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.
Hello Dr. Sher. I have had 4 miscarriages first trimester, never got over 6w2d measurements for embryo. The last one was IVF PGT-SR tested embryo. I have Hashimoto, Asthma, chronic sinus infection , Anticardiolipin IgM 23 and my husband has BT(11;18). I took Estrace 4 mg, Prometrium 2×400, Prednisone 5, Lovenox 40. After transferring a 5 day embryo at 7 days Hcg 28 at 9 days 67.6 at 16 days 3147 18days I started bleeding at 19 days HSG 4620 And TSH 37 at 21 days HSG 6154 Tsh 27 and at 27 days HSG was 3892 and Tsh 2.9 . At 32 days from transfer I miscarried. I doubled the Levothyroxine medication when I found out that TSH was so high and my levels got down in a couple of days after embryo stoped or slowed its growth. I have no clue what is going on with my body and nobody finds a solution or at least a reason . What would you recommend? What should I do next?Is it a autoimmune reaction of my body and it rejects or destroyed the embryo? Please help or show me the way because I am loosing hope here. Thank you so much!
Hello Dr. Sher
I have secondary unexplained infertility. I have a 12 year old with natural pregnancy and since then have never ever seen a positive pregnancy result. Hence last year moved to treatment. Had 2 failed IUI. Since all results, tests, my ovaries etc are great so doctor said IVF is a great option. I had 2 PGS tested 4AA six day blastocysts which failed to implant in my 2 frozen transfers. Now I have a seven day 4AA BLASTOCYST which has lower chances anyways so not going with it. My question is why my good embryos did not implant and if I do more retrieval/transfer how will it matter since nothing in my body has changed. I will fail again unless some problem is fixed or things are done differently. Please guide what should I fix or do differently if I go for another retrieval/ transfer. Also if I try naturally what Can I do to have max chance other than trying in fertile window. Thank you. Waiting to hear back. Sent an email with my phone if possible to call please. Thanks.
Dr. Sher,
I just turned 41 and going through 1st IVF cycle. I had a lap for Stage 3 endo removal in September, fell naturally pregnant in October and had a miscarriage at 7 weeks. Because of the endo, I was put on an ultra long down regulation protocol. I started Decapeptyl injections Jan 1st, and started stimming with 300 units of Puregon on Feb 13th. 75 iu of Menopur was added after the day 6 scan showed 7 follicles with slower growth (10, 9, 9, 9, 8, 8, 5). E2 levels were at 59. On day 8, the doctor was surprised to see that the follicles were growing, (19, 17, 15, 15, 15), but E2 levels were only 233 (LH was also low, but progesterone was good). We are now in a wait and see mode, but I wondered your opinion on the down regulation suppression – do you think it was too much? What would you recommend? Thanks in advance!
I would personally modify the stimulation protocol. It looks as if you could have diminished ovarian reserve.
Women who (regardless of age) have diminished ovarian reserve (DOR) have a reduced potential for IVF success. Much of this is due to the fact that such women tend to have increased production, and/or biological activity, of LH. This can result in excessive ovarian male hormone (predominantly testosterone) production. This in turn can have a deleterious effect on egg/embryo “competency”.
While it is presently not possible by any means, to reverse the effect of DOR, certain ovarian stimulation regimes, by promoting excessive LH production (e.g. short agonist/Lupron- “flare” protocols, clomiphene and Letrozole), can in my opinion, 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 women 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 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, www. SherIVF.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)
Founded in April 2019, Sher Fertility Solutions (SFS) offers online (Skype/FaceTime) consultations to patients from > 40 different countries. All consultations are followed by a detailed written report presenting my personal recommendations for treatment of what often constitute complex Reproductive Issues.
Patients are encouraged to share the information I provide, with their treating Physicians and/or to avail themselves of my personal hands-on services, provided through batched IVF cycles that I conduct every 3 months at Los Angeles IVF (LAIVF) Clinic, Century City, Los Angeles, CA.
