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.
Dr. Sher,
I did a day 5 frozen transfer on March 28th. On day 14 we did a HCG test, it was a 34, obviously low. On day 16 did another 59, still low. Day 19 we got a jump and it was 123. I have had a few days of symptoms but those seem to have stoped a few days ago. Today day 26, 5 weeks 5 days, we did another and it was again a more positive jump, 531. After the blood test we had an ultrasound, they saw the sac, and the yolk, no pole and was not as defined as they wanted to see. They mentioned it was about 4 days behind what they would like to see. I had a very uncomfortable conversation with the doctor I feel like he was more worried about not hurting my feelings rather than giving me any kind of facts or help with understanding on what I can expect. However he did said that the chances of this ending well are very low. We have another ultrasound in a 7 days. Can you help me with my expectations? Why would we see the right growth amount over the last few tests and they seem so negative about it? And don’t those numbers correlate to the current progression of the sac? Could it make up the 4 days it is behind or could it survive being behind the normal? I have never been pregnant in our 4 years of trying and I have PCOS and low count and mobility on my husband’s side, if a little more background helps you.
Thank you,
Janna
Hi Janna,
Given the information provided, this has been a slowish rise of hCG and it could gomeither way. However, the detection of a sac (albeit without clear eveidence of a viable pregnancy as yet), offers some hope. Unfortunately, only time will tell. You need at least another week before doing an US for clarification of the status quo.
I wish I could be more definitive but t is not possible.
Good luck and G-d bless!
Geoff Sher
I will be 40 in May. I have one son who is 8. I have to go through IVF. This past February we went through a cycle of IVF, when they went to retrive the eggs from the follicles, they were empty. What is the chance that this can happen again?Could we have a successful cycle if we tried again? What are your thoughts?
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
•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?
•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
•Measuring and Interpreting Blood hCG to Assess Pregnancy Viability Following ART Treatments.
•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 sher
On my ivf they told me that some of my eggs are dary and fragile. .
Is this a quality issue?.
Do dark eggs propagate vauable pregnancy?!
Is it my age or is it the protocol used?!
Is there any thing to do to improve this case?!
Iam 32..have text book PCOS… was on long protocol..used gonal-f 225 for 14 days then hcg shot the next day..
Thank you.
I am pretty sure that I have already responded to you on this issue (yesterday or the day before). If not, then I apologize. Simply re-post the question again and I will post my response.
Geoff Sher
Dr. Sher, I just turned 35 and we have an almost 5 year old son. After a miscarriage in November 2013 (only took us one month to get pregnant), and then one year of trying, we sought help. I found out my right Fallopian Tube is blocked per an HSG (all other testing is normal thus far), so they suggested IUI’s-it took 5 months of Femara and 3 actaul IUI’s and we were pregnant, only for it to be a chemical pregnancy in January of this year. I switched doctors and the new doc did a biopsy and diagnosed me with endometritis. I have finished antibiotics and am awaiting the results of the follow-up biopsy. We are ready to try IVF, but I am still afraid we may have trouble b/c of any scarring I might have. What can you suggest is the best course of action going forward, do you suggest more testing or treatment before we do IVF? We are very drained in this process and ready to have our baby, so I don’t want to risk doing IVF and it not working or we lose the pregnancy. We are considering a consultation with Sher Institute. I am afriad there is more to the story after reading your blog that talked about Asherman’s. Could I have Asherman’s or would my doctor already know from the testing i’ve had? I’ve never had a laproscopy or hysteroscopy-only two HSG’s and the biopsy. Thank you so much!
Alas, if you have a damaged lining from prior endometritis, scarring will have damaged it and antibiotics will not help. Frankly, I doubt that this is the case. However, a sonohysterogram or a hysteroscopy will diagnose obvious scarring and an US examination around the time of natural or induced ovulation can assess the thickness and configuration of the uterine lining which needs to be at least 8mm.
Frankly, I think you need IVF, but not until the above-mentioned has been assessed, and you have undergone a thorough assessment of your ovarian reserve, the status of your tubes to exclude a hydrosalpinx or set the stage for dealing with this …surgically and an evaluation for immunologic factors that could thwart implantation.
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?
•Functional” Ovarian Cysts and IVF
•IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
•Vaginally Administered Viagra is Often a Highly Effective Treatment to Help Thicken a Thin Uterine Lining
•Secondary Infertility: Addressing the Root Causes
•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)
•Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
•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
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
Hi doctor Shef, hoping you know a bit anovulatory cycles and will be kind enough to read my long explanation and shed some light on my newly discovered pregnancy…
I had my last proper period in Feb and 10 days after cd1 I had brown spotting/watery brown cm for 2 days. It seemed strange, but I researched and found you can get ‘ovulation bleeding’. Although I have never had it before.
One week later I noticed light pink spotting and thought it was implantation bleeding. But the next day it was heavier than seemed normal from when I read about it and mine lasted for four days. It was very red at points then turned to dark red and brown becoming gradually lighter through day 3 and 4.
That month I had no period….. I tested a couple of times the weekend I was due and it was negative. I assumed it was an anovulatory cycle and I simply skipped the period as a result.
I had no idea when cd1 would begin, but 7 days after the day my period was due (and never came) I noticed my CM was ovulation-like. So we tried to conceive.
Just under 3 weeks later (Friday 15th April) I got my bfp. A clear blue digi dated as 2-3 weeks since conception, so 4-5 weeks pregnant, which ties in with the CM I spotted.
Is it likely that the CBD is accurate in its dates? Can I fall pregnant immediately after skipping a period like that? Or could my anovulatory bleeding actually have been heavy implantation bleeding and just not showing as positive at the time my period was due? ‘m either 5 weeks or 8 weeks and don’t understand enough about anovulatory cycles to work it out! Thanks so much.
Yes, this can and does happen, but it is more likely that you conceived in the 1st cycle and are now 8 weeks along.
Either way, good luck and G-d speed!
Geoff Sher