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. Geoff,
I am 40 and have been struggling the past two years to conceive and am now starting the IVF process. I have a four year old daughter who was conceived our first time trying and with that pregnancy I had very high HCG levels where I was bed ridden from week 6 to 14 with major lymph fluid swelling in my legs by the end.
My second conception happened the first time we tried again but my HCG levels were extremely weak and they missed my ectopic until it had ruptured and my left tube was removed around 6-7 weeks in August 2017.
Since then I have had no libido, have been tired and my period has been more irregular. I did go to the doctor and get bloodwork done September 2019 and my first month I was anovulating but said all my bloodwork was fine and was normal. Was tested again in October and levels were good and I got a private scan of my ovaries which showed I was ovulating. I also had my follicles counted which showed 14 on the left and 4 on the right.
I took the stimulation drug I believe is Letrozole July, August and September 2019 and nothing happened. I was informed that my AMH level is low at 4.0 when I had blood work done in May 2019 and that I would be on the most aggressive drug protocol moving forward for IVF.
I just read one of your posts about older women and LH and how fertility doctors need to prescribe a more customised drug protocol to avoid overstimulation of LH. I dont want to mess up my chances and take the wrong drugs but I wanted your opinion on whether or not I should take DHEA, Vitamin D and Co Q10 and if so what daily dosage and for how long? I was reading 50mg DHEA. Secondly do I need to talk to my doctors about not overstimulating my LH based off of my previous history?
Thank you so much for your time and kindness.
Clearly your AMH level was expressed in pmol/L and this would be indicative of significant DOR.
About DOR:
The older a woman becomes, the more likely it is that her eggs will be chromosomally/genetically “incompetent” (not have the potential upon being fertilized and transferred, to result in a viable pregnancy). That is why, the likelihood of failure to conceive, miscarrying and of giving birth to a chromosomally defective child (e.g. with Down Syndrome) increases with the woman’s advancing age. In addition, as women age beyond 35Y there is commonly a progressive diminution in the number of eggs left in the ovaries, i.e. diminished ovarian reserve (DOR). So it is that older women as well as those who (regardless of age) have DOR have a reduced potential for IVF success. Much of this is due to the fact that such women tend to have increased production of LH biological activity which can result in excessive LH-induced ovarian male hormone (predominantly testosterone) production which in turn can have a deleterious effect on egg/embryo “competency”.
While it is presently not possible by any means, to reverse the age-related effect on the woman’s “biological clock, certain ovarian stimulation regimes, by promoting excessive LH production (e.g. short agonist/Lupron- “flare” protocols, clomiphene and Letrozole), can make matters worse. Similarly, the amount/dosage of certain fertility drugs that contain LH/hCG (e.g. Menopur) can have a negative effect on the development of the eggs of older women and those who have DOR and should be limited.
I try to avoid using such protocols/regimes (especially) in older women and those with DOR, favoring instead the use of the agonist/antagonist conversion protocol (A/ACP), a modified, long pituitary down-regulation regime, augmented by adding supplementary human growth hormone (HGH). I further recommend that such women be offered access to embryo banking of PGS (next generation gene sequencing/NGS)-selected normal blastocysts, the subsequent selective transfer of which by allowing them to to capitalize on whatever residual ovarian reserve and egg quality might still exist and thereby “make hay while the sun still shines” could significantly enhance the opportunity to achieve a viable pregnancy
As for DHEA:
Dehydroepiandrosterone (DHEA), is steroid hormone produced by the adrenal glands and ovary. It is involved in producing the male hormones, androstenedione testosterone and also estrogen. DHEA blood levels tend to decline naturally with age.
Under the effect if luteinizing hormone (LH), DHEA is metabolized to testosterone in ovarian connective tissue (theca/stroma). Thereupon the testosterone is transported to the granulosa cells that form the innermost layer of the ovarian follicles where, under the influence of follicle stimulating hormone (FSH)-induced desmolase and aromatase enzymatic activity the testosterone is converted to estradiol. As this happens, granulosa cells multiply, follicle fluid volume increases along with estrogen output and egg development is promoted.
