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.
Hi doc! I had some questions for you! I’m going to be starting my 3rd ivf cycle @ a new clinic each cycle I’ve done in the past I’ve gotten ohss and was ill for weeks each time I had gotten a large amount of eggs 24 the 1st and 33 the 2nd, none made it past day 3. I’m starting over at a new it has been suggested that I have pcos everything is normal except my Amh and it is very high, I’m wondering what I can do to avoid getting ohss my new cycle doctor has me on hgh 2.9mg, gonal 100iu, and menopur 75iu, the trigger will be with ovidrel! Is there anything I can do 2 help lessen the chance of ohss! Really not looking forward to getting that again I was deathly ill! And just thinking of having it again makes me want to stop the cycle please get back with me does the meds amount seem high to you? Thanks in advance for your response and time
Hi Dr. Sher,
I am 37 going on 38 next month. I have low amh and I have one PGS tested embryo which resulted in “partial aneuploidy” duplicate on 20p. Is this worth transferring? It was a day 6 blast graded 3AA.
I suspect so…but please discuss with your personal RE.
Geoff Sher
What is the optimal time between ivf cycles. My wife is 32, three high day 3 FSH reading ( 20.6 , 16.2 , 14.1). Latest AMH is 1.38 (November 2017 AMH was 1.9). We just had a failed Ivf cycle (only 2 eggs non fertilized) egg collection was on the 30th of July. We are thinking of waiting for only 1 bleed (which started 14 days after egg collection on 13 August) and start another cycle beginning September. Please advice. We also 2 previous failed cycles one in Jan 2018 and the other in May 2018.
In my opinion, one (1) full resting cycle at least!
Geoff Sher
Hi Dr Sher,
I have kind of a silly question… my RE put me on birth control pills to get my body ready for my FET which is supposed to be in mid September, if we choose to. I only say that because we are currently trying to decide if we’re transferring our “low level mosaic embryo”. I have been on the birth control now for almost 4 weeks and my concern is it’s going to prevent the transfer to work. As it is we are at risk because it is a mosaic embryo.
Could you please explain the reason for the birth control and if it will have any negative impact on the FET to work?
I had written you before about what I was told was “low level mosaic” and all I’ve researched about these embryos, as you said it would be difficult to determine a mosaic embryo from just a few cells from the biopsy. I’m leaning towards transferring – any thoughts?
That is a decision you need to make. I do not have much else to add to what I have already stated before.
Geoff Sher
Dear doctor Sher,
my question is about a long protocol IVF cycle. I’d have to start tomorrow (approximately 10 days before my next period) with Leuproreline injections (0,1 ml a day). Because my partner and I also try every month the natural way to get pregnant, it is possible that I’m pregnant now (my ovulation was end of last week). On the internet I read about that Leuproreline can cause risks; can be dangerous if you’re pregnant. Can you answer my question today by mail; I’d have to start tomorrow with Leuproreline, but can now still change to a short protocol and wait with injections untill I have my period?
Thank you. Kind regards, Ruth Geerse
All gonadotropin releasing hormone (GnRH) agonists (GnRHa) act by rapidly expunging reservoirs of follicle stimulating hormone (FSH) and luteinizing hormone (LH) from the pituitary gland. GnRH agonists can be administered by intramuscular injection (e.g. Lupron, Buserelin) or through intranasal administration (Nafarelin, Synarel). The intramuscular route which insures more even absorption is preferred.
At Sher-IVF we prescribe leuprolide acetate (Lupron) to launch moist IVF-controlled ovarian hyperstimulation (COs) cycles. Lupron is very similar in structure to gonadotropin releasing hormone (GnRH .As such, its initial effect, (for about 2-4days or so), is to stimulate the pituitary gland to produce both LH and FSH .As soon as the pituitary starts to recognize the difference in chemical structure between the Leuprolide and normal GnRH, it profoundly reduces its output of biologically active LH and FSH production. This is referred to as “pituitary down-regulation” and the effect continues for as long as Lupron therapy is maintained uninterrupted. The initial increase in FSH and LH production during the first 4-6 days of leuprolide therapy is accompanied by a transient, but very significant increase in estrogen release by the ovary. The initial rise in LH and FSH production results in a rise in estradiol, and the subsequent pituitary “down-regulation” is followed by a precipitous fall in blood estrogen levels, until gonadotropin or estrogen administration commences.
The reason that agonists are administered to women receiving Gonadotropin therapy for IVF is because of its ability to suppress LH and so prevent a premature rise in LH which is most likely to occur in older women or those with have diminished ovarian reserve. When this happens the cells lining the follicles undergo premature change (premature luteinization), compromising further follicle development and egg/embryo quality. Such premature premature luteinization (previously referred to as “premature LH surge”) severely compromises further follicle development as well as egg/embryo quality. Women with reduced ovarian reserve (who are resistant to ovarian stimulation) are most susceptible to this happening
There is often talk of “agonists “over-suppressing” ovarian response to gonadotropins. The reason for this concern is that agonists probably compete with FSH for receptor binding sites on the granulosa cells that line the ovarian follicles and produce estrogen…and so can blunt ovarian follicle response to FSH. However, since antagonists apparently do not exert the same effect, by supplanting Lupron with an antagonist prior to starting gonadotropin therapy), avoids this problem (see the agonist/antagonist conversion protocol -A/ACP is below). While both antagonists land s block LH activity, antagonists do so much more rapidly (within hours) than agonists (within a few days).
