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. Could you tell me how human growth hormone is supposed to help in a fertility stimulation protocol?
Thank you. Kerry
A woman’s reproductive potential is very much influenced affected by her “biological clock” which comprises two components:
1.Age: Advancing age is inevitably accompanied by a progressive reduction in the number of eggs in the ovaries (“ovarian reserve”). As a diminution in ovarian reserve (DOR) ultimately passes a theoretical “threshold” the woman becomes progressively more resistant to stimulation with fertility drugs. This is accompanied by a fall in blood AMH levels and a rise in basal blood FSH. After several years of progressive DOR, the ovarian reserve is ultimately depleted, and ovulation as well as cyclical menstruation ceases (menopause).
2.“Egg Competency” The second component of the biological clock is an inevitable age-related decline in egg competency (the ability of an egg, upon fertilization, to propagate a healthy embryo) . The most important manifestation of this age-related occurrence is an inevitable and rapid increase in the percentage of eggs that have numerical chromosome irregularities (aneuploidy). By way of example, at age 30Y, about one out of every two human eggs will be aneuploid while at 45Y more than nine out of ten are so afflicted. Aneuploid eggs cannot propagate healthy babies. Most will not even fertilize and those that do, will usually be lost as early miscarriages or go on to produce a birth defect such as Down syndrome.
It is important to understand is that e the two components of the biological clock (i.e. ovarian reserve and age) represent variables which while they are often interrelated and inter-dependent can often exist independently. By way of example, some older women in their mid-forties have excellent ovarian reserve while some young women in their thirties have DOR. Yet while they produce fewer eggs, the potential competency of the eggs they produce is largely tied to their age. However, the ovarian hormonal environment brought about by DOR and the protocol used for ovarian stimulation, is readily affected by the protocol used for ovarian stimulation. Selection of the wrong stimulation protocol can adversely influence egg competency. Conversely, an individualized and optimal protocol for ovarian stimulation by favorably regulating the ovarian hormonal environment, can improve the potential for optimal follicle and egg development thereby minimizing the risk of egg aneuploidy. The problem is that it becomes progressively more difficult to optimally regulate the intra-ovarian hormonal environment in older women, and in those with DOR, and it is here that the use of human growth hormone can play a valuable role.
Several researchers have shown that the administration of human growth hormone (HGH), as an adjunct to ovarian stimulation, enhances follicle response in older women and those with DOR and so can help optimize egg quality. It is thought that HGH hormone by increasing the production of insulin-like growth factor 1 (IGF-1), improves follicle development, estrogen hormone production and egg maturation. Two basic mechanisms have been proposed: 1) improving the response to gonadotropin therapy by up-regulating the FSH receptors on the granulosa cells that form the inner lining of follicles and, 2) through a direct enhancing effect of HGH on the egg’s mitochondrial activity. While human eggs do have HGH receptors, those retrieved from older women show decreased expression of such receptors (as well as a reduction in the number of functional mitochondria) as compared with those derived from younger women. In fact, it has recently been shown that older women treated with HGH showed a marked increase in functional mitochondria in their eggs along with improved egg quality.
My own experience in selectively prescribing HGH as an adjuvant to women with DOR, older women and those with unexplained egg quality deficits, is that if used in combination with individualized protocols of ovarian stimulation it does indeed enhance egg quality and ovarian response, culminating in improved IVF outcome.
I invite you to arrange to have a Skype or an in-person consultation with me to discuss your case in detail. If you are interested, please contact Julie Dahan, at:
Email: Julied@sherivf.com
OR
Phone: 702-533-2691
800-780-7437
Geoff Sher
In addition to my email I just sent, I forgot to mention the doctor said I have a little bit of adenomyosis (I didn’t have this when I conceived my daughter), but he said there is little scarring. How much is this reducing my chances?
I doubt that adenomyosis is a factor but I would need much more information to respond authoritatively on this issue.
