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.
Please help! I read your article about how all follicles contain eggs and that there is no such thing as an empty follicle…however, I just completed a retrieval and ALL of the follicles were empty!! Not just immature eggs, but they said EMPTY! No granulocytes.
Cycle Details: I am 42. No known fertility issues. On CD3 my baseline was total testosterone: 31, SBGH: 30, AMH: 1.8, FSH: 14, E2:30, LH: 7.73 and P4: 0.55. There were 7 follicles this month.
CD3 through CD7 I was on 5 mg letrozole to recruit more follicles, but none were recruited.
CD4 until trigger I was on 450 follistim and 150 menopur. (yes, injections and letrozole on same days)
CD13 until trigger I was on ganareilix 250mg
Pregnyl and lupralite dual trigger when follicles reached sizes 15, 17, 17, 18, 18, and 22.
NOTHING.
I am very confused and concerned, even more so as I did a frozen Microflare cycle two months ago and retrieved 5 eggs. (40 microlupron, 450 follistim, 50 lowdose hcg, and pregnyl trigger) RE wanted more eggs this cycle.
What went wrong and what COS protocol would you recommend?? Am I infertile now?
Thank you!
Respectfully, your situation is a perfect example of how the protocol for ovarian stimulation can impact premature luteinization which in turn imopacts egg development, egg “competency” and the chance of empty follicles.
The issue is too complex to be adequately addressed in this format. We need to talk.
I invite you to call my assistant, Patti at 702-533-2691 and set up a time for a Skype or a FaceTime consultation to discuss.
Geoff Sher
My bottom line question is: can too much progesterone inhibit implantation?
Details:
I will have my second FET on 11/19, with a 6 day 3AB blastocyst, PGS normal.
(First one, in September of this year, with a 5 day 4AB blastocyst, PGS normal, resulted in a chemical pregnancy.)
We have done a “medically enhanced” natural cycle, i.e. I was allowed to ovulate naturally (I do so regularly on a cycle that alternates between 26-29 days) and for five days mid-cycle, we used 75IU of menopur, which resulted in my dropping two oocytes, whose follicles measured around 16ml on the day of the trigger. (Ovulation was confirmed 39 hours later by ultrasound.)
Since day of ovulation, my RE has me on 2mg Estradiol 2x a day, and 1.5 ML of progesteron-in-oil 1X a day.
Previously, I had an ERA confirming receptivity at 5 days after ovulation day 0. For that ERA, I was also on 1.5 ML of progesterone. However, I was not on a natural cycle, then, so therefore had no corpus luteum.
This time, because I dropped two eggs, I have not one but two corpus luteum, which (I assume?) are already producing progesterone on their own.
I am concerned that too much progesterone will hurt my chances of implantation with my last PGS normal embryo.
I turned 43 in August. Previously carried a healthy baby to term at age 40, conceived at 39 naturally after one month of unprotected sex.
In 2019, I carried a baby conceived through a combination of IUI and timed intercourse to 19 weeks, then terminated for medical reasons.
I desperately, desperately want this transfer to work.
Please advise if you think too much progesterone is going to negatively affect my chances at implantation? I don’t want to cancel but I also don’t want to be teed up for failure. I have brought this up with my RE who says she doesn’t think there is such a thing as too much progesterone. I am dubious.
Thank you for your guidance and insight.
Anna
I really do not believe too much progesterone is a factor in your case. Rather, in my opinion it is more likely the impact of age and (possibly) diminished ovarian reserve (DOR) coupled with the protocol used for ovarian stimulation that might well have impacted your ability to achieve a viable pregnancy. Frankly, at age 43y, you should be looking at egg donor-IVF. However, if in spite of the recognition that in women of your age, the chance of success with IVF declines rapidly with a graduated advance in age, you insist on trying with own eggs , then please consider the following:
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
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
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•The Fundamental Requirements For Achieving Optimal IVF Success
•Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the “Conventional” Antagonist Approach
•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.
• A Rational Basis for selecting Controlled Ovarian Stimulation (COS) protocols in women with Diminished Ovarian Reserve (DOR)
•Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
•Controlled Ovarian Stimulation (COS) in Older women and Women who have Diminished Ovarian Reserve (DOR): A Rational Basis for Selecting a Stimulation Protocol
•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?
•Blastocyst Embryo Transfers Should be the Standard of Care in IVF
•Frozen Embryo Transfer (FET) versus “Fresh” ET: How to Make the Decision
•Frozen Embryo Transfer (FET): A Rational Approach to Hormonal Preparation and How new Methodology is Impacting IVF.
•Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
•Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
•Preimplantation Genetic Testing (PGS) in IVF: It Should be Used Selectively and NOT be Routine.
•Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
•PGS in IVF: Are Some Chromosomally Abnormal Embryos Capable of Resulting in Normal Babies and Being Wrongly Discarded?
•PGS and Assessment of Egg/Embryo “competency”: How Method, Timing and Methodology Could Affect Reliability
•Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
•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
•Premature Luteinization (“the premature LH surge): Why it happens and how it can be prevented.