If you wish to schedule an online consultation with me, please contact my assistant (Patti Converse) by phone (800-780-7437/702-533-2691), email (concierge@SherIVF.com) or, enroll online on then home-page of my website (www.SherIVF.com).
PLEASE SPREAD THE WORD ABOUT SFS!
Geoff Sher
Hi Dr Sher,
I was in the ovarian stimulation phase, being a week on 225 gonal f and menopour, I had been on it for 4 nights. Tonight I was suppose to take Orgalutron along with the other drugs however I was feeling unwell so I went to the dr and they told me I have shingles. My fertility dr has canceled my cycle.
Have you canceled cycles due to shingles before? Also should I refrain from having sex or could it give us the chance to conceive naturally as the Orgalutron stops me from ovulating. I know it’s probably not possible but thought I would ask.
I agree with your RE’s decision. I would wait until this is all over before trying.
Geoff Sher
Hi Dr. Sher,
I’d greatly appreciate your thoughts on my situation:
39 y/o healthy woman with cycle day two estradiol 31, fsh 5.3, AMH 5.3ng/ml, other normal standard pre IVF lab tests and screening USG showing good antral follicle count as per RE.
History of 3 IUIs- 3rd IUI resulting in pregnancy that was miscarried at 4 weeks post IUI.
My first IVF stim cycle looked like this:
Gonal F 150U and Menopur 3 vials (225 U) from stim days 1-8 +
Omnitrope 25 U on alternate days- Day 1,3,5,7,9 (total 5 doses)
Ganirelix 250 mcg on days 6,7,8,9,10
Lupron on day 9 + novarel 1666U (for novarel I was instructed to mix 3ml water in 5000U novarel vial- then withdraw and inject 1ml)
letrozole 2.5 mg po tab and bromocriptine 2.5 mg vaginal tab started days 9,10 and post retrieval
doxycycline 100mg tab night of day 10
retrieval was on day 11 – 36 hrs after trigger
My day 9 estradiol was 3766
on day 9 USG, RE had visualized 40 follicles, on day 11 retrieved 19/40, noted 10/19 were mature, 8/10 fertilized with ICSI, 5/8 made it to day 5 and day 6 blastocysts
cyro report on day 6 showed 3B-B-, 6BB, 3BB-, CBF, 3B-B-
Genetic testing
1. complex abnormal -16 -22 Male
2. complex abnormal -4q -6 Male
3. complex abnormal -18 -20 XO —
4. complex abnormal -11 -15q -16 Male
5. complex abnormal -19 +21 -22 Male
My RE who was very optimistic till PGTA results arrived, now wants me to be mentally prepared for further disappointments down the road and alluded that having 5/5 complex abnormal on PGTA portends an unfavourable genetic profile in future testings as well. I have therefore been asked to have an open mind about egg donation. I’m to start a second cycle of stim next month.
1. I’m left wondering if all of the complex abnormals boil down to my egg quality being bad vs the possibility of using low dose trigger shot.
2. Does having 5/5 complex abnormal blastocysts in round 1 indeed suggest a lower probability of having future genetically normal blastocysts?
3. How would you alter this regimen to maximize chances of having atleast one PGTA normal blastocyst without a significant risk of OHSS?
I would like to prepare for the worst and hope for the best.
Thanks,
CV
1. I’m left wondering if all of the complex abnormals boil down to my egg quality being bad vs the possibility of using low dose trigger shot.
A: I would need a great deal more information to respond with full confidence.
2. Does having 5/5 complex abnormal blastocysts in round 1 indeed suggest a lower probability of having future genetically normal blastocysts?
A: I personally do not believe so. In my opinion, this has to do with establishing a deliacte balance during ovarian stimulation in someone like you who over-responds.
3. How would you alter this regimen to maximize chances of having atleast one PGTA normal blastocyst without a significant risk
of OHSS?
This is right up my alley but we will need to discuss.
