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
My wife had an et done on Saturday March 7 and had her first blood test done 9 days later on Monday, March 16. The first HCG was 30. It was repeated 2 days later and it was 79. She is going to have another blood test done tomorrow but I was wondering if you had any thoughts in the meantime, Thanks so much!
Looks quite promising!
Have an US done in abour 2.5 weeks for a definitive answer.
Geoff Sher
Hello Dr. Sher,
I am 41 years old and have been trying to conceive for 3 years. We have spent the last 2 years consulting with fertility clinics. Four RE in total. I have a thin lining which has been a constant battle.
Two RE did not think I would be able to conceive with such a thin lining. In 2018; I had a chemical pregnancy from an IUI which was probably due to the thin lining. My lining the day of IUI was 4.3mm; progesterone was not started until after the positive Beta. This was done with one of the RE who summarized my case as “you will probably never be able to conceive with such a thin lining”
In 2019; I switched doctors and completed 1 round of IVF which resulted in 2 PGS normal embryos.
I also had an ERA last year before attempting a frozen transfer cycle. It indicated + receptivity after 6 doses of progesterone. For the last year, I have had 3 cancelled FET attempts due to a lining of 5mm or less. This current cycle Viagra vaginal suppositories four times daily were started as part of the protocol. They were started on cycle day 3 for a total of 14 days (as of today). I am also taking Estradiol Valerate 0.25mg IM every 3 days and Aspirin 81mg daily. Final lining check today was 4.5mm with trilaminar layers. My estrogen today is 943; progesterone 0.22
It does not appear that my lining will thicken with any protocol. We are now left with the choice of
1. “Trying” to transfer an embryo with a lining of 5mm or less OR
2. Looking into a gestational carrier for the embryos
If opting for choice 1; I would start progesterone tonight for a transfer next week.
I have read your research on Viagra to possibly thicken the uterine lining. I am obviously in that small % that did not respond. My questions for your are:
1. Have you seen a successful pregnancy with a lining of 5 or less?
2. Have all avenues been explored or should I look into another opinion ?
3. Are there any additional studies or protocol you would recommend?
Thank you for your time and reading.
If the proper administration of Viagra with estrogen did not improve the lining, then in my opinion, nothing is likely to do so and you need a gestational carrier. Anything else would be wasteful of your embryos.
Sorry!
Geoff Sher
Hi I am 29 and I have lost twins babies bcoz of miscarriage in 4th month in Dec 2019. I have infertility issue with low AMH so doctor suggested me for the ivf with donor egg. Also suggested for FET it was successful in 1st cycle. But unfortunately in 4th month bleeding started. And after stitches my water bag suddenly leaked. Dr. Said my uterus is very delicate can’t capable for the twin babies. Hence it is happened. Then we decided to take another chance for FET. Now my Dr. Is doing the different thing rather than did earlier. As my last period came in 28feb 19. Then she given me estradiol tablet to thicken the endometrium lining. After every 5days she ask to come for scan and increases my estrodial tablet. Again she asked me to come on 21th Feb for scan. Still she not declared there transfer date. I am scared as my menstrual date is 28th. And my cycle is very short 26 to 27 days. Can you pls suggest as she is making me fool or taking the good decision.
Respectfully, this is a very long duration on estrogen. There could be something else going on, but to try and get to the bottom of what this could be, I would need much more information. I suggest you call my assistant, Patti at 702-533-2691 and set up an online consultation with me to discuss in detail.
Good luck!
Geoff Sher
Good morning, Dr Sher. 4 years ago, whe I was 37 I decided to do an egg collection with the aim of being a mum later. my AMH was 21, I had 9 healthy eggs and I defroze them last year (only 5). I got pregnant but sadly I lost the baby with 8 weejs. I still hae 4 eggs from that occasion but I decided to go through the egg colelction again in order to have a plan B.I have gone to the same clinic. New doctor. I cant remember the medication last time, but it worked really well. This time they have checked the AMH and it has decreased to 3.2 which is low but it is within my age range. I used the max dose of MERIOFERT (450) and CETOCIDE since day 6 of my period. When they explained the medication to me, the nurse was extremely surprised to see that for the trigger 36h prior to the egg collection, they had decided to introduce the busereline. Then I thought something was not right as when the coordinator of the egg collection phoned me in order to arrange my appointment, she showed real surprise when se heard the busereline drug as well. I started becoming very suspicious. I had the scan on Monday and they were surprised as my body had follicles of really good size and my body had reacted really well to the medication. Yesterday i did the egg collection and the doctor who did the egg collection came and said that they didnt retrieve any egg. Nothing, she was surprised as well with the medication but I reckon she wanted to protect her colleague. She was surprised as she didnt find anything in the follicle, not even tissue that you normally see even if there is no egg. She was surprised that, based on the size of the follicles NONE of them had anything. I am really suspicious. I am very healthy, never had any problem with my periods or anything related and all of my tests have been ok so far. i have a meeting with them tomorrow as I am goig to challege the medication, especially when the doctor who performed the collection yesterday said that it is extremely rare that no tissue was even flushed in the follicle. It is very strange that this happens, she said. Based on the fact that I had a good response some years ago, i assume that my follicles would have eggs,….perhaps eggs with lower quality but eggs there. And there was absolutely nothing there. Is this normal? THANK YOU
Perhaps we should talk. I suggest you call my assistant, Patti Converse at 702-533-2691 and set up an online consultation to discuss in detail. In the interim, please consider the following:
Ideal egg development sets the scene for optimal egg maturation that occurs 36-42h prior to ovulation or egg retrieval. Without prior optimal egg development (ovogenesis), egg maturation will be dysfunctional and most eggs will be rendered “incompetent” and unable upon fertilization to propagate viable embryos. In IVF, optimal ovogenesis requires the selection and implementation of an individualized approach to controlled ovaria stimulation (COS). Thereupon, at the ideal time, maturational division of the egg’s chromosomes (i.e. meiosis) is “triggered” through the administration of hCG or an agonist such as Lupron, which induces an LH surge. The, dosage and timing of the “trigger shot” profoundly affects the efficiency of meiosis, the potential to yield “competent (euploid) mature (M2) eggs, and as such represents a rate limiting step in the IVF process .
