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,
For a 30 year old women, what is the average of (pgs normal) blastocyts per cycle?
In optimal circumstances the chance of a viable pregnancy following the transfer of a non-PGS tested blastocyst to a woman of 30Y is about 30-35%.
Geoff Sher
I meant how many pgs normal blastos is average in one cycle (retrieval) in a 30 year old woman?
Hi doc, if an embryo reaches blastocysts and hatching, does it mean its a good quality?
Not necessarily because you cannot know then chromosomal/genetic make-up of an potential
Sir i had 2 grade 3 blastocysts transferred on dec 31 2018….14 days after transfer i got upt negative with hcg 21…on day 16 my beta hcg was49.1…on day 18 my beta hcg was 112 and upt i got a very very faint line…my ivf doc me day21 for scan to rule out ectopic pregnancy..she is more worried about ectopic..is my pregnancy an ectopic? Cant it be a normal intrauterine pregnancy with delay in rise in hcg levels? Is the sac seen so early with low hcg levels?
Indeed! It could still be a normal IU pregnancy. You should do an US in 2 weeks to determine this.
Good luck!
Geoff Sher
Hello Dr. Sher
I’m 41 and just underwent an unsuccessful IVF attempt. I produced 19 follicles and my trigger was Lupron. 12 follicles were not accessible due to my right ovary position, behind my iliac artery. 7 were retrieved and 6 failed to fertilize due to abnormal chromosome counts in the egg! The 1 normal fertilized ovum stopped developing on day 6, never reaching blastocyst.
Could the Lupron trigger have caused poor chromosome division/ maturation? Would HCG be better?
Adi
Traditionally egg retrievals are timed for about 36 hours after a 10,000U hCG “trigger”. The hCG hormone thereupon remains in the system for up to a week. When patients who overstimulate following ovarian stimulation experience prolonged exposure to hCG the risk of developing severe ovarian hyperstimulation syndrome with its incumbent life-endangering complications escalates. Attempts to mitigate this risk have included:
a)withholding the hCG trigger altogether thereby preventing luteinization of follicle granulosa cells and preventing the production of vasoactive substances (e.g. VEGF) which when overproduced escalate the risk/severity of OHSS,
b)prematurely administering the hCG trigger to arrest further follicular growth and escalation in blood estradiol levels,
c)reducing the dosage of hCG by half, to 5,000U in the hope of limiting/restricting the luteinization process and,
d) supplanting the “hCG trigger’ by an “Agonist (e.g. Lupron) trigger” that causes promotes meiotic egg maturation buy causing a surge in the release of pituitary LH.
All of the options above do indeed reduce the risk of developing OHSS. “a)” completely prevents egg maturation from occurring and thus virtually precludes the harvesting of “competent” eggs, while “b), c), and d)”all adversely affect egg “competency” to a lesser or greater degree, thereby compromising both embryo quality and IVF outcome.
Use of the “Lupron trigger” bears further mention: Since its recent introduction, this approach has really gained popularity and caught on in a big way. In truth, there can be little argument that it markedly reduces the incidence, severity and risk of complications associated with severe ovarian hyperstimulation. However use of the “Lupron trigger” often comes at the expense of egg/embryo quality as well as IVF outcome. Thus, the question arises as to whether this approach is advisable, and if not, what the best alternative to its use would be. The reason why the “Lupron trigger” is in my opinion ill-advised, is that in cases of ovarian hyperstimulation, where there are numerous follicles with eggs that need to undergo meiosis following the “trigger”, the magnitude of the LH surge, induced by a “Lupron GnRHa trigger” is often insufficient. This can result in suboptimal egg maturation (meiosis), leading to the generation of an inordinate number of immature/dysmature eggs as well as in an increase in the number of large follicles that fail to yield eggs at all (“so called “empty follicles). This is why I do not employ the “Lupron trigger” approach in my practice, preferring instead to use the long pituitary down-regulation, along with “prolonged coasting” in women who are deemed to be at risk for developing OHSS. My position is further supported by a recent publication showing that for this very reason, the use of a GnRHa-induced “trigger is not helpful.
Prolonged Coasting, my preferred choice!: My approach is consistently to have my patients who are at risk of developing OHSS, launch their ovarian stimulation, coming off a monophasic birth control pill (BCP). The last few days on the BCP is accompanied by the addition of Lupron. Thereupon the BCP is stopped and Lupron therapy is continued. After 3-7 days menstruation usually ensues, at which point the dosage of Lupron is reduced and low dosage FSHr (Follistim/Gonal-F/Puregon) -dominant ovarian stimulation is commenced. Lupron and gonadotropins are then continued together. This approach is referred to as the “Long Pituitary Down-regulation protocol” Use of the BCP is intended to lower LH and thereby reduce stromal activation (hyperthecosis) in the hope of controlling ovarian androgen (mainly testosterone) release (too much ovarian testosterone is harmful to egg development). Seventy five (75) units of LH/hCG (Luveris/Menopur) is added from the 3rd day of gonadotropin stimulation. Starting on the 7th day of ovarian stimulation with gonadotropins, I start watching daily for the # and size of follicles developing and for the rise in blood [E2]. If there are > 25 follicles, the patient becomes a candidate for “prolonged coasting” I keep stimulating with gonadotropins (regardless of the [E2]) until: a) 50% of all follicles reach 14mm and b) the [E2] reaches 2500pg/ml. At that point, gonadotropin stimulation is discontinued abruptly while daily Lupron injections continue. Thereupon I follow the daily blood [E2] without doing further US examinations. The [E2] will almost invariably continue to rise. I carefully plot the rise in [E2] (regardless of how high it goes). Usually, within 1-3 days it will plateau and then start to decline. As soon as the [E2] drops below 2500pg/ml (and not before then), I administer the 10,000U hCGu (Novarel/Pregnyl/Profasi) “trigger” or 500mcg of hCGr (Ovidrel) and then schedule an egg retrieval for 36h later. ICSI is a MUST because “coasted” eggs usually have few or no surrounding cumulus cells and eggs without a cumulus layer will not readily fertilize on their own. All fertilized eggs are cultured to the blastocyst (up to 6 days) whereupon I transfer up to two into the uterus, or vitrify all expanded blastocysts for subsequent dispensation at the directive of the patient. In some cases the embryos are biopsied for PGS testing prior to being cryostored. Subsequent frozen embryo transfers are conducted as per the wishes of the patients.
