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.
I had ivf abroad and am currently on clexane (lovenox) once a Day injection for those patients that take this medicine how long do you prefer them to continue into pregnancy and what decisions make this so? Thank you! Also my doctor abroad says 12 weeks but I have read many stay entire pregnancy or late pregnancy thank you so much!
Here is how I prescribe Lovenox for my patients:
If it is to counter the effect of antiphospholipid antibodies…up to the 10th week of pregnancy.
If it is for the treatment of a thrombophilia (hereditary clotting defect…throughout pregnancy
If for deep vein thrombosis, throughout pregnancy and the 1st 6 weeks post-partum (at least).
Good luck!
Geoff Sher
Dear Dr. Sher,
Would you suggest that a day 3 Estradiol level of 61 is too high and warrants cycle cancellation? My FSH is good and I am 30 and do not have low ovarian reserve. Moreover, could said level be impacted by oral administration ( 4mg) of Progynova, starting the day before – Cycle day 2- (and during the luteal phase of last cycle with a break of 3-4 days)? I am so confused. Thank you so much for your input. You are simply amazing.
1.Would a day 3 Estradiol level of 61 be too high and warrant cycle cancellation?
A. No!
2. Could said level be impacted by oral administration ( 4mg) of Progynova, starting the day before – Cycle day 2
A. Yes
Good luck!
Geoff Sher
at the time of the HCG trigger.
I am 32 years old with AMH of .67 and Day 3 FSH of roughly 7.8. My FSH has tested higher 12-13 on Days 5-6 of my period. I have stage III endometriosis, suspected adenomyosis, and have had an endometrioma removed from one ovary, a simple 1mm cyst removed from the other.
I just completed an egg retrieval cycle, with the goal of freezing my eggs. At the time of my HCG trigger, I had 10 follicles size 14 and higher (with 4 of these size 18-22), but we retrieved only 7. Of these 7, only 4 of these were mature eggs; another 2 were immature and frozen, and the last was too immature to freeze.
The RE who did the retrieval surgery (not my RE) told me the low number of eggs retrieved compared to the number of large follicles I had going into the surgery indicates that I have egg quality issues, and that I likely have or will have chromosomal abnormalities in my eggs going forward. She said nothing odd occurred during the retrieval itself. There was no sign that I’d already ovulated, and she said that none of the eggs had seemed “overcooked.” Does this suggest that the 4 mature eggs we did freeze will likely be of poor quality?
I’ll be discussing this with my RE in the next week or so, and would like your thoughts on 1) good questions to ask her, 2) what might have gone wrong during my retrieval cycle or surgery, 3) what sort of testing you’d recommend to gain more information about this going forward, and 4) more effective stim protocols for the future.
Here’s a rundown of the retrieval cycle:
My RE told me that I should keep my Skyla IUD in leading up to the egg-retrieval procedure because of my endometriosis / suspected adenomyosis. She said IUDs do not make a difference in egg-retrieval outcome. She also told me it was ok to stay on supplements like “Cortisolv” and “Cortisol Manager,” which can impact the thyroid. I took DHEA/COQ10/prenatal vitamins/vitex throughout. My RE cleared me for all physical activity, and I did some fairly heavy weightlifting twice during the stim phase.
My RE had planned to do a birth control pill ? Lupron ? aggressive stim protocol, and for two months ahead of the procedure told me that I did not need to monitor my period cycle to do this. I monitored it anyway until the month before the retrieval cycle was supposed to start, and was getting an LH surge fairly consistently at 11 days, with a roughly 25-26 day cycle (though with a very light IUD period, I don’t get a “flow,” and it’s tough to tell when my period really starts).
On the day I was supposed to begin the retrieval cycle, my nurse asked me basic screening questions about my family history of blood clots, etc, before prescribing the birth control pills. I responded that my father had two blood clots from sports injuries, and suddenly we switched to a “late luteal Lupron plan” that excluded birth control pills and was more period-cycle dependent. I began Lupron 10U on a Friday, reported what I thought might be spotting the following Tuesday, and after receiving an ultrasound, was directed to start stims the following day (Wednesday). I asked to receive an estradiol test before starting the stim shots, and when it came back 120, my RE pushed my stim shots back for three days, until my Estradiol tested at 20.
The protocol was 5U Lupron + 300 Follistim morning / 150 Follistim + 150 Menopur evening], starting on Friday (about 7 days after I began the Lupron). Also starting that Thursday/Friday and through the weekend, I had the first heavy, bright blood, “real” period I’d had since inserting my IUD more than a year earlier. It lasted about 4 days.
On day 11 of the stim protol, my RE measured 10 follicles size 12-18 (estradiol 1213). On Day 13, I had 10 follicles size 15-21 (estradiol ~1700). On Day 14, I had 10 follicles sized 14-22 with estradiol of 2038. (On this day, a different RE took over because mine was on vacation, and this new RE measured some follicles of smaller sizes. My RE had measured three 16mm follicles on Day 13, for instance; on Day 14, the new RE measured these follicles at 14, 15, and 16. The new RE did measure a size increase in the larger follicles, however.)