Severe ovarian hyperstimulation syndrome (OHSS) is a life-endangering complication that occurs in some women undergoing controlled Ovarian Stimulation (COS). OHSS is often accompanied by a profound reduction in egg “competency” and on fertilization often yield an inordinately high percentage of “incompetent” embryos which have a reduced potential to propagate viable pregnancies.
Concern that a patient will develop of OHSS often leads the treating RE to take measures aimed at reducing the risk of this life-endangering condition. One such measures is to “trigger” egg maturation prematurely in the hope of arresting further follicular growth and the other, is to initiate the “trigger” with a reduced dosage of hCG (i.ed. 5,000U rather than the usual 10,000U of of Pregnyl/Profasi/Novarel, to use or 250mcg rather than 500mcg of Ovidrel or to supplant the hCG “trigger” with a Lupron “trigger” which causes a prompt LH surge from the woman’s pituitary gland to take place. While such measures do indeed reduce the risk of OHSS to the mother, this often comes at the expense of egg quantity and “competency”. Fewer than the anticipated number of eggs are harvested and those that are retrieved are far more likely to be “immature” and chromosomally abnormal (aneuploid”), or “immature” , thereby significantly compromising IVF outcome.
Against this background, It is my considered opinion that when it comes to performing IVF in women at risk of developing OHSS, the most important consideration must be the selection and proper implementation of an individualized or customized ovarian stimulation protocol. Thereupon, rather than prematurely initiating the “trigger” to arrest further follicle growth, administering a reduced dosage of hCG or “triggering with a GnRH agonist (e.g. Lupron/Buserelin) that can compromise egg “competency”….. use of one of the following techniques will often markedly reduce the risk of OHSS while at the same time protecting egg quality:
1.PROLONGED COASTING (PC): OHSS can be a life-endangering complication of ovarian stimulation with gonadotropins. The risk of OHSS begins with the hCG “trigger”. The complication occurs in very high responders to gonadotropin stimulation. Women with PC0S, irregular cycles and AMH levels that are X3 the normal are at the greatest risk of developing OHSS. In such patients, ovarian stimulation commences with the same approach as above (using a BCP launch and an agonist (e.g Lupron/buserelin/Superfact/aminopeptidyl) overlap. Only in such patients a very low dosage regime of FSHr /menotropin isused . Then, starting on day 7 of ovarian stimulation, serial daily blood estradiol (E2) and ultrasound follicle assessments are done to track follicle development and [E2]. If there are > 25 follicles, gonadotropin stimulating continues, regardless of the [E2]. As soon as 50% of all follicles reach 14mm and the [E2] exceeds 2,500pg/ml gonadotropin stimulation id abruptly stopped, while daily agonist injections continue. Daily blood [E2 ] is tracked, (without necessarily continuing serial ultrasound follicle measurements). The [E2] will almost invariably continue to rise for a few days whereupon it will begin to, drop. As soon as the [E2] drops below 2,500pg/ml, a “trigger” shot of 10,000U hCGu or hCGr is administered and an egg retrieval is performed 36 hours later. At this point, All mature (MII) eggs are either cryobanked (vitrified) or (as is far more commonly the case), are fertilized by intracytoplasmic Sperm Injection (ICSI) and are then cultured for 5-6 days to the blastocyst stage whereupon they are either biopsied for preimplantation genetic screening and then cryopreserved (vitrified) for future use vitrified without prior biopsy for PGS or e transferred fresh, to the uterus during the same cycle of treatment. The outcome of PC depends on the precise timing of the initiation and conclusion of “prolonged coasting”. If you start PC too early, follicle growth will arrest, and the cycle will be lost. Conversely, if you start too late, you will encounter too many post-mature/cystic follicles (>22mm) that usually harbor abnormally developed eggs. Use of “Coasting” avoids severe OHSS, and minimizes the risk of poor egg/embryo quality in a group of women who otherwise would be at severe risk of life-endangering complications and prone to producing a high percentage of “incompetent” eggs/embryos.
