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.
Hello Dr.,
I have had two ER’s and with both my doctor told me I was actively ovulating during the procedure(35.5 hours after trigger).
During my 1st IVF cycle I was on an antagnoist protocol(BCP, Gonal F and Menopur) and only stimulated for 6 days. The E2 was checked two days before trigger(Lupron) and was 2547pg/mL. My E2 was not checked again! Ganirelix was started three days before retrieval but LH was not checked. On the day of trigger, ultrasound observed 14 follicles > 18mm with largest being 24mm, a few others were on the smaller side. On the day of ER there were 14 eggs retrieved with only 6 being mature and fertilized. I believe my best eggs(biggest follicles) were lost during this ER. One made it to blastocyst at day 5 and one at day 6. The day 5 was a failed fresh transfer and the day 6 was a chemical pregnancy.
During my 2nd IVF cycle I was on a long Lupron protocol. I was on BCP for about 4 weeks and then overlapped with Lupron and kept on the Lupron(plus Gonal F, Menopur) until ER. I stimulated for 11 days and E2 on day of trigger(Pregnyl) was 5533pg/mL. Also checked on the trigger day was the LH and it was at 1.8 mIU/mL. Ultrasound on the day of trigger showed 7 follicles > 20mm(largest was 24mm) and 6 follicles >18mm. There were a few more around 16mm. On the day of ER, 5 eggs were retrieved with 4 being mature and fertilized and none made it to day 5.
I’m a 27 years old female and my AMH is 4.4ng/mL with no known issues. My husband has slight MFI with low morphology. He also checked sperm DNA fragmentation and it is normal.
My question for you Dr. is, how does premature ovulation occur during a long agonist down regulation protocol? Do some women always ovulate before 36 hours and how can this be avoided? Thank you for your time.
There is so much more I need to know before I am able to comment authoritatively.
We really should talk.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.
Also, my 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
I am 37 with v.low ovarian reserve. Amh less than 0.5pmol/L. Usual afc 4. Early recruiter and early ovulator with shortening cycles.On high dose stims ( antagonist protocol) I did poorly. this cycle I had baseline afc 7 and using mild stims ( d2 onward bemfola 150, from d5 cetrotide, trigger 250 ovitrelle 36hr pre- retrieval) they retrieved 2 eggs on day 10. Given good sperm we did ivf and resulted in abnormal fertilisation ie one with 3 Pronucleii & the other 4 pronucleii after 12hrs. We will certainly try icsi next but should I be questioning the trigger?
Hello Doctor,
We are very suffering for babies almost 4 years.So please how can we get an appointment with you and I just want to know how much cost for the IVF.Thank You so much Doctor.we are waiting for your quick response.
Hi Dinusha,
So sorry for your pain.
Please call Julie at 702-533-2691 and she will answer your questions and can set you up for a Skype consultation with me.
Geoff Sher
Hi I have a history of poor egg quality. Total of five ivf retrieval’s starting at age 38, now 39. My first I used long protocol 450U follistim, 4 menopur vials. Produced 12 eggs, out of 5 fertilized none made it to freeze. #2- micro flare, 450 follistim 4 vials menopur( tapered off to less as I grew too fast), along with omnitrope, out of 9 retrived I had 1 to freeze. In between this and my next cycle I had a cancelled cycle and I changed doctors within the practice. I needed more individual care and attention from my doctor. New doc #3 ivf-microflare 450follistim, decreased throughout cycle, 2menopur vials, omnitrope 0.3ml/day. Had 5 blasts to freeze. #4, same protocol, 3blasts to freeze. Sent all 9 I had banked-all PGS abnormal. I know this is a numbers game so I’m doing 2 more banking cycles to see if I can get some results that are better. I’m on cycle #5 now, day 5, and have 10 follicles. I guess my question is, due to poor quality outcomes, what protocol would you try to yield the best quality outcomes. (FYI, fsh-9 and amh 0.6. I take 2000mg metformin for mild insulin resistance, prenatals, omegas, Vit D, folate, ubiquinol. Also on synthroid for tsh of 4). Any other advice or knowledge would be greatly appreciated.
Whenever a patient fails to achieve a viable pregnancy following embryo transfer (ET), the first question asked is why! Was it simply due to, bad luck?, How likely is the failure to recur in future attempts and what can be done differently, to avoid it happening next time?.
It is an indisputable fact that any IVF procedure is at least as likely to fail as it is to succeed. Thus when it comes to outcome, luck is an undeniable factor. Notwithstanding, it is incumbent upon the treating physician to carefully consider and address the causes of IVF failure before proceeding to another attempt:
1.Age: The chance of a woman under 35Y of age having a baby per embryo transfer is about 35-40%. From there it declines progressively to under 5% by the time she reaches her mid-forties. This is largely due to declining chromosomal integrity of the eggs with advancing age…”a wear and tear effect” on eggs that are in the ovaries from birth.
2.Embryo Quality/”competency (capable of propagating a viable pregnancy)”. As stated, the woman’s age plays a big role in determining egg/embryo quality/”competency”. This having been said, aside from age the protocol used for controlled ovarian stimulation (COS) is the next most important factor. It is especially important when it comes to older women, and women with diminished ovarian reserve (DOR) where it becomes essential to be aggressive, and to customize and individualize the ovarian stimulation protocol.