Geoff Sher
Hi there,
My question is whether or not I have a chance at success for ivf with my own eggs. Here’s my history, did fertility testing at 36 after trying for 5 months. Everything was very good for both myself (very good FSH, great ovarian reserve and tubes open) and my partner except that no follicle was growing in the one natural cycle that my clinic followed and my partner’s motility was a little low – I put him on supplements and his motility is now normal. So they gave me clomid and I had one follicle grow at age 36 and I got pregnant right away but it ended up floating to the opposite tube from the side I ovulated and I lost my tube since it ruptured. We tried 2 or 3 timed intercourse and iui with no success so decided to be more aggressive since I was then 37. We did ivf – they retrieved 15 eggs and I ended up with 5 blasts – 5AA hatching, 5AA, AB, BB and BB. We did single transfers for all. All were a fail except the 2nd blast (5AA) – frozen transfer which ended up in my healthy 2 year old. Also had a miscarriage in there. After the birth of my daughter the doctors told me it was very likely I would have another baby or more with the 3 remaining blasts but that didn’t happen. So now I’m 40, my FSH is still very good and my ovarian reserve is the same at 40 as it was when I was 37. They retrieved 19 eggs (was on menopur 150 and puregon 150, towards end they had to lower my dose to 100 and then 50 because of high estrogen – estrogen was about 14,000 and I had mild OHSS (gained about 5lbs and bloating with some pain). 14 of 19 fertilized naturally, but ended up with 3 blasts (the third didn’t become a blast until day 6). WE put in 2 on day 5 – 4BC and 3BB and froze the 5BB on day 6). The two didn’t work. I still have one frozen. I’m considering doing a fresh cycle and adding in the frozen one. So my question is should I be using donor eggs – if of 19 eggs it looks like none are going to work, I worry that I only have maybe a very low chance of conceiving a healthy baby, I also worry about the health risks to the baby. I’m in very good health (actually got a discount on my life insurance bec my numbers were so good), other than neck pain from herniated disk. I’m considering doing 2 more ivf’s before giving up. What are my chances with my own eggs and should I be doing donor eggs?
Thank you,
Kerri
I do not think you need an egg donor. However, at 40Y of age I would seriously consider adding staggered IVF (St-IVF) with PGS embryo selection to the process.
While Primary infertility refers to the inability of a woman who has never been pregnant in the past, to conceive, Secondary Infertility is defined as an inability to conceive more than 1 year after having conceived in the past. Most patients find it difficult to accept the fact that having once been able to conceive they are now unable to do so. When confronted with the proposition that they need IVF, women who have Secondary Infertility find it harder to accept than do those who have Primary Infertility. It commonly raises issues of guilt, a declining sense of self-worth and ultimately self-recrimination impacting rational decision making, family dynamics that involve partners and siblings and relatives. The fact is that secondary infertility can be just as difficult for individuals and family to deal with as primary infertility.
There are several factors that contribute to the problem of Secondary Infertility. These include:
•Social and marital factors: In this modern day and age where at least one in two marriages ends in divorce, it is not surprising that there would be an inevitable hiatus in childbearing. This often results in a considerable delay in re-initiating family building. Since the biological clock keeps on ticking in the interim, advancing age can, and often does, have a profound effect on a woman’s ability to subsequently conceive and successfully complete a pregnancy. In my experience, this is one of the most common reasons for secondary infertility. In addition, by the time a decision is made to enter a new relationship, many men and women will have undergone a prior sterilization procedure which now needs to be addressed. To make matters worse, many such men and women first opt for surgical reversal of their occlusive surgery, only to learn in the end that the procedures were not successful, and they now need to consider in vitro fertilization (IVF) in one form or another.
•Financial factors: Here, the cost of raising a child often weighs heavily, especially in this present tough economic climate. This is becoming more of an issue as women playing an ever increasing role as a primary bread winner.
•Career demands: There can be little doubt that when it comes to climbing the career ladder, women are considerably disadvantaged by the fact that pregnancy and the immediate demands of child rearing take away from their ability to compete with men. As such, many women choose to delay having another child until such time as they have been able to make up for prior lost opportunity.
•Medical barriers to fertility: Certain common medical conditions, while not absolutely precluding pregnancy, make it much more difficult to conceive.
•Endometriosis: It is not uncommon for women with endometriosis to achieve a pregnancy, but find difficulty in doing so again at a later date. The reason for this is that while most women with endometriosis have patent fallopian tubes, the environment surrounding their tubes is compromised due to pelvic toxins that are produced by the endometriotic implants. These toxins compromise egg fertilization potential, making it more difficult for sperm in the fallopian tube to fertilize the egg upon its arrival there. As such, endometriosis is one of the commonest causes of secondary infertility.
•Tubal damage due to prior pelvic inflammatory disease: In first world countries, the early and often indiscriminate use of antibiotics for the slightest symptom has led to the point where an acute attack of pelvic inflammatory disease is often masked. As such, less than 30% of American women with tubal damage have knowledge that their tubes are compromised and that they might have subsequent difficulty in conceiving. Since, in many such cases the tubal damage will not have totally blocked both tubes, some of the women so affected might experience a pregnancy but have difficulty in conceiving again later down the line.
