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 Sher
My husband and I have been trying for a 2nd baby for over a year now. I turn 45 years old soon.. We had our 1st child, a girl over 2 years ago through IVF. Last year we tried 3 cycles of IVF-both failed and I produced very few eggs. Twice I had day 3 transfers (2 embroyos the 1st time and 1 embroyo the 2nd time). The 3rd IVF didnt results in any viable embroyos. We also had a few rounds of IUI last year. 1 resulted in a chemical pregnancy and the other IUIs failed.
Moving to this year, we moved on to try donor eggs due to my very low AMH levels and lack of response to IVF.
We used a fresh donor cycle. 16eggs and 6 fertilizied but only one embryo made it to day 5
Then we used frozen donors ( 2 different donors) so a total of 25 eggs, 9 fertilized
by day 3 there were only 2 decent embryos. By Day 5 there were 2 blastocycts graded 3CC.
Now we are waiting for day 6 to see if these become hatching.
We are feeling so demoralized by the poor outcome and the waiting.
Do you think my husband has a sperm issue? We used donors eggs from 3 dffierent young women and the embryos mostly arrested or deteriorated by day 3.
What kind of tests should my husband undergo.
With the last donor cycle his sperm morphology was 5% post wash.
I look forward to hearing from you
Sincerely
Adeline
I am not a fan of frozen egg banks because the stimulation information of the donors is not readily available and results are not as good as when fesh eggs are used. Yes, it is possible that there is a sperm issue. However, given past performance this is less likely. Perhaps you can send me the results of your husband’s most recent semen analysis. Also, it would be helpful for his sperm to be subjected to a sperm chromatin structure assay (SCSA).
If you would like to talk, call 800-780-7437 and set up a Skype consultation with me.
Geoff Sher
Dear Dr. Sher,
I have previously had a failed Fresh and a failed FET cycle. During the fresh cycle I had pessaries for progesterone support and my period arrived the day after I stopped them. For my FET I was given progesterone injections on top of the pessaries. It took 3 days for my period to arrive after I stopped taking them. I have since found out my NK cells are elevated and am due to commence another fresh cycle soon. In your opinion would progesterone injections be necessary in addition to the cyclogest.
Probably advisable…yes!
I hope you will be on Intralipid with Steroids for your next cycle.
Good luck!
Geoff Sher
Hello Dr. Sher,
Thank you for this opportunity to ask you questions.
I am 45 years old (as of this month) and 6.5 months ago gave birth (normal, vaginal) to a healthy, beautiful baby girl. I had no complications during my pregnancy except for mild gestational diabetes which I controlled with diet and exercise. I did not need any medication. I am otherwise very healthy with no pre existing conditions. My OB has said that I could be 10 years younger 🙂
My husband and I have two remaining embryos that have been tested with PGS and have been determined to be euploid.
Given my age, we hope to proceed as soon as possible with another transfer and our Doctor has encouraged the same. We are now at the point of trying to decide to proceed with one or both embryos. If we transfer one and it takes, I don’t think a third pregnancy would be ideal. If it does not take, we would have another embryo to transfer. This is versus transferring them both at the same time. or this opportunity to ask you questions.
I am 45 years old (as of this month) and 6.5 months ago gave birth (normal, vaginal) to a healthy, beautiful baby girl. I had no complications during my pregnancy except for mild gestational diabetes which I controlled with diet and exercise. I did not need any medication. I am otherwise very healthy with no pre existing conditions. My OB has said that I could be 10 years younger 🙂
My husband and I have two remaining embryos that have been tested with PGS and have been determined to be euploid.
Given my age, we hope to proceed as soon as possible with another transfer and our Doctor has encouraged the same. We are now at the point of trying to decide to proceed with one or both embryos. If we transfer one and it takes, I don’t think a third pregnancy would be ideal. If it does not take, we would have another embryo to transfer. This is versus transferring them both at the same time.
We really hope to have a chance with both embryos. If we transfer both embryos, what is the chance of having twins with euploid embryos? What is the risk of losing both embryos? Would there be significant risk to the embryos themselves? These questions are what concern me the most.
I was also interested to know if it is absolutely necessary to stop breastfeeding before starting a cycle. I am not exclusively breastfeeding, I would say about 40% breastfeeding and 60% formula.
I know there are not clear cut answers but any insight you have would be appreciated. We want to be respectful of the risks and remain hopeful for our chances.
Thank you,
Jade
Yes! I would stopbreast feeding before the FET cycle because a raise in prolactin with breast feading could compromise implantation. Also, at 45y, I would transfer 1 euploid embryo at a time since a 30-40% risk of twns exists and carrying twins at any age is potentially prejudicial to moter and baby. Carrying twins at 45y (no matter how young yuou feel or look), is much more hazardous.
Good luck!
Geoff Sher
Hi Dr Sher,
Thank you for such an informative blog. It has been very insightful and a great resource for me and my husband.
I am 37 years old, and have had 2 natural pregnancies that both led to miscarriages (they were 2 years ago – first at 12 weeks and, 5 months later the second at 5 weeks). After the 2nd miscarriage we came to a fertility clinic to get some assistance. Our tests (blood, semen, hormone etc.) have shown nothing abnormal except for a DOR and a slightly hyperthyroid (started taking thyroxide before IVF cycles to get TSH into ideal range). Starting this year we have begun the IVF process and just completed our 3rd IVF retrieval cycle. We have had little success.
