy and my immunity and genetic tests all tested healthy. My husband’s sperm tested to be healthy. We have been trying to conceive for two years, with two natural cycle pregnancies that resulted in first trimester miscarriage. The first time I primed with estrogen and Ganirelix, then started stimming with Gonal F and Menopur, then reintroduced the Ganirelix in addition to staying on Gonal F and Menopur until the Pregnol trigger. There were 3 follicles, yielding only 1 egg which fertilized and became a blast but didn’t pass the Next Generation Sequencing test. My second IVF involved priming with estrogen, then switching to stimming with Lupron and Gonal F and Menopur, triggering with Pregnol. There were 5 follicles of good size, and retreival only yielded one egg that was not mature and didn’t fertilize. My third IVF was a mini IVF and it involved priming with birth control, stimming at first with Clomid and Letrazol, then only with Clomid, then introducing Ganirelix in addition to the Clomid, and triggering with Lupron. There were 4 follicles of good size, and one ovulated before retrieval and the other 3 did not yield an egg. I have read that DHEA supplentation, begun by Dr Norbert Gleicher, can potentially help women yield more and better quality eggs in an IVF cycle after taking 75 units a day for 1-3 months. My understanding is that DHEA is considered a “weak androgen” and it is converted to estrogen and testosterone. I saw in your article about MK’s success that avoiding testisterones was key, so I wanted to ask you, please, whether you would recommend DHEA for me or not? I have not taken DHEA supplements; my natural DHEA sulfate level us 89 (where the normal range is 23-266) and my natural DHEA LC/MS/MS is 189 (where the normal range is 102-1185).
Hi Shirin,
Given you age and the the severity of your diminished ovarian reserve, I would strongly advise you to consider egg donor-IVF. However if in spite of the odds being so severely against you you still want to try with own eggs then I would suggest that you avoid taking DHEA and consider the following:
The older a woman becomes, the more likely it is that her eggs will be chromosomally/genetically “incompetent” (not have the potential upon being fertilized and transferred, to result in a viable pregnancy). That is why, the likelihood of failure to conceive, miscarrying and of giving birth to a chromosomally defective child (e.g. with Down Syndrome) increases with the woman’s advancing age. In addition, as women age beyond 35Y there is commonly a progressive diminution in the number of eggs left in the ovaries, i.e. diminished ovarian reserve (DOR). So it is that older women as well as those who (regardless of age) have DOR have a reduced potential for IVF success. Much of this is due to the fact that such women tend to have increased production of LH biological activity which can result in excessive LH-induced ovarian male hormone (predominantly testosterone) production which in turn can have a deleterious effect on egg/embryo “competency”.
While it is presently not possible by any means, to reverse the age-related effect on the woman’s “biological clock, certain ovarian stimulation regimes, by promoting excessive LH production (e.g. short agonist/Lupron- “flare” protocols, clomiphene and Letrozole), can make matters worse. Similarly, the amount/dosage of certain fertility drugs that contain LH/hCG (e.g. Menopur) can have a negative effect on the development of the eggs of older women and those who have DOR and should be limited.
I try to avoid using such protocols/regimes (especially) in older women and those with DOR, favoring instead the use of the agonist/antagonist conversion protocol (A/ACP), a modified, long pituitary down-regulation regime, augmented by adding supplementary human growth hormone (HGH). I further recommend that such women be offered access to embryo banking of PGS (next generation gene sequencing/NGS)-selected normal blastocysts, the subsequent selective transfer of which by allowing them to to capitalize on whatever residual ovarian reserve and egg quality might still exist and thereby “make hay while the sun still shines” could significantly enhance the opportunity to achieve a viable pregnancy
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 Fundamental Requirements For Achieving Optimal IVF Success
•Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the “Conventional” Antagonist Approach
•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.
• A Rational Basis for selecting Controlled Ovarian Stimulation (COS) protocols in women with Diminished Ovarian Reserve (DOR)
•Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
•Controlled Ovarian Stimulation (COS) in Older women and Women who have Diminished Ovarian Reserve (DOR): A Rational Basis for Selecting a Stimulation Protocol
•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?