2.EMBRYO FREEZING AND DEFERMENT OF EMBRYO TRANSFEDR (ET): OHSS is always a self-limiting condition. In the absence of continued exposure to hCG, symptoms and signs as well as the risk of severe complications will ultimately abate. Thus, in the absence of pregnancy, all symptoms, signs and risks associated with OHSS will disappear within about 10-14 days of the hCG trigger. Conversely, since early pregnancy is always accompanied by a rapid and progressive rise in hCG , the severity of OHSS will increase until about the 9th or tenth gestational week whereupon a transition from ovarian to placental hormonal dominance occurs, the severity of OHSS rapidly diminishes and the patient will be out of risk. Accordingly, in cases where in spite of best effort to prevent OHSS, the woman develops symptoms and signs of progressive overstimulation prior to planned ET, all the blastocysts should be vitrified and cryostored for FET in a subsequent hormone replacement cycle. In this way women with OHSS can be spared the risk of the condition spiraling out of control.
I strongly recommend that you visit http://www.DrGeoffreySherIVF.com . Then go to my Blog and access the “search bar”. 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.
·The IVF Journey: The importance of “Planning the Trip” Before Taking the Ride”
·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
·Use of GnRH Antagonists (Ganirelix/Cetrotide/Orgalutron) in IVF-Ovarian Stimulation Protocols.
·Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
·Egg Maturation in IVF: How Egg “Immaturity”, “Post-maturity” and “Dysmaturity” Influence IVF Outcome:
·Commonly Asked Question in IVF: “Why Did so Few of my Eggs Fertilize and, so Many Fail to Reach Blastocyst?”
·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?
·Taking A Fresh Look at Ovarian Hyperstimulation Syndrome (OHSS), its Presentation, Prevention and Management
·Preventing Severe Ovarian Hyperstimulation Syndrome (OHSS) with “Prolonged Coasting”
·Understanding Polycystic Ovarian Syndrome (PCOS) and the Need to Customize Ovarian Stimulation Protocols.
·“Triggering” Egg Maturation in IVF: Comparing urine-derived hCG, Recombinant DNA-hCG and GnRH-agonist:
·The “Lupron Trigger” to Prevent Severe OHSS: What are the Pro’s and Con’s?
•.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.
•Implications of “Empty Follicle Syndrome and “Premature Luteinization”
•Premature Luteinization (“the premature LH surge): Why it happens and how it can be prevented.
•Preventing Severe Ovarian Hyperstimulation Syndrome (OHSS) with “Prolonged Coasting”
______________________________________________________
ADDENDUM: PLEASE READ!!
INTRODUCING SHER FERTILITY SOLUTIONS (SFS)
Founded in April 2019, Sher Fertility Solutions (SFS) offers online (Skype/FaceTime) consultations to patients from > 40 different countries. All consultations are followed by a detailed written report presenting my personal recommendations for treatment of what often constitute complex Reproductive Issues.
Patients are encouraged to share the information I provide, with their treating Physicians and/or to avail themselves of my personal hands-on services, provided through batched IVF cycles that I conduct every 3 months at Los Angeles IVF (LAIVF) Clinic, Century City, Los Angeles, CA.
If you wish to schedule an online consultation with me, please contact my assistant (Patti Converse) by phone (800-780-7437/702-533-2691), email (concierge@SherIVF.com) or, enroll online on then home-page of my website (www.SherIVF.com).
PLEASE SPREAD THE WORD ABOUT SFS!
Geoff Sher
Dr. Sher, I just did my 2nd Day 3 transfer with 2 embryos and again, they failed to implant. The first time both had 7 cells, this time I had a compounding 8 cell and an 8 cell. I have 3 more blasts that were frozen 2 of grade A quality and one BB. I feel like we are wasting my embryos each try we do.
What tests can we do to figure out the implant issue? Or is this an egg quality issue?
Should I do another cycle before trying to implant the blasts as I’m already 38? I’m afraid the blasts will fail and we wanted multiple children.