I took the HCG trigger shot (Pregnyl 10,000U) on the evening of Day 14, again with follicles ranging from 14-22 (four of these 18+), and the retrieval 36-37 hours after that.
As I said before, the operating RE was only able to retrieve 7 eggs from the 10 large follicles seen on the ultrasound, 4 of which were mature, 2 immature but able to freeze, and 1 discarded.
After reading your responses to other commenters, I’m wondering if I was on too much Menopur and/or DHEA given that I had an endometrioma and DOR. Any other factors I should look at?
Thank you so much for your insight.
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 producing a sufficient number of “competent eggs/embryos. 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), the use of DHEA and high dosage menotropins that contain LH/hCG (e.g. Menopur) 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 an aggressive 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 egg banking over several cycles 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 ultimately achieve an optimal yield of good quality eggs.
When you ultimately identify a designated sperm provider and contemplate trying for a baby, I would urge you to have all blastocysts generated, tested by PGS and to have yourself evaluated for an immunologic implantation dysfunction which often occurs with endometriosis (regardless of its severity)…see below.
Please visit my 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?
• Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
• Traveling for IVF from Out of State/Country–
•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!
•Endometriosis and Immunologic Implantation Dysfunction (IID) and IVF
•Endometriosis and Infertility: The Influence of Age and Severity on Treatment
•Treating Ovarian Endometriomas with Sclerotherapy.
•Effect of Advanced Endometriosis with Endometriotic cyst.
• Premature Luteinization (“the premature LH surge):.
• Frozen Embryo Transfer (FET)
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.
Hi Dr. Sher
We did IVF with simultaneous mTESE and known donor back-up sperm. We had an unsuccessful mTESE so had to use our donor back-up which was my husbands brother. No PGS preformed because my age is 26 and donors age was 33.
Our fresh transfer of an very early blastocyst fail. Our next cycle we did a FET with vaginal estrace and PIOs started 5 days prior to transfer. We had a successful transfer with a single intrauterine pregnancy. Unfortunately at our 22 weeks anatomy scan we were informed of incompatible with life anomalies. A lethal form of skeletal dysplasia and hydranencephaly with large portions of brain tissue missing. We terminated that pregnancy through the L&D process due to head size being 10 weeks ahead in growth.
To achieve a pregnancy quicker and reduce failed cycles due to chromosomal abnormalities we thawed all embryos and performed PGS. 4 came back normal and 2 were undiagnosed. Those 2 were appearing to break down but did survive the process.
I began my next FET cycle immediately after starting my first postpartum cycle using the same protocol. 15 days after meds my ultrasound scan reported 7.2 lining thickness and no trilaminar presentation. They extended my time on the vaginal estrace and 6 days later I had 8mm thickness and had the trilaminar presentation. I began PIOs 2 days later and transferred a single embryo that appeared collapsed after re-expansion.
I got positive at home pregnancy tests just to see them turn negative. We experienced a chemical pregnancy.
Am I on the best protocol for my situation? What are the chances of having a chemical pregnancy with a PGS tested embryo and a hospitable environment for transfer?
Should I add additional methods to increase off of a successful pregnancy?
I am so sorry for your repeated disappointments. I do have a few comments:
1. In my opinion, the re-testing of embryos followed by the transfer of euploid embryos, while capable of yielding pregnancies, reduces the chance of success. The thaw (for testing) followed by the re-freeze while awaiting results and then the re-thaw for transfer takes its toll on embryo viability.
2. The abnormality you experienced is probably a multifactorial genetic defect and if so…is simply bad luck anot likely to recur.
3. It is important to exclude an anatomical or immunologic implantation dysfunction before trying again.
4. The protocol used for stimulation is an important variable, but probably not central to the results you experienced in your case.
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 .
*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
Dear dr sher, next mont i will have IL (intralipid) and FET(frozen embriyo transfer)
what day of mensturiation would you start 0.75mg deksametazon when you use IL +deksametazon treatment for naturall killer cells
My patients begin dexamethasone at the time ovarian stimulation with gonadotropins begins. It is phased out over 2 weeks with a negative pregnancy test or at 8 weeks pregnancy.
Geoff Sher
Update: Had our 3rd FET on Sept 6th. We transferred 2 embryos (1 PGS and 1 Undiagnosed from PGS). Beta at 11dp5dt -26, 13dp5dt – 67, 15dp5dt – 213. Numbers started low but have risen appropriately. This FET cycle included lovenox, prednisone, and extra estradiol patches on top of the vaginal pills with the 24 hours extra of progesterone. Awaiting to see scan at 6w6d to confirm intrauterine pregnancy and hopefully heart beat.