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 Dr Sher
After 3 years of break I decide to go back to IVF, well at least do a second opinion at 2 different clinics since with my previous doctor i had 3 completely failed IVF. At age 35 (2011) i decided to go straight for IVF since at that time 10 years of marriage didn’t produce a baby. I can’t say that we were actively trying, but even if we didn’t accident would happen by that time. Anyways my doctor told me that I’m prefect candidate since all my hormones are intact , my uterus was perfect , BMI right on spot etc, etc. I can’t remember exact protocol or numbers but i know all tree times involved Lupron and/or Folistim HCG maybe even something starting with O. Start was always with BC pills for a week or so. Any who all tree IVF’s resulted in tons of follicles, extremely high E2 and 20+eggs retrieved. They were all immature, every single one of them locked in MI phase, failed to split as my doc put it. Also thru second and third one i had to do lots of research and suggest things to my doc cause i believed that I’m over responding and something different should be done . I believed i shouldn’t have 50 follicles. i also suggested that i might have pcos (or just pco) he said no maybe just on IVF but u don’t look like or have symptoms like pcos person). Anyways every time they trigger me they did it when my E2 was really high to prevent OHS. After 3d failed IVF with exact same results 22 immature egg that were 18mm+ in size he said that he doesn’t know what is wrong with my eggs but it’s probably something on biochemical level of the egg, and that im unique case and should go for a donor egg. Now tree years latter I’m turning 40 and i think it’s my last chance to have a baby so i will do it again (not with him) but i ask u for advice so i can be prepared with these new doctors. Could i have pcos (no symptoms, regular but 7 day long periods, all hormones ok, never caught ovulation on those strips or temp but i assume i ovulate) and my doc didn’t pay attention to it , or do i sound like one in the million that should go straight for the donor egg.
I doubt that your problem resides in an inherent egg defect. In my opinion, your egg quality deficit is much more likely to be the result of Rather, it isFirst, it is possible that you were triggered with Ovidthe protocol used for ovarian stimulation and that is something that can be addressed. There are several factors relating to this that might apply in your case:
1. The make-up of the protocol used is in my opinion, critical….see below.
2. There is an ever-present risk of OHSS in very high responders. This often leads to initiating the hCG trigger before the follicles are fully developed..in an attempt to arrest the rise in blood estradiol so as to reduce the risk. When this happens the eggs are not ready for the trigger and thus will mature abnormally resulting in a high incidence of immature and dysmature eggs. Some RE’s use an agonist such as Lupron (rather than hVCG) as a trigger. This does reduce the risk of OHSS but alas it does so at the expense of egg/embryo quality (see below). My preference is to use an approach called “prolonged coasting”….see below.
3. THe use of 20mcg of Ovidrel asthe hCG trigger: Ovidrel is recombinant hCG . It comes in 250mcg vials . This dosage is in my opinion inadequate. You would need double that dosage, lest many eggs should fail to undergo appropriate reproductive division with a high percentage of “imature” or chromosomally incompetent (aneuploid) eggs.
My approach is consistently to use a long pituitary DR protocol with an agonist, coming off 1-2 months on the BCP. The latter is intended to lower LH and thereby reduce stromal activation (hyperthecosis) in the hope of controlling ovarian androgen release. I then stimulate with low dosage FSHr to which I add a smidgeon of LH/hCG (Luveris/Menopur) from the 3rd day and watch for the # of follicles and [E2] starting on the 7th day of COS. If there are > 25 follicles, I keep stimulating (regardless of the [E2] until 50% of all follicles reach 14mm. Then, provided the [E2] is >2500pg/ml, I stop the agonist and the gonadotropin stimulation and follow the E2 (only) daily, without doing further US examinations. The [E2] will almost invariably climb and I watch it go up (regardless of how high the concentration of E2reaches) and track it coming down again. As soon as the [E2] drops below 2500pg/ml (and not before then ever), I administer 10,000U hCGu or hCGf (Ovidrel/Ovitrel-500mcg) as the “trigger” and perform an egg retrieval 36h later. ICSI is a MUST because “coasted” eggs usually have no cumulus oophoris and eggs without a cumulus will not readily fertilize on their own. All fertilized eggs are cultured to blastocyst (up to 6 days). And up to two (2) are transferred transvaginally under US guidance.
The success of this approach depends on precise timing of the initiation and conclusion of “prolonged coasting”. If you start too early, follicle growth will stop and the cycle will be lost. If you start too late, you will encounter too many post-mature/cystic follicles (>22mm) that usually harbor abnormally developed eggs.
