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 am puzzled by my IVF outcome thus far and am hoping you might have insight. I had 17 eggs retrieved, of which 13 were mature and 10 fertilized with ICSI. Only one made it to blastocyst. We are currently awaiting PGS results on that one embryo. My history is somewhat complex. We have an almost three year old who was conceived easily on Metformin despite having been diagnosed with PCOS (ovaries appeared normal on ultrasound and normal FSH:LH ratio but was obese, was anovulatory, and have moderate isolated hirsituism). Two years ago I underwent successful RNY gastric bypass surgery and lost nearly 200 lbs in 9 months. After discontinuing BCP 15 months ago, I had no periods for 6 months, after which they spontaneously returned, albeit irregularly. I am 36 and have low AMH (ranging from 0.41 to 0.86 ng/ml). Highest FSH was 7.0, LH 2.6. AFC ranges from 9 to 12. Leading up to IVF I was taking 75 mg DHEA along with Inositol, CoQ10, etc. One set of labs, my testosterone was slightly elevated, which was attributed to the DHEA. My husband’s semen analyses initially showed high count but low morphology and motility. His most recent showed great values. My protocol for IVF was an antagonist. 225 IU GonalF stepped up to 300 after a few days along with 150 IU Menopur until starting Cetrotide on day 8 when it was increased to 225 IU. All 10 embryos were doing great through day 2. Next check in was on day 5 when we began to hear about being down to three (as you’d expect). These were allowed to go to day 7. It seems that only being left with one out of ten and it taking all the way to day 7 to go to a biopsiable blastocyst (although we were told it was grade 4AA and it was an “early” blastocyst on day 6) seems unexpected. Any insights on why the result occurred and how to remedy it in the likely event our one embryo does not result in pregnancy?
Thank you for communicating your difficult journey with me here. You clearly have DOR and as such, in my opinion, use of DHEA is not a good idea. It is converted to ovarian testosterone which reaches the follicle where if in excess compromises egg development and I believe substantially increases the percentage of aneuploid (incompetent) eggs/embryos, regardless of sperm quality. Secondly, again in my opinion, your protocol used for ovarian stimulation needs to be carefully reviewed and revised, and I think this in large part has contributed to egg embryo incompetence and failure to produce more blastocysts. By the way, day 7 embryos are hardly ever chromosomally normal and I (after a trial in which we tried using such late blastocysts without a single success) have abandoned the plight of recommending transferring such embryos.
In my opinion, “microdose” (“flare”) Lupron protocols, the use of clomiphene or Letrozole, high dosage Menopur protocols and even late antagonist protocols, are best avoided in women with DOR (see below). It surges LH and with it ovarian testosterone as the stimulation begins and this can have a deleterious effect on egg quality/competency…especially in older women and also in women such as yourself who have DOR. You need a modified, robust, long pituitary down-regulation protocol. I would use an agonist/antagonist conversion protocol with human growth hormone (HGH) augmentation and would recommend Staggered IVF with embryo banking of PGS (next generation gene sequencing)-normal blastocysts, to make hay while the sun still shines.
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
•Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion 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.
•Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
•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.
•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 Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
•IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
•Implications of “Empty Follicle Syndrome and “Premature Luteinization”
•Premature Luteinization (“the premature LH surge): Why it Happens and how it can be Prevented.
Please call or email Julie Dahan, my patient concierge. She will guide you on how to set up an in-person or Skype consultation with me. You can reach Julie at on her cell phone or via email at any time:
Julie Dahan
•Email: Julied@sherivf.com
•Phone: 702-533-2691
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,
If LH is very low at start of and during stimulation with 75 Menopur, 225 Gonal F, 250 Ganirelix and remains very low (LH=2 on CD 7), then is it beneficial to increase Menopur to 150 if LH stays at such low levels?
I never go above 75U Menopur daily in IVF cycles.
Geoff Sher
Hi Dr. Sher, we wanted to know how embryo quality and pgs are related? We are both 38 years old and in the last IVF cycle we had 12 embryos out of which 5 are normal per PGS. The doctors have classified the embryos as 2BC quality embryos. We don’t know what this means, but everything we find on the internet seems to say A is better quality and as such gives a better chance of having a baby. We want to have 3 children, will 5 normal PGS embryos be enough or do we need to bank more quality A embryos? If so, how many more would you recommend? Thanks so much!
Tara
Hi mTara,
5 PGS-normal blastocysts (all other things being equal, should be enough.
Geoff Sher
Dear Dr Sher
If a man undergoes surgery for varicocele repair – is there a risk that the surgery could do more damage than good – lead to infertility?
Thank you
Richy
Very unlikely!
Geoff Sher
Dr Sher,
I have posted before and I thank you for your answers. I’m 34, husband is 38. Thus far, only thing “wrong with me” is what you referred to as irregular endometrial shedding, which yes went away with the trigger shots. All my labs are normal, but they are treating me with metformin as if I have PCOS (I am of normal weight with all normal lab values). Husband has “normal” sperm, but 4% normal head morphology (which we were told is normal). Count and mobility are excellent. We had 6 failed IUIs (where I produced, on average, 6 follicles each time on Letrozol). Moved to IVF, 21 follicles, 14 eggs all fertilized with ICSI, 14 viable day 5. 2 blastos transferred, 2 frozen as the other 10 “degenerated.” IVF failed in chemical pregnancy. FIRST TIME PREGNANT EVER!! Very devestated.
Before proceeding forward with FET, we are meeting with our RE.
1-What questions should I ask to make sure all concerns are addressed to increase our chances of FET success (as this is our last chance)? He has always said things will work, and they don’t and I’m losing trust (though he has the highest success rates and reputation where we live)
2- Could 4% head morphology explain our 4+year struggle and IUI failures?
And 3- Is there anything I can do during natural cycles to get rid of my irregular endometrial shedding besides birth control pills (which only the NuvaRing works for), progesterone pills have not helped after natural ovulation (I start discharging typically 1 week post ovulation, have my bleed, then discharge an additional week before I’m “clear” during my “fertile window”.
Thank you so much!
Patti
1-What questions should I ask to make sure all concerns are addressed to increase our chances of FET success (as this is our last chance)? He has always said things will work, and they don’t and I’m losing trust (though he has the highest success rates and reputation where we live)
A: That is a tough one. Read the articles I referred you to before (on my blog) and use that to base questions. Also read the addendum below.
2- Could 4% head morphology explain our 4+year struggle and IUI failures?
A: I doubt it!
3- Is there anything I can do during natural cycles to get rid of my irregular endometrial shedding besides birth control pills (which only the NuvaRing works for), progesterone pills have not helped after natural ovulation (I start discharging typically 1 week post ovulation, have my bleed, then discharge an additional week before I’m “clear” during my “fertile window”.
Aside from hormonal regulation with BCP and possible progesterone supplementation…not much, I am afraid.
Geoff Sher
ADDENDUM:
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).
Thank you so much!