•Blastocyst Embryo Transfers Should be the Standard of Care in IVF
•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.
•Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
•Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
•Preimplantation Genetic Testing (PGS) in IVF: It Should be Used Selectively and NOT be Routine.
•Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
•PGS in IVF: Are Some Chromosomally Abnormal Embryos Capable of Resulting in Normal Babies and Being Wrongly Discarded?
•PGS and Assessment of Egg/Embryo “competency”: How Method, Timing and Methodology Could Affect Reliability
•Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
•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
•Premature Luteinization (“the premature LH surge): Why it happens and how it can be prevented.
•IVF Egg Donation: A Comprehensive Overview
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
Dear Dr Sher – I wish We met you when you were in NY!!!
Im 39 years old, 40 In a couple weeks. We need your honest opinion on IVF protocol as we embark on a 5th and final attempt due to financial costs
We recently met 2 different clinics which seem to have different approaches
Clinic A: begin estrogen patch on day 21 and also+ ganirelix/cetrotide injections until period comes. Then starting Gonal F/ Follistim and Menopur.
Trigger : HCG
*Supplements: Ubiquinol, DHEA
Clinic B: Estrogen patch until period, then start Menopur, Gonal-f, HGH for 10-12 days and adding cetrotide last 7 days
Trigger: HCG, Lupron
*Supplements for 1 month prior – ubiquinol, DHEA,Melatonin, inositol, reservetrol
We lean towards clinic B due to HGH added which is different from all other cycles we had.
We had 4 IVF with PGD in 2017, all with the same doctor (not with the above clinics) but now must try our luck elsewhere. We are doing PGD to rule out for a specific disease which I have a 50% chance to pass. Our protocols have been as follows:
Cycle 1: Menopur 150 mg, Gonal-f 300, and last 6 days added cetrotide 0.25, Trigger: HCG 10, 000 units
Results: 10 eggs retrieved, 7 mature, 6 fertilized, 3 made it to PGD
This is the only cycle with minor hyperstimulation symptoms which I experienced after Retrieval
Cycle 2: day after my period stopped I began Lupron microdose of Leuprolide 40mcg/.2ml + Menopur 150mg + Gonal-f 300 + And Trigger of HCG 5,000
Results: 6 fertilized, 2 made it to blast/PGD
Cycle 3: Estrogen priming patch 0.1 mg on day 21, then after period began Lupron microdose of Leuprolide 40mcg/.2ml + Menopur 150mg + Gonal 300, Trigger HCG 5000
Results: 19 retrieved, 11 mature, 9 fertilized, 5 blast / PGD
Cycle 4: same as above but trigger of hcg 10, 000
Results: 13 retrieved, 7 mature, 5 fertilized and 1 PGD/blast
Of all our cycles – all our 11 embryos except for 1 (in storage from cycle 3)are abnormal- either carry disease gene and/or chromosomaly abnormal.
All our cycles I have taken Prenatal Vitamins, CoQ10, DHEA, Vit D3, Melatonin, (last 2 cycles I had been on Asprin 81 from my primary care md)
I know you will perhaps tell me about donor eggs (which we are really against), but after you tell me that can you give me the feedback about my own eggs. My lining is good per the clinics with 10 follicles each side.
What is your take Dr Sher?
Thank you kindly
Gego
Dear Dr. Sher
I am 39 years old, AMH 0.86. FSH 4.95 IU/mL.
In the 1st IVF the doctor prescribed me: Diane 35 (since 17/11/2017 until 3/12/2017). The follicle stimulation started (4/12/2017) with Gonal 300 IU (since day 1 until day 13), plus Menopur 75 IU (since day 5 until day 13) dan Cetrotide (since day 7 until day 13). The injection trigger is Ovidrel (on day 14). The retrieved eggs were 6 but then only 4 were considered normal, resulted only 1 embryo grade good for ET, and later a failed implantation. What do you think Doctor, with this protocol for DOR, what should be changed (if any) for the next IVF?