•Dysfunctional ovulation: Since ovulation as well as normal hormonal support of the early implanting embryo are both essential for a healthy pregnancy to occur, it follows that women with irregular or dysfunctional ovulation (e.g., polycystic ovarian syndrome – PCOS, persistent follicular luteal phase deficiencies or post birth control pill ovulatory problems) might sporadically conceive and thereupon find it difficult to do achieve another pregnancy later on.
•Immunologic Implantation Dysfunction (IID): has become ever more apparent that immunologic factors play an important role in achieving healthy implantation. Women with endometriosis (regardless of its severity), those with a personal or family history of autoimmune diseases such as lupus erythematosus, rheumatoid arthritis and thyroid autoimmunity (TAI), and some cases where the man and the woman share certain genetic similarities involving DQ alpha and HLA genotype (alloimmune implantation dysfunction), will have activated T cells (cytotoxic lymphocytes) and natural killer cells (NKa)CTL/NK cells that can inhibit or compromise healthy implantation. This is an often overlooked cause of secondary infertility. Most such autoimmune/alloimmune cases require selective immunotherapy and IVF.
•Anti-sperm Antibodies: Although infrequent, some cases of secondary infertility might also be caused by the woman harboring anti-sperm antibodies. In such cases IVF is mandated.
•Previous post-pregnancy uterine inflammation: Retention of products of conception after the birth of a child, miscarriage, or abortion can so damage the uterine lining as to result in subsequent implantation failure. Unless specifically looked for, this will usually be unknown to the patient, who will simply present with secondary infertility. Treatment is often difficult because such patients might not respond adequately to surgical removal of intrauterine scar tissue or to hormonal or Viagra therapy.
Male immunologic factors: Most men who have undergone a previous vasectomy more than 10 years earlier, will have anti-sperm antibodies that will interfere with fertilization. Such cases require IVF with intracytoplasmic sperm injection (ICSI). Here we offer a few words of caution to men who are considering undergoing surgical reversal of vasectomy. Always first have a test done to exclude the presence of circulating anti-sperm antibodies, because in such cases, even if the reversal is successfully performed, they will not be able to initiate a pregnancy without IVF/ICSI.
Whatever the cause, Secondary Infertility often affects older couples disproportionately, creating a sense of urgency and even desperation in achieving a viable pregnancy before time runs out. It is for this reason that IVF becomes the treatment of choice in such cases. However, even IVF becomes progressively less successful with advancing age of the woman (whose eggs are being fertilized). In such cases it is important for the couple to be realistic with regard to their expectations. Here, options that include embryo banking and egg donation should be carefully considered.
Finally, whenever a regularly ovulating younger woman (under 36 years of age) with patent fallopian tubes is diagnosed with secondary infertility, it is essential to consider underlying endometriosis or non-obstructive tubal disease as a possible cause. In such cases, IVF often becomes the treatment of choice.
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
•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?
•Why did my IVF Fail
•Frozen Embryo Transfer (FET): A Rational Approach to Hormonal Preparation and How new Methodology is Impacting IVF.
•Staggered IVF:
•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?
•IVF Failure and Implantation Dysfunction:
•The Role of 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
•Intralipid and IVIG therapy: Understanding the Basis for its use in the Treatment of Immunologic Implantation Dysfunction (IID)
•Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
•Endometrial Thickness, Uterine Pathology and Immunologic Factors
•Vaginally Administered Viagra is Often a Highly Effective Treatment to Help Thicken a Thin Uterine Lining
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF
•Ectopic (Tubal) Pregnancy and IVF
•Advancing Age of the Woman and IVF: How Old is too old?
. Adenomyosis
I invite you to arrange to have a Skype or an in-person consultation with me to discuss your case in detail. If you are interested, please contact Julie Dahan, at:
Email: Julied@sherivf.com
OR
Phone: 702-533-2691
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,
What is the earliest I can check by a home pregnancy test after a 3 day transfer?
About 2 weeks after.
Good luck!
Geoff Sher
Good morning Dr. Sher.
Can you pls. clarify. I had my Embryo Transfer a week back. Doctor has also been giving me HCG shots once in 4 days. I have my Beta HCG test next week. Wont that show a false positive ?
If so what is a sure way of confirming the pregnancy.
Is it that we need to take multiple Beta HCG tests once in 2 days and see if the values are doubling. Or should we wait for the week 6 ultrasound results.
Thanks in advance and have a great day.
Regards
Dhivya
You would need about 14 days after the last hCG booster and then repeat the hCG test 2 days later to see if it rises appropriately.
Geoff Sher