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, do i need Endometrial Receptivity Array if i already have 4 natural full term pregnancies? I am doing IVF for Gender selection and i have 1 normal XY to transfer (FET) . Do i need to do the ERA?
Hi Dr Sher. 33yr old 6 months trying. I have tracked my luteal phase and noticed a steady 8 days between ovulation and start of period. I was given 400mg cyclogest rectally from 3 days after ovulation. However, my period still arrived (7 day luteal phase this time!) I note from previous posts that progesterone alone is insufficient and follicular phase treatment is also necessary. I am keen to understand prognosis for luteal phase defect. I am wary of advancing age and would like advice on whether natural conception is a realistic expectation in the medium term.
Following ovulation, what remains of the ruptured follicle transforms itself into a structure called the Corpus Luteum (CL) which produces progesterone. The purpose of progesterone is to prepare the uterus to accept and support an early pregnancy until it is able to sustain itself at around 8-10 weeks of gestation.
The life span of the CL is predetermined to be 12-13 days, unless rescued by a signal from the early pregnancy. If no pregnancy occurs, the CL stops making progesterone and menses ensues 1-2 days later. For most women the length of the second half of the menstrual cycle (the luteal phase) is constant at 14 days. A small percentage of infertile women (3-4%) have a shortened luteal phase. This may result in the loss of pregnancy support before the budding pregnancy has a chance to signal the ovary that it is there.
The lining of the uterus (the endometrium) has a specific appearance that changes throughout the menstrual cycle, such that a biopsy of the lining a few days prior to expected menstruation, can accurately date endometrial development. A 3 or more day difference between endometrial dating by biopsy and cycle day as determined by the start of the next menstrual period is indicative of a luteal phase defect (LPD). Sequential mid luteal progesterone levels < 10 ng/dl can also be used to diagnose a LPD. Luteal phase defect can be treated with Clomiphene Citrate, Progesterone supplementation or hCG injection PROGESTERONE LEVELS Normal Progesterone (P) levels rise sharply after ovulation, peaking a week after ovulation. Because P secretion occurs in a pulsatile fashion (around every 90 minutes), single low levels are often found in the course of a normal luteal phase and cannot be used as a predictor of luteal defect or poor fertility potential. In pregnancy, P is secreted by the corpus luteum (of pregnancy) until about 10 weeks of gestation. Because of the large variation in individual P levels, the predictive value of single P measurement in early pregnancy is limited. Usually levels above 20 ng/ml indicate a normal pregnancy while levels below 5 ng/ml suggest a potential problem. It is also important to point that persistent low P levels are usually the result, rather than the cause, of poor outcome and that unfortunately, as a result, P supplementation does not prevent the inevitable. Geoff Sher
What should e2 level be on transfer day for FET or does it not matter so long as lining is thick enough before commencing progesterone?
It depends on the regime being used hormonally to prepare the uterus. I use parenteral estradiol valerate (Delestrogen) injections twice weekly and I shoot for an E2 vof 500-1000pg/ml prior to progesterone.
Geoff Sher
Hi Dr. Sher I would like to know what you feel is a good e2 level range for fet thanks
Hi Dr Sher. I am 39 years old. 6 years ago I did 2 IVF . Both on menopur . Both were unsuccessful due to low amh and I was told poor egg quality. Two months after my failed IVF I fell pregnant naturally and had a healthy baby.
I have now gone back to the fertility specialist. My AMH is 0.27 . Ihave tried an IUI in December 2017 which was unsuccessful. It was also established that my husbands sperm motility was 35%.
I have again done IUI . This time with clomid and pergoveris from day 3-8 . There were 3 follicles . Also did trigger on day 9. IUI day 10. And no success . I am wondering whether you would recommend IVF . Because it previously did not work 6 years ago I am unclear on the route to follow .
You have very much diminished ovarian reserve (DOR) and IUI is in my opinion contrindicated because it is very unlikely to succeed. You need IVF done strategically (see below:
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