It is important to point out that the success of this “prolonged coasting” approach depends on precise timing of the initiation and the 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.
The use of an agonist or GNRH trigger while reducing the risk of severe OHSS developing comes at the expense of egg/embryo quality and could compromise IVF outcome.
My final IVF cycle at SIRM-LV commences on March 19th and concludes on April 2nd. If you are interested in undergoing a fresh IVF treatment cycle with me or if you have embryos cryopreserved at SIRM-LV and wish to undergo a Frozen Embryo Transfer (FET) prior to my departure, please contact me immediately….. My March cycle is likely to be very much in demand…….So, time is of the essence!
Following my departure from SIRM in mid-April, 2019, I will continue to provide comprehensive consultations to those of you that wish to have my guidance. Upon scheduling a SKYPE consultation with me, you will promptly receive a detailed questionnaire, along with a request that you submit available medical records for my review prior to our consultation. Additional tests and records can/will be requisitioned later, as needed. Your +/- 1 hour comprehensive SKYPE consultation will be followed by a detailed written report which you can also share with your personal Fertility Physician.
I will soon be posting a list of internationally regarded Fertility Specialists whom I endorse and who will have expressed a willingness to implement my suggested approaches, at their discretion. It is to one of these doctors that I would selectively refer you…upon request.
CONTACT INFORMATION:
•Online: Go to sherivf.com and Schedule a Skype Consultation. Upon doing so, you will be able to download a free copy of my new eBook ” Recurrent Pregnancy Loss (RPL) and Unexplained IVF Failure: The Immunologic Link”
•Phone
oIf you live in the USA or Canada: Please call 1-800-780-7437 or 702-533-2691
oIf you reside elsewhere Abroad: Please call 702-533-269
oEmail: concierge@SherIVF.com
Please monitor this website for future announcements on further developments.
Geoff Sher
Hi Dr. Sher,
I am 34 years old and have been trying to conceive for over 1.5 years. I’ve never been pregnant. I have a regular 28-30 day cycle, day 14 ovulation but have been told that I have low AMH.
My husband and I have had two failed IVF cycles.
Our first cycle was in October – I took 300IU of Gonal-F which was reduced to 225IU mid-cycle, 150IU of Menopur and 100mg of Clomid. Cetrotide was halfway through stims. I had 8 good sized follicles and was triggered with 2,500 U of HCG and Suprefact (can’t remember the exact dose of this). The doctor advised me they did not give me the full HCG trigger shot as my estrogen was very elevated during the cycle and they wanted to take precaution against OHSS. At retrieval, they were only able to get three eggs – 2 mature and 1 immature. Only 1 egg fertilized via ICSI and was frozen at day 3.
I met with my RE after this cycle and was advised that I have “empty follicles”. My RE changed our protocol for the second cycle.
I just completed my second cycle and it was even worse than the first cycle.
On the second cycle I was taking Saizen (HGH), 5mg of Letrozole, 300IU of Gonal-F, 150IU of Menopur. Cetrotide was added half way during stims. I had 9 good sized follicles and was triggered with 10,000 U of HCG and Suprefact (can’t remember the dose of suprefact). At retrieval, we got three immature eggs. One egg matured in the lab, fertilized successfully via ICSI but arrested on day 3.
I feel frustrated and am starting to lose hope.
I am wondering what you would suggest in this case.
Thank you in advance for your guidance.
There is no such thing as empty follicles.
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.
My final IVF cycle at SIRM-LV commences on March 19th and concludes on April 2nd. If you are interested in undergoing a fresh IVF treatment cycle with me or if you have embryos cryopreserved at SIRM-LV and wish to undergo a Frozen Embryo Transfer (FET) prior to my departure, please contact me immediately….. My March cycle is likely to be very much in demand…….So, time is of the essence!
Following my departure from SIRM in mid-April, 2019, I will continue to provide comprehensive consultations to those of you that wish to have my guidance. Upon scheduling a SKYPE consultation with me, you will promptly receive a detailed questionnaire, along with a request that you submit available medical records for my review prior to our consultation. Additional tests and records can/will be requisitioned later, as needed. Your +/- 1 hour comprehensive SKYPE consultation will be followed by a detailed written report which you can also share with your personal Fertility Physician.
I will soon be posting a list of internationally regarded Fertility Specialists whom I endorse and who will have expressed a willingness to implement my suggested approaches, at their discretion. It is to one of these doctors that I would selectively refer you…upon request.
CONTACT INFORMATION:
•Online: Go to sherivf.com and Schedule a Skype Consultation. Upon doing so, you will be able to download a free copy of my new eBook ” Recurrent Pregnancy Loss (RPL) and Unexplained IVF Failure: The Immunologic Link”
•Phone
oIf you live in the USA or Canada: Please call 1-800-780-7437 or 702-533-2691
oIf you reside elsewhere Abroad: Please call 702-533-2691
oEmail: concierge@SherIVF.com
Please monitor this website for future announcements on further developments.
Geoff Sher