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.
Dear Doctor Sher,
I’m 39 years old. My husband was diagnosed with oligoasthenoteratozoospermia and AZF c deletion Y chromosome . We made so far 2 failed IVF cycles. During my first IVF cycle ( micro flare protocol : Diphereline – day 2 of menstrual cycle, gonal :150 UI and Menopur 150 UI – day 6 of menstrual cycle with tapering doses based on ultrasounds and test lab results) we had 8 eggs, 3 embryos (no so good quality) , BFP and miscarriage at 7 weeks (aneuploidy). The second IVF cycle ( with same protocol) we had 2 egg, 1 poor quality embryo and no pregnancy. My AMH level is 1,38 ng/ml.
We prepare for our 3-th IVF cycle. The doctor recommend me antagonist protocol ( menopur and orgalutran ). This time we will do IVF with donor sperm.
What is your opinion regarding this protocol? Do you thing that it is an appropriate protocol for me? Can I hope for better quality embryos?
Thank a lot!
Anna
Older women as well as those who (regardless of age) have diminished ovarian reserve (DOR) tend to produce fewer and less “competent” eggs, the main reason for reduced IVF success in such cases. The compromised outcome is largely due to the fact that such women tend to have increased LH biological activity which often results in excessive LH-induced ovarian testosterone production which in turn can have a deleterious effect on egg/embryo “competency”.
Certain ovarian stimulation regimes either promote excessive LH production (e.g. short agonist/Lupron- “flare” protocols, clomiphene and Letrozole), augment LH/hCG delivered through additional administration (e.g. high dosage menotropins such as Menopur), or fail to protect against body’s own/self-produced LH (e.g. late antagonist protocols where drugs such as Ganirelix/Cetrotide/Orgalutron that are first administered 6-7 days after ovarian stimulation has commenced). I try to avoid using such protocols/regimes (especially) in older women and those with DOR, favoring instead the use of a modified, long pituitary down-regulation protocol (the agonist/antagonist conversion protocol-A/ACP) augmented by adding supplementary human growth hormone (HGH). I further recommend Staggered IVF with embryo banking of PGS (next generation gene sequencing/NGS)-normal blastocysts in such cases. This type of approach will in my opinion, optimize the chance of a viable pregnancy per embryo transfer procedure and provide an opportunity to capitalize on whatever residual ovarian reserve and egg quality still exists, allowing the chance to “make hay while the sun still shines”.
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 Aproach
•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.
•Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
•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
•Why did my IVF Fail
•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 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?
•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
•IVF Egg Donation: A Comprehensive Overview
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
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
I’m 38 years old with a AMH of 6.3 and a recent miscarriage from an IUI. I just had my retrieval for IVF 2 days ago and am very disappointed with my results. I had 14 eggs retrieved but found out yesterday that only 9 were mature – and of those 9 only 5 fertilized with ICSI (we have no known sperm issues). My last ultrasound before retrieval showed 13 follicles between 16mm and 19mm plus a few at 13, 12 and 11. I took birth control for two weeks before starting 75 Menopure and 225 gonal F. How did I go from 14 to 5 and what would you change next time? Should I do another IVF cycle back to back or wait? Did they trigger me too early? Thx!
Should have also mentioned that I triggered with Gainrelix
In my opinion this could well have to do with the protocol used for ovarian stimulation and its implementation, including the timing and method used for “triggering”.
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.
•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 Aproach
•Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
•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
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF
Please call or email Julie Dahan, my patient concierge. She will guide you on how to set up an in-person or Skype consultation with me. You can reach Julie at on her cell phone or via email at any time:
Julie Dahan
•Email: Julied@sherivf.com
•Phone: 702-533-2691
?800-780-7437
Geoff Sher
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.
Hi,
In 2013 I was diagnosed with endometriosis and PCOS During a laparoscopy. The endometriosis was lasered away. It’s been three years since treating the endometriosis. Iv also taken metformin for the pcos. We’re now looking at IVF funding. My husband has also been diagnosed with unexplained azoospermia his fh levals are normal so they suspect that the azoospermia is down to a blockage. Going back to the endometriosis I watched a video you recorded explaining about the killer cells that develops after endometriosis is finally discovered. I’m 28 years old is there anything I could do to help the process of having a baby? Naturally for us it’s impossible the only way we will convince would be through IVF. I take folic acid every month and every 2-3 months have ovulation pain on my right side (this only ever occurs on my right side).
Clearly endometriosis does not preclude natural pregnancy BUT it does reduce the likelihood greatly. And, the coexistence of an immunologic implantation dysfunction reduces that possibility even more. Besides, given your husband’s probable obstructive azoospermia, Testecular Sperm aspiration and intracytoplasmic sperm injection is mandatory and that of course means IVF.