Use of the above approach avoids unnecessary cycle cancellation, severe OHSS, and optimizes egg/embryo quality. The worst you will encounter is mild to moderate OHSS and this too is uncommon.
I do not use antagonists in high responders (e.g., PCOS) because it interferes with the assay of E2 (often causing the value to be understated), a valuable index in assessing risk for the development of severe/critical OHSS. I also do not believe in the agonist trigger to prevent OHSS. The reason is that the magnitude of the induced LH surge varies and if too little LH is released, meiosis can be compromised, thereby increasing the oocyte aneuploidy index.
Please visit my new Blog on this very site, 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 BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
•Frozen Embryo Transfer (FET): What Does it Involve?
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF
•The Role of Nutritional Supplements in Preparing for IVF
•Understanding Polycystic Ovarian Syndrome (PCOS) and the Need to Customize Ovarian Stimulation Protocols.
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,
I am 42 years old and had a fairly good response to IVF with fertilized eggs resulting in good embryos that have been frozen. Unfortunately my RE gave me Clomid for 5 days and after that the eggs in subsequent cycles are not fertilizing and it has been over 3 months since I took Clomid. I am devastated and wondering if the effects are permanent?
The effects should not be permanent. It should be gone within 6 weeks.
Geoff Sher
Dear Dr. Sher,
Thank you for reading my post. I would really appreciate if I could get your advise on my medical evaluations and prescription by my RE. I am 35 yrs old and have been trying from last 13 months with no success. I recently got my blood tests and hsg done as suggested by my RE. HSG test showed my tubes are clear. Blood test report is:
Estradiol (day 3) 44pg/mL
FSH (day 3) 3.9 mU/mL
LH (day 3) 2.5 mU/mL
AMH 3.8 ng/mL
Progestron (day 23rd) 12ng/mL
MY RE has suggested Letrozole 2.5 mG twice/day for 5 days and Novarel (10,000 IU) 1 vial followed by IUI for my next cycle. It would be great to know what you think for the treatment. Many thanks.
That sounds reasonable in my opinion.
Geoff Sher
I just turned 37 yrs old – gave birth to my daughter (completely naturally conceived with former partner, healthy pregnancy, vaginal delivery) 3 years ago. No history of mc or RPL. Trying for second with frozen sperm donor(s). 12 failed IUIs (some medicated, some not) and 3 failed fresh IVF transfers – not even a chemical. About to do my first FET. Had lap/hysteroscopy done a few days ago – 3 VERY tiny spots of endo on ovaries removed, tubes look great, uterus looks great according to my RE. Other than trying a FET for a change and doing Intralipids 10-14 days before transfer, would you recommend any other testing/protocol for me? My AMH (1.28) and FSH (2.8) are “ok/good” for my age – no answers yet as to why this isn’t happening. Thank you so much.
When confronted with “unexplained” IVF failures where morphologically good embryos were transferred, the question arises as to whether the problem is due to inherent egg/embryo “incompetence” (which usually equates with an irregular chromosomal configuration [aneuploidy]) or whether it is due to an implantation dysfunction. The younger the woman and the higher the quality of available embryos (preferably blastocysts), the less likely it is that the fault lies with embryo “incompetence” and the greater is the likelihood that it is due to underlying implantation dysfunction.
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)
Implantation dysfunction (anatomical or immunologic) is a common cause of repeated “unexplained” IVF failure with good embryos. 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.
Please visit my new Blog at http://goo.gl/4hvjoP , 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
•Ovarian Stimulation for IVF: Comparing “conventional” use of GnRH antagonists to the Agonist/Antagonist Conversion Protocol (A/ACP)
•IVF: Factors Affecting Egg/Embryo “competency” during C
•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)
•Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
•The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
•IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
•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)
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF
•The Role of Nutritional Supplements in Preparing for IVF
•IVF for Women Who Have Previously Conceived (Secondary Infertility).
