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,
I am 42 – just had a miscarriage- I had 5 grade 1 embryo’s transferred. I will try one more time in Feb – My Dr suggested taken DHEA to help improve the quality of my eggs. Would you suggest this? also i have always had a slightly elevated level of testosterone for as long as I can remember – would taken DHEA be more harmful than beneficial in your opinion?
Hi Dr. Sher. I have read your protocol for women with thin lining. Will be starting compound viagra and injectable estradiol. I’ve had ongoing issues with thin lining and another RE suggested adding pentoxifylline. Do you have any thoughts on adding this to the protocol? Thank you!
In my opinion, pentoxphyline does not work in the vast majority of cases.
Geoff Sher
Hi Dr. Sher,
When using compund viagra in a FET cycle, what day do you recommend starting it? Should I start it on day 1 of menstruation or do I wait until after my period? Thank you!
As long as it is started 72h before hCG trigger or commencing progesterone it can still have a therapeutic benefit. Optimally, I recommend starting as soon as menstruation is over.
Geoff sher
Dr Sher,
I have a few questions and would appreciate your help. I am 39 years old and day 3 often has low LH like 1 or 2 though my FSH is often around 6.
1. Do you watch LH level during the stimulation? What is a good level of LH? Does a low LH like 2 indicate some negative sign on the follicle/egg growth or quality?
2. How do you think about ganirelix? When would be a good time to start to use? For example, when the follicles is 14? or 16 etc? Any rule on when to use it? I saw an article says younger ovary tends to respond to FSH/HCG stimulation well and therefore lead to early surge of LH. Therefore, ganirelix helps to prevent early ovulation. However, someone like me is very poor responder with AMH of only 0.27 and won’t easily have early surge. It seems Ganirelix slow down the follicle growth by pressing LH and E2, correct? Does it mean I should not use ganirelix as much as other normal responders? maybe use ganirelix when my foclicles grow enough like 17?
3. What is the good range of follicle sizes when you do the trigger? Is it 18 to 20 mm? or it can be over 20mm? is 22mm very likely to be over mature?
4. How do you think about the amount of FSH and HCG for stimulation for patients around 40? I saw one article says high does helps patient with 35 or younger age to develop more follicles, but have insignificant effects on patients around 40. Does it mean patients at 40 should have low dose of HCG + FSH because the number of follicles growing won’t increase much anyways? If the growing follicle numbers are the same, maybe less dose will have less potential side effects on ovary?
Thank you very much!
1. Do you watch LH level during the stimulation? What is a good level of LH? Does a low LH like 2 indicate some negative sign on the follicle/egg growth or quality?
A: No I do not!
2. How do you think about ganirelix? When would be a good time to start to use? For example, when the follicles is 14? or 16 etc? Any rule on when to use it? I saw an article says younger ovary tends to respond to FSH/HCG stimulation well and therefore lead to early surge of LH. Therefore, ganirelix helps to prevent early ovulation. However, someone like me is very poor responder with AMH of only 0.27 and won’t easily have early surge. It seems Ganirelix slow down the follicle growth by pressing LH and E2, correct? Does it mean I should not use ganirelix as much as other normal responders? maybe use ganirelix when my foclicles grow enough like 17?
A: I use antagonists starting on day 1 of stimulation. The protocol is the “agonist/antagonist conversion protocol.With the A/ACP, GnRH antagonist (Ganirelix, Cetrotide, and Orgalutron) is administered by daily injection from the onset of COS. The A/ACP COS-cycle is launched with the woman coming off a monophasic birth control pill that was administered starting in the 1st 5 days of the preceding cycle and continued for at least 10 days. The BCP is then overlapped with an agonist (e.g. Lupron/buserelin) for three days, whereupon the BCP is stopped and the agonist (Lupron/buserelin) is continued until the onset of menstruation. At or around this point, the agonist (Lupron/Buserelin) is supplanted by an antagonist (Cetrotide/Ganirelix/Orgalutron) and concurrently COS is initiated using an FSH-dominant bias (mainly Follistim/Gonal-F/ Puregon + a small dosage of a menotropins such as Menopur). The combined antagonist/gonadotropin therapy is continued until the hCG trigger. For the reasons cited above, I prescribe some form of the A/ACP for my older IVF patients and those with DOR. ]
A/ACP with estrogen priming: The A/ACP can be modified for women with very severe DOR through incorporation of “estrogen priming”. We have reported on the fact that the administration of intramuscular estradiol starting about a week prior to commencement of COS. This often markedly enhances ovarian response (presumably by “estrogen priming” enhancing the sensitivity of ovarian FSH-receptors).
There is one draw-back to the use of the A/ACP. This is the fact that prolonged administration of GnRH antagonist throughout the stimulation phase of the COS cycle compromises the predictive use of serial plasma estradiol measurements as an indication of ovarian response to COH. The blood estradiol levels tend to be much lower in comparison with cases where GnRHa alone is used.The reason for the lower blood concentration of estradiol seen with prolonged exposure to GnRH-antagonist might be due to the result of subtle, antagonist-induced alterations in the configuration of the estradiol molecule, such that currently available commercial test used to measure estradiol levels are rendered less sensitive/specific. Accordingly, when the A/ACP protocols are employed, we rely much more heavily on the measurement of follicle growth by ultrasound than on the estradiol levels. Because of this downside, I refrain from using this approach in “high responders” who may be at risk of developing of severe ovarian hyperstimulation syndrome (OHSS) and in whom the accurate measurement of plasma estradiol plays a very important role in the safe management of their COS cycles.
3. What is the good range of follicle sizes when you do the trigger? Is it 18 to 20 mm? or it can be over 20mm? is 22mm very likely to be over mature?
A:18-22mm
4. How do you think about the amount of FSH and HCG for stimulation for patients around 40? I saw one article says high does helps patient with 35 or younger age to develop more follicles, but have insignificant effects on patients around 40. Does it mean patients at 40 should have low dose of HCG + FSH because the number of follicles growing won’t increase much anyways? If the growing follicle numbers are the same, maybe less dose will have less potential side effects on ovary?
A: That decision is made on an individualized basis.
Geoff Sher
My beta hcg report show 322.75 . What does it means is there a pregnancy. Is it a good pregnancy or there is a reason to be afraid of .my doctor did not gave me all the answers but told to repeat it once more after 48 hrs. Can you give me some advice
That is encouraging but the level needs to double in 48 hours…If so, that would be a good sign but not a confirmation of a total viable pregnancy. An ultrasound of a viable pregnancy performed 2 week later would be confirmatory.
Good luck!
Geoff Sher