Thank your for the advise doctor.
Dear Dr. Sher
My progesterone is 1.450 np/mL in the morning day of injection trigger. The OPU will be at 09.30, 2 April 2018. The doctor recommended me to freeze all embryos and wait until two menstrual cycles before FET. What do you think? If I choose ET, will this hormon level reduce the chance of implantation/pregnancy? The estradiol is 2,265 pg/mL (USG shown 8 potential folicles).
Thank you Dr Sher
Respectfully,
I am not of the opinion that a progesterone level of 1.4ng/ml would seriously compromise implantation.
Geoff Sher
Dear Doctor,
Im 38 about to turn 39 and on the infertility route. We’ve been trying to conceive for 2 years this month. After 9 months we started all the investigations and it turned out that: my husband had a bad spermiogram, with 1% normal shape and low motility, but so far we’ve managed to boost the values to 5-16% and more motility with supplements (prescribed).
as for me, Ive been diagnosed with one endometrioma in one ovary and that tube is closed, poor ovarian reserve, amh is 0.18, ive done 3 afc, the first one after the first stymulated cycle and it was 2 (only the good ovary) the second was 2 again, the third one was 5 follicles. fsh fluctuates.
I went through the sty, 275 gonalf for 9 days and meropur 150, then a medicine for 4 days on day 6-7-8-9, which I can’t remember. The dormant ovary didn’t respond. the other one had 4 follicles, from which they retrieved only one egg… which was atresic and they didn’t fertilize.
this was 4 months ago. in the last 3 months, I’ve been through a drastic lifestyle change. I took up swimming or yoga, acupuncture, changed diet and introduces lots of legumes and vegetables, cut on milk, refined carbs, alcohol (not coffee). unfortunately i have IBS and the veggies and legumes don’t do me good and I’ve had to limit them, but the diet has become a difficult path as I want to introduce fresh healthy food but it apparently harms me on another level.
I also take folic acid, omega 3, ubiquinol, vitamin D (I had under-threshold levels) but don’t take any prenatal.
Now I’m ready to cycle again at another clinic where I also had immunes tests which came out clear. Nonetheless, they’ve given me very low chances to conceive…
the first result I’ve experienced through this lifestyle change is that my hormones dropped. bot fsh (8, from 16-17) and estradiol (60 pg, from 110-120). I don’t know if this is going to get better, if it is due to supplements acu diet or all things together, but the clinic seemed to dismiss it, probably because of the dormant ovary and the low AFC.
Could you give me an honest, sensible opinion? do I have better chances now that I’m being proactive(and found a better clinic? the previous one went ahead with the stymulation without testing that month fsh and afc).
Kind regards,
Cory
There are several issues:
1. Age and its inevitable effect on egg “competency”
2. Diminished Ovarian reserve (AMH=0.1ng/ml + poor response to gonadotropins). This ideally should raise the important consideration of using an egg donor and if this is not acceptable to you, then it certainly mandates a very individualized approach to ovarian stimulation, with Staggered IVF, PGS and embryo banking.
3. Endometriosis with an endometrioma that in my opinion should be addressed prior to any future stimulation.
4. Endometriosis-related immmunologic implantation dysfunction, linked to natural killer cell activastiomn in about 1/3 of cases:
______________________________________________
A: Age and Diminished Ovarian Reserve (DOR) and declining egg/embryo competency and yield:
The older a woman becomes, the more likely it is that her eggs will be chromosomally/genetically “incompetent” (not have the potential upon being fertilized and transferred, to result in a viable pregnancy). That is why, the likelihood of failure to conceive, miscarrying and of giving birth to a chromosomally defective child (e.g. with Down Syndrome) increases with the woman’s advancing age. In addition, as women age beyond 35Y there is commonly a progressive diminution in the number of eggs left in the ovaries, i.e. diminished ovarian reserve (DOR). So it is that older women as well as those who (regardless of age) have DOR have a reduced potential for IVF success. Much of this is due to the fact that such women tend to have increased production of LH biological activity which can result in excessive LH-induced ovarian male hormone (predominantly testosterone) production which in turn can have a deleterious effect on egg/embryo “competency”.
