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. I have 1 frozen embryo (acquired when I was 42yrs old), that was labeled “Mosaic/Trisomy 19”. I have spent a lot of time researching Chromosome 19, but there is not much written about it so far. I am thinking of taking a chance of implantation before going to donor eggs. My doctor says that over the last two years she has had 5 different mosaic pregnancies, and 3 out of 5 resulted in healthy newborns (after counseling & CVS) . Is this worth the chance- Opinion? Ps – You are a Godsend to us women who have found ourselves on this trying journey. Thank you.
I would transfer that embryo.
Good luck!
Geoff Sher
Hello Dr.
I am Suman From India. I am 34 and sufferuing from PCOD. Have period problem and my weight is 70kg. I am trying to get pregannat. Last year during I had a misscarriage after about 2 months. This time am under consultation with my obgyn. She gave me letrozole from day 3 and because of thin linking on day 10th she gave probera. After that I have been given HCG injection with 10000 mg. My egg got raptured on 16th day. Me and my husband were together from day 13th to day 16. Sir, today is 24th day of cycle. Is there any chance of getting pregnant during this cycle. plesae answer.
Respectfully, giving Provera prior to the hCG trigger, is not a good idea.
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.
Geoffrey Sher MD
Hi Dr. Sher,
Just some history.
At age 35 diagnosed with severe endometriosis, one Fallopian tube (blocked) other missIng. FSH 18, Amh 2.5 !!!
15 eggs
12 fertilized
9 fertilized normally
4 blastocyst—- froze them all they became blast on day 6.
First FET transferred 2 embryos (not tested) resulted biochemical pregnancy
Second FET transferred 2 first hcg reading 452 pregnant with twins one heart beat!
Have a 4 year Old child.
She wants a sibling but I’m 40 now.
I don’t know how I responded well
With fsh of 18!!!
Can fsh be affected by twins running in family? I’ve read many research on this?
Anyways whats your suggestion now.
I would rather try with one egg is this a possibility?
Thanks !!!!
Dhurata
I just finished watching “Future Baby” on Netflix and thoroughly enjoyed your contribution to the film. 3/4 of the way through, when you are meeting with the PGD/PGS technician and are talking about the family that wanted a boy and they had four normal females and no normal males hit me particularly hard as that is what we are going through right now. We are two, healthy, non-smoking, drug-free 31 year olds with a 6 year old daughter. On our first retrieval in December we had 7 sent for biopsy- 3 normal females, 2 complex abnormal males, 1 abnormal females, and 1 complex unknown.
What I am asking is, are we kidding ourselves going for a second retrieval in July (at MCRM St. Louis), or can is there any chance in this world that we could have at least one, healthy male? If we are destined to fail, then we should save our money and heartache, but is each cycle different? I would have never guessed we would not even have one.
Thank you.
I am so embarrassed, It was not you in the film but Steinberg, I just assumed it was you. I am so sorry. I know you can also help with my question, though, so it still stands.
My apologies
The gender of your embryos and their “competency was random chance. You should consider trying again, in my opinion.
Geoff Sher
Hi Dr Sher
Im reaching out for my cousin whom doesn’t speak English. She’s has a prolapsed uterus. She has many normal embryos frozen. She’s had 1 natural ectopic pregnancy.
Than she turned to IVF first attempt was a fail with normal tested embryos second attempt pregnancy with low hcg ended In miscarriage.
Now her third ivf at 6 weeks her hcg was 1300 now at 7 weeks she still gets a positive pregnancy test but the dr can not see a baby in her uterus today. He advised her to stop all medication and wait for a period. What’s your opinion in this should she go to an obgyn and see if they can “find” the baby???
She still has 3 normal embryos frozen left. She’s 25 years old and dr has done 2 surgeries to correct her prolapsed uterus.
Thank you sooooooo much !!
Dee
Also want to add that all my FET cycles were done with normal tested embryos.
Dee
I would wait one more week before making a decision. Also, bear in mind that this could again be an ectopic. If she experiences any sudden pain or bleeding or should she experience light headedness of fainting …she should see her OB immediately or go to the nearest emergency room.
Geoff Sher