Endometriosis is a condition that occurs when the uterine lining (endometrium) grows not only in the interior of the uterus but in other areas, such as the fallopian tubes, ovaries and the bowel. Endometriosis is a complex condition where, the lack or relative absence of an overt anatomical barrier to fertility often belies the true extent of reproductive problem(s).
All too often the view is expounded that the severity of endometriosis-related infertility is inevitably directly proportionate to the anatomical severity of the disease itself, thereby implying that endometriosis causes infertility primarily by virtue of creating anatomical barriers to fertilization. This over-simplistic and erroneous view is often used to support the performance of many unnecessary surgeries for the removal of small innocuous endometriotic lesions, on the basis of such “treatment” evoking an improvement in subsequent fertility.
It is indisputable that even the mildest form of endometriosis can compromise fertility. It is equally true that, mild to moderate endometriosis is by no means a cause of absolute “sterility”.
Rather, when compared with normally ovulating women of a similar age who do not have endometriosis, women with mild to moderate endometriosis are about four to six times less likely to have a successful pregnancy.
Endometriosis often goes unnoticed for many years. Such patients are frequently, erroneously labeled as having “unexplained infertility”, until the diagnosis is finally clinched through direct visualization of the lesions at the time of laparoscopy or laparoscopy. Not surprisingly, many patients with so called “unexplained” infertility, if followed for a number of years, will ultimately reveal endometriosis.
Women who have endometriosis are much more likely to be infertile. There are several reasons for this:
•First-Ovulation Dysfunction: In about 25 – 30% of cases, endometriosis is associated with ovulation dysfunction. Treatment requires controlled ovarian stimulation (COS). The problem is that the toxic pelvic environment markedly reduces the likelihood that anything other than IVF will enhance pregnancy potential.
•Second- Toxic Pelvic environment that compromises Fertilization Endometriosis is associated with the presence of toxins in peritoneal secretions while it is tempting to assert that normally ovulating women with mild to moderate endometriosis would have no difficulty in conceiving if their anatomical disease is addressed surgically or that endometriosis-related infertility is confined to cases with more severe anatomical disease…nothing could be further from the truth. The natural conception rate for healthy ovulating women in their early 30’s (who are free of endometriosis) is about 15% per month of trying and 70% per year of actively attempting to conceive. Conversely, the conception rate for women of a comparable age who have mild or moderate pelvic endometriosis (absent or limited anatomical disease) is about 5-6% per month and 40% after 3 years of trying. As sperm and egg(s) travel towards the fallopian tubes they are exposed to these toxins which compromise the fertilization process. In fact it has been estimated that there is a 5-6 fold reduction in fertilization potential because of these toxins which cannot be eradicated. Frankly, it really does not matter whether an attempt is made to remove endometriosis deposits surgically as this will not improve pregnancy potential. The reason is that for every deposit observed, there are numerous others that are in the process of developing and are not visible to the naked eye and whether visible or not, such translucent deposits still produce toxins. This also explains why surgery to remove visible endometriosis deposits, controlled ovarian stimulation with or without intrauterine insemination will usually not improve pregnancy potential. Only IVF, through removing eggs before they are exposed to the toxic pelvic environment, fertilizing them in-vitro and then transferring the embryos to the uterus represents the only way to enhance pregnancy potential.
•Third-Pelvic adhesions and Scarring: In its most severe form, endometriosis is associated with scarring and adhesions in the pelvis, resulting in damage to, obstruction or fixation of the fallopian tubes to surrounding structures, thereby preventing the union of sperm and eggs.
•Fourth-Ovarian Endometriomas, Advanced endometriosis is often associated with ovarian cysts (endometriomas/chocolate cysts) that are filled with altered blood and can be large and multiple. When these are sizable (>1cm) they can activate surrounding ovarian connective tissue causing production of excessive male hormones (androgens) such as testosterone and androstenedione. Excessive ovarian androgens can compromise egg development in the affected ovary (ies) resulting in an increased likelihood of numerical chromosomal abnormalities (aneuploidy) and reduced egg/embryo competency”. In my opinion large ovarian endometriomas need to be removed surgically or rough sclerotherapy before embarking on IVF.
•Fifth- Immunologic Implantation Dysfunction (IID). Endometriosis, regardless of its severity is associated with immunologic implantation dysfunction linked to activation of uterine natural killer cells (NKa) and cytotoxic uterine lymphocytes (CTL) in about 30 of cases. This is diagnosed by testing the woman’s blood for NKa using the K-562 target cell test or by endometrial biopsy for cytokine analysis, and, for CTL by doing a blood immunophenotype. These NKa attack the invading trophoblast cells (developing “root system” of the embryo/early conceptus) as soon as it tries to gain attachment to the uterine wall. In most cases, this results in death of the embryo even before the pregnancy is diagnosed and sometimes, in a chemical pregnancy or even an early miscarriage. . As such, many women with endometriosis, rather than being infertile, in the strict sense of the word, often actually experience repeated undetected “mini-miscarriages”.