It is recognition of the essential/indispensable role that male hormones (mainly testosterone) play in follicle and egg development that prompted the belief that by giving DHEA and boosting ovarian testosterone production might benefit follicle/egg development. This belief was given some credence by an Israeli study that in 2010 reported on improved fertility when a group of infertile women were given the administration of 75mg of oral DHEA for 5 months. However, this study was seriously flawed by the fact that it did not separate out women who had diminished ovarian reserve, older women and those with PCOS, all of whom have increased LH-induced production of testosterone. In fact, we recently completed a study (currently being processed for publication) where we conclusively showed that when follicular fluid testosterone levels exceeded a certain threshold, egg quality was seriously prejudiced as evidenced by a marked increase in the incidence of egg chromosomal defects (aneuploidy).
Consider the following: Ovarian testosterone is needed for follicular development. However, the amount required is small. Too much ovarian testosterone spills over into the follicular fluid and has a deleterious effect on egg/follicle development. Some women (women with diminished ovarian reserve –DOR, older women and those with polycystic ovarian syndrome-PCOS) who tend to have increased LH biological activity, already over-produce testosterone. To such women, the administration of DHEA to such women, by “adding fuel to the fire” can be decidedly prejudicial, in my opinion. Young women with normal ovarian reserve do not over produce LH-induced ovarian testosterone, and are thus probably not at significant risk from DHEA supplementation. It is noteworthy that to date, none of the studies that suggest a benefit from DHEA therapy have differentiated between young healthy normal women with normal ovarian reserve on the one hand and older women, those with DOR and women with PCOS on the other hand.
In Some countries DHEA treatment requires a medical prescription and medical supervision. Not so in the U.S.A where it can be bought over the counter. Since DHEA is involved in sex hormone production, including testosterone and estrogen, individuals with malignant conditions that may be hormone dependent (certain types of breast cancer or testicular cancer) should not receive DHEA supplementation. Also, if overdosed with DHEA some “sensitive women” might so increase their blood concentrations of testosterone that they develop increased aggressive tendencies or male characteristics such as hirsuites (increased hair growth) and a deepening voice. DHEA can also interact other medications, such as barbiturates, corticosteroids, insulin and with other oral diabetic medications.
BUT the strongest argument against the use of routine DHEA supplementation is the potential risk of compromising egg quality in certain categories of women and since there is presently no convincing evidence of any benefit, why take the risk in using it on anyone.
Finally, for those who in spite of the above, still feel compelled to take DHEA, the best advice I can give is to consult their health care providers before starting the process.
Addendum: One potential advantage of DHEA therapy if used appropriately came from a study conducted by Washington University School of Medicine in St. Louis, MI and reported in the November 2004 issue of the “Journal of the American Medical Association” which showed that judicious (selective) administration of 50mg DHEA daily for 6 months resulted in a significant reduction of abdominal fat and blood insulin in elderly women.
Good luck!
Geoff Sher
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Hi Dr. Sher,
I am confused now since I got your reply about HIV instead of CMV (Cytomegalovirus).
I was tested CMV negative several months ago. I worked in a risk field for 9 months and now I need to be retested if I am still CMV negative. How many days or weeks after the last exposure should this test be redone?
Thanks
Oops! The reference to HIV was in error. I was referring to CMV. The same #s apply!
Geoff Sher
Could low progesterone impact implantation? On the day my beta was positive (131) my progesterone was only 14.5. Could this impact the growth of the embryo? My RE said my progesterone was low, he wanted to see it about 30.
In my opinion this progesterone level would not be responsible for an implantation dysfunction.
Good luck!
Geoff Sher
How long should you stay on estradiol valerate injections after fetal heartbeat is detected? I’m 7w3d, is this to early to stop?
It all depends whether this was an embryo recipient cycle (Egg Donation-ET, FET embryo donation, Gestational surrogacy-ET) or conventional IVF with a fresh ET. With the former…at 10 weeks. If the latter, then any time after ET depending on the recommendation of your treating RE.
Geoff Sher
Hi is there a way you can get even follicle growth . I did mini ivf , without any medications before , got 12 eggs only 3 mature , only trigged with Lupron . Have transferred all those , now gotta stim again , this time I need even follicle growth , bc my numbers were way off . More mature eggs .