•IVF Egg Donation: A Comprehensive Overview
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ADDENDUM: PLEASE READ!!
INTRODUCING SHER FERTILITY SOLUTIONS (SFS)
Hitherto I have personally performed IVF- treatment and related procedures on patients who, elected to travel to Las Vegas to be managed by me. However, with the launching of Sher-Fertility Solutions (SFS) in April 2019, I have taken on a new and expanded role. Now, rather than having hands-on involvement I confine my services to providing hour-long online Skype consultations to an ever-growing number of patients (emanating from >40 countries), with complex Reproductive problems, who seek access to my input, advice and guidance. All Skype consultations are followed by a detailed written report that meticulously describes and explains my recommendations for treatment. All patients are encouraged to share this report with their personal treating doctor(s), with whom [subject to consent and a request from their doctor] I will, gladly discuss their case with the “treating Physician”.
Through SFS I am now able to conveniently provide those who because of geography, convenience and cost, prefer to be treated at home or elsewhere by their chosen Infertility Physician.
“I wish to emphasize to all patients with whom I consult, that in the final analyses, when it comes to management, strategy, protocol and implementation of treatment, my advice and recommendations are always superseded by that of the hands-on treating Physician”.
Anyone wishing to schedule a Skype consultation with me, can do so by: Calling my concierge (Patti Converse) at 1-800-780-7437 (in the U.S.A or Canada) or 702-533-2691, for an appointment. Patients can also enroll online on my website, http://www.SherIVF.com, or email Patti at concierge@SherIVF.com .
I was very recently greatly honored in receiving an award by the prestigious; International Association of Top Professionals (IAOTP). For more information, go to the press release on my website, http://www.sherIVF.com .
PLEASE HELP SPREAD THE WORD ABOUT SFS!
Geoff Sher
I had 2 low grade mosaic embryos placed August 29, one was -11 and one was -16. I am currently pregnant with one healthy fetus 14 weeks today. I am scheduled for an amniocentesis on November 27. My high risk OB/GYN says that since everything looks normal on ultrasound I can pass on the amino if I want and just run the baby’s DNA after it is born. My question is should I still do the amniocentesis? This entire time I have prepared myself mentally that I needed to have one and now I am confused. I don’t want to take any unnecessary risks but I also want to be prepared if something is wrong. Since you were so helpful when I was deciding to implant the mosaic embryos I thought I would ask.
Autosomal monosomies (such as your -11 and -16) , very rarely result in pregnancies that progress beyond the 1st trimester. Thus it is HIGHLY unlikely that this is an aneuploid pregnancy. Notwithstanding the above, I would still do an amniocentesis…just to be certain that all is well.
Good luck!
Geoff Sher
Hi, i am 42 hoing to be 43 soon,lowest amh,got tested two years before.Never had regular periods from almost many many years.Used to get longer cycle with heavy bleeding.Used to het transamic acid to stop.Than i started agnus cactus which helped to regulate .Currently have no cycle since nearly two months..Iam looking for some pricate cheap options to go with mh own egg.Mever smoke or drink no health ossue yet except lowest amh.Please suggest me something and can i ever het pregnant only using letrozole i did use for couoke of months.Should i go on contraception to regikate my cycle and than get letrozole or any private clonic can help me to go for ivf in uk ,i really am desperate to have kids.Thanks so much.
I would need to know what your recent basal FSH/LH/E2 and AMH are, in order to be able to respond authoritatively.
Geoff Sher
Dear Dr. Sher,
I am currently undertaking a donor egg recipient cycle, after two previous own egg cycles where we had no embryos to transfer.
On my previous cycle during the down regulation stage I developed a follicular cyst, which was aspirated. At the time I was taking synarel nasal spray.
During my current cycle, at a new clinic, I am using daily buserelin injections and have been taking them now for just over 4 weeks. I had a bleed after 1 week but then on my down regulation scan a week and half later my lining was at 6mm and I have a cyst on my right ovary. The clinic advised me to take an injection of HCG to induce ovulation, I think. This was 4 days a go and I am now waiting for another bleed.
My question is do you think this is going to negatively affect my donor recipient cycle (this also means the donor is now likely down regulating for longer than she needs to due to waiting for me) and why do you think I have developed a cyst for the 2nd time when I did bleed as I should have done? I’m worried that the buserelin isn’t working properly. I don’t want to continue with this cycle and waste our money if it’s likely to negatively impact everything, but equally we’ve come so far now, I don’t want to stop at this point.
Do you think there is an option to undertake donor recipient IVF without needing to down regulate? As down regulation just doesn’t seem to work well for me!
I’m really interested to hear your thoughts.
It is hard to say, given the available information. However, I think that it would be preferable to have an embryo transfer in a cycle progressing according to plan. My recommendation would be to discontinue proceeding to a fresh ET and instead proceed with the ovum donor cycle, retrieve eggs, generate blastocysts and freeze (vitrify)them for subsequent transfer in a subsequent FET cycle where your response is more orderly and you can confirm an endometrium of >8mm by the day progesterone therapy is initiated.
Geoff Sher