We used to believe that the uterine environment is more beneficial to embryo development than is the incubator/petri dish and that accordingly, the earlier on in development that embryos are transferred to the uterus, the better. To achieve this goal, we used to select embryos for transfer based upon their day two or microscopic appearance (“grade”). But we have since learned that the further an embryo has advanced in its development, the more likely it is to be “competent” and that embryos failing to reach the expanded blastocyst stage within 5-6 days of being fertilized are almost invariably “incompetent” and are unworthy of being transferred. Moreover, the introduction into clinical practice about a decade ago, (by Levent Keskintepe PhD and myself) of Preimplantation Genetic Sampling (PGS), which assesses for the presence of all the embryos chromosomes (complete chromosomal karyotyping), provides another tool by which to select the most “competent” embryos for transfer. This methodology has selective benefit when it comes to older women, women with DOR, cases of unexplained repeated IVF failure and women who experience recurrent pregnancy loss (RPL).
3.The number of the embryos transferred: Most patients believe that the more embryos transferred the greater the chance of success. To some extent this might be true, but if the problem lies with the use of a suboptimal COS protocol, transferring more embryos at a time won’t improve the chance of success. Nor will the transfer of a greater number of embryos solve an underlying embryo implantation dysfunction (anatomical molecular or immunologic).Moreover, the transfer of multiple embryos, should they implant, can and all too often does result in triplets or greater (high order multiples) which increases the incidence of maternal pregnancy-induced complications and of premature delivery with its serious risks to the newborn. It is for this reason that I rarely recommend the transfer of more than 2 embryos at a time and am moving in the direction of advising single embryo transfers …especially when it comes to transferring embryos derived through the fertilization of eggs from young women.
4.Implantation Dysfunction (ID): Implantation dysfunction is a very common (often overlooked) cause of “unexplained” IVF failure. This is especially the case in young ovulating women who have normal ovarian reserve and have fertile partners. Failure to identify, typify, and address such issues is, in my opinion, an unfortunate and relatively common cause of repeated IVF failure in such women. Common sense dictates that if ultrasound guided embryo transfer is performed competently and yet repeated IVF attempts fail to propagate a viable pregnancy, implantation dysfunction must be seriously considered. Yet ID is probably the most overlooked factor. The most common causes of implantation dysfunction are:
a.A“ thin uterine lining”
b.A uterus with surface lesions in the cavity (polyps, fibroids, scar tissue)
c.Immunologic implantation dysfunction (IID)
d.Endocrine/molecular endometrial receptivity issues
Certain causes of infertility are repetitive and thus cannot readily be reversed. Examples include advanced age of the woman; severe male infertility; immunologic infertility associated with alloimmune implantation dysfunction (especially if it is a “complete DQ alpha genetic match between partners plus uterine natural killer cell activation (NKa).
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.
•Ovarian Stimulation in Women Who have Diminished Ovarian Reserve (DOR): Introducing the Agonist/Antagonist Conversion protocol
•Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
•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
•IVF: How Many Attempts should be considered before Stopping?
•“Unexplained” Infertility: Often a matter of the Diagnosis Being Overlooked!
•IVF Failure and Implantation Dysfunction:
•The Role of Immunologic Implantation Dysfunction (IID) & Infertility (IID): PART 1-Background
•Immunologic Implantation Dysfunction (IID) & Infertility (IID): PART 2- Making a Diagnosis
•Immunologic Dysfunction (IID) & Infertility (IID): PART 3-Treatment
•Thyroid autoantibodies and Immunologic Implantation Dysfunction (IID)
•Immunologic Implantation Dysfunction: Importance of Meticulous Evaluation and Strategic Management 🙁 Case Report)
•Intralipid and IVIG therapy: Understanding the Basis for its use in the Treatment of Immunologic Implantation Dysfunction (IID)
•Intralipid (IL) Administration in IVF: It’s Composition; how it Works; Administration; Side-effects; Reactions and Precautions
•Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
•Endometrial Thickness, Uterine Pathology and Immunologic Factors
•Vaginally Administered Viagra is Often a Highly Effective Treatment to Help Thicken a Thin Uterine Lining
•Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
•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
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 .
*The 4th edition of my 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
Addendum:
Here is the protocol I advise for women, <40Y who have adequate ovarian reserve.
My advice is to use a long pituitary down regulation protocol starting on a BCP, and overlapping it with Lupron 10U daily for three (3) days and then stopping the BCP but continuing on Lupron 10u daily (in my opinion 20U daily is too much) and await a period (which should ensue within 5-7 days of stopping the BCP). At that point an US examination is done along with a baseline measurement of blood estradiol to exclude a functional ovarian cyst and simultaneously, the Lupron dosage is reduced to 5U daily to be continued until the hCG (10,000u) trigger. An FSH-dominant gonadotropin such as Follistim, Puregon or Gonal-f daily is started with the period for 2 days and then the gonadotropin dosage is reduced and a small amount of menotropin (Menopur---no more than 75U daily) is added. This is continued until US and blood estradiol levels indicate that the hCG trigger be given, whereupon an ER is done 36h later. I personally would advise against using Lupron in “flare protocol” arrangement (where the Lupron commences with the onset of gonadotropin administration.
I’m 46 yrs with 2 failed IVFs. I used donor eggs, my ET was done on 16 April with 4 embryos & yesterday 14dpt my beta hcg level was 6 & they said it’s negative.Doc has told to me to do repeat test. Why should I retest my hcg levels. Will I get a positive result tomrw.
You should retest because the levels sometimes do rise even from a low baseline!
Good luck!
Geoff Sher