While it is presently not possible by any means, to reverse the age-related effect on the woman’s “biological clock, certain ovarian stimulation regimes, by promoting excessive LH production (e.g. short agonist/Lupron- “flare” protocols, clomiphene and Letrozole), can make matters worse. Similarly, the amount/dosage of certain fertility drugs that contain LH/hCG (e.g. Menopur) can have a negative effect on the development of the eggs of older women and those who have DOR and should be limited.
I try to avoid using such protocols/regimes (especially) in older women and those with DOR, favoring instead the use of the agonist/antagonist conversion protocol (A/ACP), a modified, long pituitary down-regulation regime, augmented by adding supplementary human growth hormone (HGH). I further recommend that such women be offered access to embryo banking of PGS (next generation gene sequencing/NGS)-selected normal blastocysts, the subsequent selective transfer of which by allowing them to to capitalize on whatever residual ovarian reserve and egg quality might still exist and thereby “make hay while the sun still shines” could significantly enhance the opportunity to achieve a viable pregnancy
B. Endometriosis/Endometrioma and Immunologic implantation Dysfunction :
Advanced endometriosis is often associated with ovarian cysts (endometriomas/chocolate cysts) that are filled with altered blood and can be large and multiple. When these are sizable (>1cm) they can activate surrounding ovarian connective tissue causing production of excessive male hormones (androgens) such as testosterone and androstenedione. Excessive ovarian androgens can compromise egg development in the affected ovary (ies) resulting in an increased likelihood of numerical chromosomal abnormalities (aneuploidy) and reduced egg/embryo competency”. In my opinion large ovarian endometriomas need to be removed surgically or rough sclerotherapy before embarking on IVF.
Immunologic Implantation Dysfunction (IID). Endometriosis, regardless of its severity is associated with immunologic implantation dysfunction linked to activation of uterine natural killer cells (NKa) and cytotoxic uterine lymphocytes (CTL) in about 30 of cases. This is diagnosed by testing the woman’s blood for NKa using the K-562 target cell test or by endometrial biopsy for cytokine analysis, and, for CTL by doing a blood immunophenotype. These NKa attack the invading trophoblast cells (developing “root system” of the embryo/early conceptus) as soon as it tries to gain attachment to the uterine wall. In most cases, this results in death of the embryo even before the pregnancy is diagnosed and sometimes, in a chemical pregnancy or even an early miscarriage. . As such, many women with endometriosis, rather than being infertile, in the strict sense of the word, often actually experience repeated undetected “mini-miscarriages”.
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 Fundamental Requirements For Achieving Optimal IVF Success
•Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the “Conventional” Antagonist Approach
•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.
• A Rational Basis for selecting Controlled Ovarian Stimulation (COS) protocols in women with Diminished Ovarian Reserve (DOR)
•Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
•Controlled Ovarian Stimulation (COS) in Older women and Women who have Diminished Ovarian Reserve (DOR): A Rational Basis for Selecting a Stimulation Protocol
•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?
•Blastocyst Embryo Transfers Should be the Standard of Care in IVF
•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.
•Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
•Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
•Preimplantation Genetic Testing (PGS) in IVF: It Should be Used Selectively and NOT be Routine.
•Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
•PGS in IVF: Are Some Chromosomally Abnormal Embryos Capable of Resulting in Normal Babies and Being Wrongly Discarded?
•PGS and Assessment of Egg/Embryo “competency”: How Method, Timing and Methodology Could Affect Reliability
•Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
•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
•Premature Luteinization (“the premature LH surge): Why it happens and how it can be prevented.
•IVF Egg Donation: A Comprehensive Overview
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