“Triggering meiosis with Urine-derived (hCGu-Pregnyl/Profasi/Novarel) versus recombinant hCG-(hCGr-Ovidrel):
Until quite recently, the standard method used to “trigger” egg maturation was through the administration of 10,000 units of hCGu. Subsequently,, a DNA recombinant form of hCGr (Ovidrel)was introduced and marketed in 250 mcg doses. But clinical experience strongly suggests that 250 mcg of Ovidrel is most likely not equivalent in biological potency to 10,000 units of hCG. It probably only has 50%-70%of the potency of a 10,000U dose of hCGu and as such might not be sufficient to fully promote meiosis, especially in cases where the woman has numerous follicles. For this reason, I firmly believe that when hCGr is selected as the “trigger shot” the dosage should best be doubled to 500 mcg at which dosage it will probably have an equivalent effect on promoting meiosis as would 10,000 units of hCGu. Failure to “trigger” with 10,000U hCGu or 500mcg hCGr, will in my opinion increase the likelihood of disorderly meiosis, “incompetent (aneuploid) eggs” and the risk of follicles not yielding eggs at egg retrieval (“empty follicles”). Having said this, it is my personal opinion that it is unnecessary to supplant hCGu with hCGr since the latter is considerably more expensive and is probably no more biopotent than the latter.
Using a GnRHa (Lupron/Buserelin/aminopeptidyl/Superfact/Supercur) for the “Trigger”:
Some clinicians, when faced with a risk of OHSS developing will deliberately elect to reduce the dosage of hCG administered as a trigger in the hope that by doing so the risk of critical OHSS developing will be lowered. It is my opinion, that such an approach is not optimal because a low dose of hCG (e.g., 5000 units, hCGu or 250mcg hCGr) is likely inadequate to optimize the efficiency of meiosis particularly when it comes to cases such as this where there are numerous follicles. It has been suggested that the preferential use of a GnRHa trigger” in women at risk of developing severe ovarian hyperstimulation syndrome could potentially reduce the risk of the condition becoming critical and thereby placing the woman at risk of developing life-endangering complications. It is with this in mind that many RE’s prefer to trigger meiosis by way of an “agonist (Lupron) trigger rather than through the use of hCG. The agonist promptly causes the woman’s pituitary gland to expunge a large amount of LH over a short period of time and it is this LH “surge” that triggers meiosis. The problem with using this approach, in my opinion, is that it is hard to predict how much LH will be released in by the pituitary gland. For this reason, I personally prefer to use hCGu for the trigger, even in cases of ovarian hyperstimulation hyperstimulated, with one important proviso…that being that is she underwent “prolonged coasting” in order to reduce the risk of critical OHSS, prior to the 10,000 unit hCGu “ trigger”.
Triggering with a combination of a GnRHa + a small dosage of hCG is often a good compromise, but in my opinion is not as good as using hCG alone in the proper dosage, provided that a) coasting is used (if needed) and that in cases suspected of overstimulation, all embryos are frozen for subsequent dispensation and are NOT transferred during the “fresh” cycle.
Until we talk…
Good luck and G-d bless!
Geoff Sher
The timing of the “trigger shot “to initiate meiosis: This should coincide with the majority of ovarian follicles being >15 mm in mean diameter with several follicles having reached 18-22 mm. Follicles of larger than 22 mm will usually harbor overdeveloped eggs which in turn will usually fail to produce good quality eggs. Conversely, follicles less than 15 mm will usually harbor underdeveloped eggs that are more likely to be aneuploid and incompetent following the “trigger”.
Buenos días. Hace 4 años y medio, con 37 años,decidí sacarme ovulos con el fin de ser madre más adelante.Todo fue perfecto,mi AMH era de 21 y saqué 9 ovulos en perfecto estado. Los congelé y el año pasado me quedé embarazada pero desgracia perdí el bebé al de 8 semanas. Tengo aun 4 ovulos de esa ocasión, pero decidí volver a sacarme los ovulos como plan B para un futuro. He ido a la misma clínica, pero mi doctor es otro. Me cambio la medicación a meriofert (Max dosis a 450) y cetodine. Mi amh ha decrecido a 3,2 debido a mi edad. Para el trigger,36 horas antes me puso busereline….pero la reacción de la coordinadora de la extracción y la enfermera cuando vieron que el doctor me había puesto busereline fue muy llamativa,ya que se sorprendieron mucho. Ahí pensé que algo iba mal. Ayer me hice la extracción de los ovulos y aunque aperntemente la respuesta de mi cuerpo (dijeron que era maravilloso cómo mi cuerpo había respondido aparentemente a la medicación) y número de folículos con un buen tamaño era bueno, no consiguieron sacar ningún ovulo. Es más, la médico que hizo la extracción estaba asustada de que ni siquiera hubiese tejido en el folículo. Nada de nada. Incluso ella se sorprendió de que hubiese usado busereline. Me dijo que es extraño no tener nada de nada en el folículo, en ninguno? Voy a poner una queja porque sé que algo ha cambiado en el protocolo y ha afectado a la producción de ovulos. Quiero saber si hay razones para pensar que algo ha ocurrido para que mi cuerpo no haya producido ningún ovulo. Tengo reglas súper regulares, una persona súper sana y súper deportista. Gracias
Please translate into English!
Geoff Sher