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.
Dear Dr. Sher,
I have just found you and I’m very appreciative of this opportunity to ask for your expert opinion.
My husband and I recently married, I just turned 45, neither one of us has children. We had a recommendation for a clinic from a friend of my husbands that had success with twins at 42. We visited the clinic out-of-state and did a One Day work up where they counted 5 fibroids, which cause heavy bleeding on day 2 & 3 of my cycle. I visited a local GYN surgeon that requested an MRI and found possibly 8 fibroids and that I possibly may also have endometriosis, maybe even on my ovaries. I will require surgery, but the RE said that we should do egg retrieval first although the surgeons thought I should do surgery first…. Frozen Embryos with ICSI and CCS testing. The ultrasound at the clinic showed I had 12 follicles and strong doplar of 2.1 – 2.7. Day 3 blood work: FSH 8.8, Estrogen 83, LH 4.3, AMH .67 Day 16 blood work: LH 2.2, Progestrone 10.0
No genetic screening carrier issues. The Anti-Phospholipid Anitbody Panel showed an abnormally high ACG 34.1 GPL Husband’s sperm is above average with no issues.
I’m new to IVF and sensitive to drugs and want to make sure this is the best protocol, I realize my age is the biggest factor but was told my numbers are that of someone 10 years younger…. I was told I was on the strongest protocol and I have to commit today….
2mg Estradiol
Stim Meds:
Menopur, 75 Unit Vial, 20 Vials
Gonal-F, 1-300 pen and 3-900 pen
Clomid, 50 mg, 10 tabs
Cetrotide, .25mg, 6 syringes
Dexamethanasone, 0.5 mg, 15 tabs
Trigger Meds:
Pregnyl, 1-10,000 unit vial
Leuprolide Acetate Trigger Kit, Sandoz brand only, 1 kit
Post Retrieval Meds:
Doxycline, 100 mg, 8 tabs
Please let me know your honest thoughts.
Heartfelt appreciation…..
Respectfully, while I could critique the protocol used, it is my opinion that at 45y, given the dismal success rate potential, you should rather be doing IVF with donor eggs. You would probably still require having the fibroids addressed surgically.
Geoff Sher
Dr. Sher, Are you able to do a Skype consultation and then order labs for someone if living in another state not within driving distance? The only tests that I have not had done are the DQ Alpha genotyping on my husband and I, and testing my Natural Killer Cell Activity. I have an IID issue, just not sure if it’s brought on by autoimmune or if my husband and I are a DQ Alpha match/partial match. Thanks so much!
Yes I am!
Geoff Sher
I have pcos . I just had a 5 day frozen embryo transfer on 4/23 . I used a PGS normal embryo . I am on synthroid , estrace , ovasitol , plaquenil , prednisone , LDN, neupogen , low dose aspirin, prenatal vitamin, lovenox , endometrin, and prometrium, I also take fish oil , extra folate , and vitamin d. My pregnancy test on 5/2 was positive with an hcg of 50. The redraw today 5/4 the hcg went down to 38. My progesterone 5/2 was over 41 and today went down to 25. Tbis was my 6th frozen embryo transfer . The first with a PGS normal embryo. I have had 3 previous early miscarriages and it is looking as though that will happen again as my hcg went down and did not increase . In your opinion am I doing too many medications ? What can I do different next time ? Start the cycle with birth control ? Any suggestions would be greatly appreciated! Thank you !
Hi Dr. Sher,
I’ve now had three failed fresh ivf cycles. The main problem is my eggs. I’m 38 with low reserve. On maximum menopur I get three eggs each time. I’m considering trying a milder ivf with clomid and 225 menopur. Would you use clomid for an older lady and a poor responder?
In my opinion, neither clomiphene nor Letrozole should be used in women with DOR and too much Menopur is also in my opinion bad for eggs.
In my opinion, the protocol used for ovarian stimulation, against the backdrop of age, and ovarian reserve are the drivers of egg quality and egg quality is the most important factor affecting embryo “competency”.