The meds taken have stayed consistent over all three; Gonal F dosage of 350mg, Cetrotide, and Repronex. Trigger of Ovidrel 250mg
Cycle 1: Day 12 & Injection Day 10 = E2 7541, LH 3.00, PROG 1.42, ET = 12.7
AFC = 10, 4 follicles > 2.0 and 1 follicle = 1.5 and the other 3 2.0, 1 follicle = 1.5, the other 4 were 2.0, 2 follicle >1.5 and 1 other follicle > 1.1. Day 14 was trigger day.
1 Egg retrieved; 1 Mature, 0 fertilized (ICSI).
The results of the third cycle were shocking. When we asked if our empty follicles were the result of a late trigger, our RE said no, as this was “empty follicle syndrome”. I was hoping you could give us some advice on our situation given the outcomes. We were hoping to “bank” embryos after several retrieval cycles. We’re not so sure now. Should we do another retrieval? If so, should we reconsider dosage and/or type of meds? Should we try a transfer cycle with the only viable embryo which has not gone for PGS testing?
Thank you,
Anjali
Sorry, just noticed that part of my message didn’t get posted…
Cycle 2: Day 12 & Injection Day 10 = E2 5003, LH 2.21, PROG 1.11, ET 10.1
AFC = 9, 2 follicles > 2.0, 1 follicle >1.5, 4 follicles 2.0, 1 follicle >1.5, 2 follicle <1.5. Day 14 trigger
RE said 5 follicles were empty, and there was only 1 egg retrieved. It did not fertilize.
First let me explain that the most important determinant of egg/embryo quality is the protocol used for ovarian stimulation.
Empty Follicle Syndrome: Frequently, when following vigorous and often repeated flushing of follicles at egg retrieval they fail to yield eggs, it is ascribed to “Empty Follicle Syndrome.” This is a gross misnomer, because all follicles contain eggs. So why were no eggs retrieved from the follicles? Most likely it was because they would/could not yield the eggs they harbored.
This situation is most commonly seen in older women, women who have severely diminished ovarian reserve, and in women with polycystic ovarian syndrome (PCOS). In my opinion it is often preventable when an optimal, individualized and strategic protocol for controlled ovarian stimulation (COS) is employed and the correct timing and dosage is applied to the “hCG trigger shot.”
Normally, following optimal ovarian stimulation, the hCG “trigger shot” is given for the purpose of it triggering meiosis (reproductive division) that is intended to halve the number of chromosomes from 46 to 23 within 32-36 hours. The hCG trigger also enables the egg to signal the “cumulus cells” that bind it firmly to the inner wall of the follicle (through enzymatic activity), to loosen or disperse, so that the egg can detach and readily be captured at egg retrieval (ER).
Ordinarily, normal eggs (and even those with only one or two chromosomal irregularities) will readily detach and be captured with the very first attempt to empty a follicle. Eggs that have several chromosomal numerical abnormalities (i.e., are “complex aneuploid”) are often unable to facilitate this process. This explains why when the egg is complex aneuploid, its follicle will not yield an egg…and why, when it requires repeated flushing of a follicle to harvest an egg, it is highly suggestive of it being aneuploid and thus “incompetent” (i.e., incapable of subsequently propagating a normal embryo).
Older women, women with diminished ovarian reserve, and those with polycystic ovarian syndrome, tend to have more biologically active LH in circulation. LH causes production of male hormone (androgens, predominantly testosterone), by ovarian connective tissue (stroma/theca). A little testosterone is needed for optimal follicle development and for FSH-induced ovogenesis (egg development). Too much LH activity compromises the latter, and eggs so affected are far more likely to be aneuploid following meiosis.
Women with the above conditions have increased LH activity and are thus more likely to produce excessive ovarian testosterone. It follows that sustained, premature elevations in LH or premature luteinization (often referred to as a “premature LH surge”) will prejudice egg development. Such compromised eggs are much more likely to end up being complex aneuploid following the administration of the hCG trigger, leading to fruitless attempts at retrieval and the so called “empty follicle syndrome.”
The developing eggs of women who have increased LH activity (older women, women with diminished ovarian reserve, and those with PCOS) are inordinately vulnerable to the effects of protracted exposure to LH-induced ovarian testosterone. Because of this, the administration of medications that provoke further pituitary LH release (e.g., clomiphene and Letrozole), drugs that contain LH or hCG (e.g., Menopur), or protocols of ovarian stimulation that provoke increased exposure to the woman’s own pituitary LH (e.g., “flare-agonist protocols”) and the use of “late pituitary blockade” (antagonist) protocols can be prejudicial.
The importance of individualizing COS protocol selection, precision with regard to the dosage and type of hCG trigger used, and the timing of its administration in such cases cannot be overstated. The ideal dosage of urinary-derived hCG (hCG-u) such as Novarel, Pregnyl and Profasi is 10,000U. When recombinant DNA-derived hCG (hCG-r) such as Ovidrel is used, the optimal dosage is 500mcg. A lower dosage of hCG can, by compromising meiosis, increase the risk of egg aneuploidy, and thus of IVF outcome.
There is in my opinion no such condition as “Empty Follicle Syndrome.” All follicles contain eggs. Failure to access those eggs at ER can often be a result of the protocol used for controlled ovarian stimulation.
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
•Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•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.
•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?
•Frozen Embryo Transfer (FET): A Rational Approach to Hormonal Preparation and How new Methodology is Impacting IVF.
•Why did my IVF Fail
•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
I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoff Sher
Dear Dr Sher,
Are there IVF protocols without priming and how does that work?
Of course there are: Please see below.
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
•Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
•Frozen Embryo Transfer (FET): A Rational Approach to Hormonal Preparation and How new Methodology is Impacting IVF.
•Why did my IVF Fail
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF
•
I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoff Sher