•Endometriosis and Infertily
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
Hi Dr Sher
After 3 years of break I decide to go back to IVF, well at least do a second opinion at 2 different clinics since with my previous doctor i had 3 completely failed IVF. At age 35 (2011) i decided to go straight for IVF since at that time 10 years of marriage didn’t produce a baby. I can’t say that we were actively trying, but even if we didn’t protect ourselves and we never got pregnant. Anyways my doctor told me that I’m prefect candidate since all my hormones are intact , my uterus was perfect , BMI right on spot etc, etc. I can’t remember exact protocol or numbers but i know all tree times involved Lupron and/or Folistim HCG maybe even something starting with O. Start was always with BC pills for a week or so. Any who all tree IVF’s resulted in tons of follicles, extremely high E2 and 20+eggs retrieved. They were all immature, every single one of them locked in MI phase, failed to split as my doc put it. Also thru second and third one i had to do lots of research and suggest things to my doc cause i believed that I’m over responding and something different should be done . I believed i shouldn’t have 50 follicles. i also suggested that i might have pcos (or just pco) he said no, well maybe just on IVF but u don’t look like someone who has it or have symptoms like pcos person). Anyways every time they trigger me my E2 was extremmly really high (~5000) . They said they need to prevent OHS. After 3d failed IVF with exact same results 22 immature egg that were 18mm+ in size he said that he doesn’t know what is wrong with my eggs but it’s probably something on biochemical level of the egg, and that I’m unique case that should go for a donor egg. Now tree years latter I’m turning 40 and i think it’s my last chance to have a baby so i will do it again (not with him) but i ask u for advice so i can be prepared with these new doctors. Could i have pcos (no symptoms, regular but 7 day long periods, all hormones ok, never caught ovulation on those strips or temp but i assume i ovulate) and my doc didn’t pay attention to it and if i do what would be the best protocol, or do i sound like I’m the one in the million unexplained (as he said) that should go straight for the donor egg.
In my opinion, this could be related to the protocol used for ovarian stimulation in a woman who has PCOS and tends to over-respond and be at risk of developing OHSS.
My approach is consistently to use a long pituitary DR protocol with an agonist, coming off 1-2 months on the BCP. The latter is intended to lower LH and thereby reduce stromal activation (hyperthecosis) in the hope of controlling ovarian androgen release. I then stimulate with low dosage FSHr to which I add a smidgeon of LH/hCG (Luveris/Menopur) from the 3rd day and watch for the # of follicles and [E2] starting on the 7th day of COS. If there are > 25 follicles, I keep stimulating (regardless of the [E2] until 50% of all follicles reach 14mm. Then, provided the [E2] is >2500pg/ml, I stop the agonist and the gonadotropin stimulation and follow the E2 (only) daily, without doing further US examinations. The [E2] will almost invariably climb and I watch it go up (regardless of how high the concentration of E2reaches) and track it coming down again. As soon as the [E2] drops below 2500pg/ml (and not before then ever), I administer 10,000U hCGu or hCGf (Ovidrel/Ovitrel-500mcg) as the “trigger” and perform an egg retrieval 36h later. ICSI is a MUST because “coasted” eggs usually have no cumulus oophoris and eggs without a cumulus will not readily fertilize on their own. All fertilized eggs are cultured to blastocyst (up to 6 days). And up to two (2) are transferred transvaginally under US guidance.
The success of this approach depends on precise timing of the initiation and conclusion of “prolonged coasting”. If you start too early, follicle growth will stop and the cycle will be lost. If you start too late, you will encounter too many post-mature/cystic follicles (>22mm) that usually harbor abnormally developed eggs.
Use of the above approach avoids unnecessary cycle cancellation, severe OHSS, and optimizes egg/embryo quality. The worst you will encounter is mild to moderate OHSS and this too is uncommon.
Separately: When confronted with “unexplained” IVF failures where morphologically good embryos were transferred, the question arises as to whether the problem is due to inherent egg/embryo “incompetence” (which usually equates with an irregular chromosomal configuration [aneuploidy]) or whether it is due to an implantation dysfunction. The younger the woman and the higher the quality of available embryos (preferably blastocysts), the less likely it is that the fault lies with embryo “incompetence” and the greater is the likelihood that it is due to underlying implantation dysfunction.
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)
Implantation dysfunction (anatomical or immunologic) is a common cause of repeated “unexplained” IVF failure with good embryos. 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.
Please visit my new Blog at http://goo.gl/4hvjoP , 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
• Ovarian Stimulation for IVF: Comparing “conventional” use of GnRH antagonists to the Agonist/Antagonist Conversion Protocol (A/ACP)
• IVF: Factors Affecting Egg/Embryo “competency” during C
• 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)
• Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
• The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
• IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
• 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)
• Traveling for IVF from Out of State/Country–
• A personalized, stepwise approach to IVF
• The Role of Nutritional Supplements in Preparing for IVF
• IVF for Women Who Have Previously Conceived (Secondary Infertility).
• Endometriosis and Infertily
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.