Women 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 effect of DOR, certain ovarian stimulation regimes, by promoting excessive LH production (e.g. short agonist/Lupron- “flare” protocols, clomiphene and Letrozole), can in my opinion, 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 women 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 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, https://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
Hello Doctor Sher, we are trying for a second child. I am about 40 years old and husband is 41 years old. One natural effortless pregnancy 10 years back. Waited to try IVF for family balancing. First IVF in Dec. 2016, only one good embryo, resulted in chemical pregnancy. Tried naturally, had not tried at all after first child. Got pregnant in summer of 2017, had miscarriage in 3rd month. No detected health and fertility issue in both husband and myself. My periods and ovulation have always been regular. Sperm morphology of husband was about 6% in 2016, has not been tested since then.
Went for second IVF at another clinic. My TSH before the 2017 pregnancy had been around 1.8, but after that pregnancy it had not lowered from its elevated value of about 3.5. So for the IVF cycle, the doctor put me on a 25microgram of levothyroxine that has brought TSH value down to about 0.8 since Feb. 2018. For blood work done in Dec. 2017, AMH was about 1.31ng/ml and FSH was 6.73mIU/ml. I am about 5′.1″ and my weight has been around 145 pounds since the end of pregnancy in Oct. 2017.
For this IVF cycle, I was asked to take prenatal and baby aspirin regularly. After my periods of March 3rd week, 2018, I was put on birth control for about 2 weeks. After suppression check, two days before starting stimulation, they asked me to start taking a low dose of dexmethasone.
Stimulation details starting Mid-April of 2018, were as follows:
6 days: Menopur- 150 IU and Omnitrope-5.8mg, 33 units in the morning and Gonal F-300 units at night
7-10 days-Menopur- 150 IU and Cetrotide-0.25mg in the morning and Gonal F-300 units at night
10th day my follicle sizes were as follows:
Left ovary: 24.40mm, 20.80mm, 17.20mm, 18.60mm, 18.80mm and No cysts
Right ovary: 18.60mm, 19.70mm, 17.20mm, 17.80mm, 13.50mm and No cysts
Estradiol level 2576pg/ml (Levels were constantly monitored and increased in a controlled manner during the stimulation)
10th night, I was asked to do the trigger shot: Was told to take 0.8ml of 4mg Lupron shot to control estradiol level, and HCG shot of only 1000IU (not 10000IU), 36 hours before retrieval.
The next day my estradiol level was 2675pg/ml and progesterone was 5.78ng/ml.
Egg retrieval was done on 36 hours after trigger and we were told they could only retrieve 6 eggs from both sides, out of which only 4 were mature, only 2 fertilized with ICSI and these two did not grow to become blastocysts with enough number of healthy of cells.
So essentially, this cycle was a total failure and devastating for us.
Given our history and health records, doctor, kindly provide your advice as to what we are doing wrong. We were hoping, that with my fertility records, I should respond well and we were hoping for some good results with this cycle. Given my age, I am eager to quickly go for multiple egg retrievals now before trying for a transfer. Kindly let us know what your thoughts are. We will be very thankful for the same.
Regards
In my opinion, the trigger with Lupron which relies on promoting an LH surge, is used to prevent hyperstimulation. It does reduce the risk of OHSS but this comes at the expense of egg competency…in my opinion. First, based upon your vE2 and the # of follicles, I do not think you were so at risk and thus I personally would have “triggered you with 10,000U hCG or 500mcg ovidrel., in which I case you would likely not have has so many “empty follicles”.
As for your prior IVF failures…please read below:
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
Thank you so much Dr. Sher for your valuable inputs. Can you please let me know what you think of the protocol followed in the recent IVF cycle? Should we be doing things differently for the next cycle with regards to birth control pill duration, type of protocol, type of stimulation and medicines etc.? Also, is it a good idea for me to go for back to back egg retrievals within quick intervals say of 6-8 weeks in the next few months to bank as many good quality eggs/embryos as we can? Please let me know.
Regards