Use of Lupron to launch COS for IVF: At SIRM we launch COH for IVF by putting the woman on a birth control pill (BCP) for 10-25 days, to suppress ovarian response to FSH/LH. Thereupon, Lupron is overlapped with the BCP for 2-4 days. Then thee BCP is discontinued and daily Lupron therapy is continued until menstruation ensues. By varying the length of time on Lupron it is possible to control the timing of the onset of menstruation and reduces the incidence of cycle cancellation due to ovarian cyst formation. Menstruation will usually occur 4-7 days after stopping the BCP. Thereupon, one of two variations in approach is taken. Either the long Lupron approach or the agonist/antagonist conversion protocol (A/ACP) is used. With the A/ACP, Lupron is supplanted by low dosage antagonist therapy. In both cases daily Gonadotropin (FSH and LH) injections are concomitantly initiated and continued with the agonist or antagonist until the day of the hCG trigger. In some cases of markedly diminished ovarian reserve, we preempt the initiation of gonadotropin therapy with “estrogen priming”. It involves twice weekly injections of estradiol valerate for 8-10 days and then we initiate Gonadotropins therapy which is continued until more than 50% of the developing follicles reach at least 12mm in diameter. The addition of estrogen in this way is believed to improve ovarian response to gonadotropins as well as endometrial response to estrogen stimulation. In both the long Lupron approach and the A/ACP daily shots of antagonist or antagonist are continued up to the day of the hCG trigger. The egg retrieval (ER) is performed 35-37 hours following hCG administration.
Lupron use in embryo recipient cycles In cases of egg donation and gestational surrogacy, embryo donation and with frozen/thawed thawed embryo transfers (FET) undergo a similar regime of BCP/agonist preparation as do those who undergo ovarian stimulation, except that instead of receiving gonadotropins injections, these women receive daily estradiol valerate injections. Thereupon, progesterone therapy (administered by intramuscular injection and/or by vaginal administration) is added for several days. The combination of estrogen and progesterone therapy prepares the uterine lining for embryo implantation. Lupron therapy is discontinued 5-7 days prior to Embryo Transfer (ET) in such cases.
The Lupron “trigger” to prevent severe ovarian hyperstimulation syndrome. Some clinicians, when faced with a risk of OHSS developing will deliberately elect to reduce the dosage of hCG administered as a trigger in the hope that by doing so the risk of critical OHSS developing will be lowered. It is my opinion, that such an approach is not optimal because a low dose of hCG (e.g., 5000 units, hCGu or 250mcg hCGr) is likely inadequate to optimize the efficiency of meiosis particularly when it comes to cases such as this where there are numerous follicles. It has been suggested that the preferential use of an “agonist (Lupron) trigger” in women at risk of developing severe ovarian hyperstimulation syndrome could potentially reduce the risk of the condition becoming critical and thereby placing the woman at risk of developing life-endangering complications. It is with this in mind that many RE’s prefer to trigger meiosis by way of an “agonist (Lupron) trigger rather than through the use of hCG. The agonist promptly causes the woman’s pituitary gland to expunge a large amount of LH over a short period of time and it is this LH “surge” that triggers meiosis. The problem with using this approach, in my opinion, is that it is hard to predict how much LH will be released in by the pituitary gland. For this reason, I personally prefer to use hCGu for the trigger, even in cases of ovarian hyperstimulation hyperstimulated, with one important proviso…that being that is she underwent “prolonged coasting” in order to reduce the risk of critical OHSS, prior to the 10,000 unit hCGu “ trigger”.
There is little need to be alarmed at what at first might seem to be a complex treatment regimen. Extensive studies on non-human primates, as well as limited human evaluations, indicate that Lupron is relatively harmless to both mother and baby. The drug is eliminated from the system within hours of discontinuing its administration. At SIRM we discontinue Lupron therapy at least 5-7 days prior to transferring embryos/blastocysts to the woman’s uterus. The administration of subcutaneous or trans-nasal agonist is rarely associated with significant side effects. Some women experience temporary fluctuations in mood, hot flashes, nausea, and symptoms not vastly dissimilar from PMS. No serious long-lasting side-effects have been reported.
The subcutaneous injection of Lupron is relatively painless. Unfortunately, the drug will incur a modest additional financial burden. Lupron administration as described above spares women the inconvenience and frustration of unnecessary cancelled treatment cycles with gonadotropins. As such, the use of Lupron in reality reduces the overall cost of ovulation induction.
Here is the protocol I advise for women, 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 strongly recommend that you visit https://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.
• Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
• Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas
• Should IVF Treatment Cycles be provided uninterrupted or be Conducted in 7-12 Pre-scheduled “Batches” per Year
• A personalized, stepwise approach to IVF
• “Triggering” Egg Maturation in IVF: Comparing urine-derived hCG, Recombinant DNA-hCG and GnRH-agonist:
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