Advanced Endometriosis: In its most advanced stage, anatomical disfiguration is causally linked to the infertility. In such cases, inspection at laparoscopy or laparoscopy will usually reveal severe pelvic adhesions, scarring and “chocolate cysts”. However, the quality of life of patients with advanced endometriosis is usually so severely compromised by pain and discomfort, that having a baby is often low on the priority list. Accordingly, such patients are usually often more interested in relatively radical medical and surgical treatment options (might preclude a subsequent pregnancy), such as removal of ovaries, fallopian pubis and even the uterus, as a means of alleviating suffering.
Moderately Severe Endometriosis. These patients have a modest amount of scarring/ adhesions and endometriotic deposits which are usually detected on the ovaries, fallopian tubes, bladder surface and low in the pelvis, behind the uterus. In such cases, the fallopian tubes are usually opened and functional.
Mild Endometriosis: These patients who at laparoscopy or laparotomy are found to have no significant distortion of pelvic anatomy are often erroneously labeled as having “unexplained” infertility. To hold that the there can only infertility can only be attributed to endometriosis if significant anatomical disease can be identified, is to ignore the fact that, biochemical, hormonal and immunological factors profoundly impact fertility. Failure to recognize this salient fact continues to play havoc with the hopes and dreams of many infertile endometriosis patients.
TREATMENT:
The following basic concepts apply to management of endometriosis-related infertility:
1.Controlled Ovulation stimulation (COS) with/without intrauterine insemination (IUI): Toxins in the peritoneal secretions of women with endometriosis exert a negative effect on fertilization potential regardless of how sperm reaches the fallopian tubes. This helps explain why COS with or without IUI will usually not improve the chances of pregnancy (over no treatment at all) in women with endometriosis. IVF is the only way by which to bypass this problem.
2.Laparoscopy orLaparotomy Surgery aimed at restoring the anatomical integrity of the fallopian tubes does not counter the negative influence of toxic peritoneal factors that inherently reduce the chances of conception in women with endometriosis four to six fold. Nor does it address the immunologic implantation dysfunction (IID) commonly associated with this condition. Pelvic surgery is relatively contraindicated for the treatment of infertility associated with endometriosis, when the woman is more than 35 years of age. With the pre-menopause approaching, such women do not have the time to waste on such less efficacious alternatives. In contrast, younger women who have time on their side might consider surgery as a viable option. Approximately 30 -40 percent of women under 35 years of age with endometriosis will conceive with in two to three years following corrective pelvic surgery.
3.Sclerotherapy for ovarian endometriomas.: About 10 years ago I introduced “sclerotherapy”, a relatively non-invasive, safe and effective outpatient method to permanently eliminate endometriomas without surgery being required. Sclerotherapy for ovarian endometriomas involves needle aspiration of the liquid content of the endometriotic cyst, followed by the injection of 5% tetracycline into the cyst cavity. Treatment results in disappearance of the lesion within 6-8 weeks, in more than 75% of cases so treated. Ovarian sclerotherapy can be performed under local anesthesia or under general anesthesia. It has the advantage of being an ambulatory office- based procedure, at low cost, with a low incidence of significant post-procedural pain or complications and the avoidance of the need for laparoscopy or laparotomy
4.The role of selective immunotherapy Women with antiphospholipid antibodies (APA’s) experience improved IVF birth rates when heparinoids (Clexane/Lovenox) is administered from the onset of ovarian stimulation with gonadotropins until the 10th week of pregnancy.
a.About Intralipid (IL) and steroid therapy: Intralipid (IL) is a solution of small lipid droplets suspended in water. When administered intravenously, IL provides essential fatty acids, linoleic acid (LA), an omega-6 fatty acid, alpha-linolenic acid (ALA), an omega-3 fatty acid.IL is made up of 20% soybean oil/fatty acids (comprising linoleic acid, oleic acid, palmitic acid, linolenic acid and stearic acid) , 1.2% egg yolk phospholipids (1.2%), glycerin (2.25%) and water (76.5%).IL exerts a modulating effect on certain immune cellular mechanisms largely by down-regulating activated natural killer cells (NKa). This effect is enhanced through the concomitant administration of corticosteroids such as dexamethasone, prednisone, and prednisolone which enhance the therapeutic effect by suppressing cytotoxic/activated T-lymphocytes (CTL). This effect of IL might is likely due to its ability to
5. In vitro fertilization is the treatment of choice for women with endometriosis. This is especially true for women more than 35 years of age or where surgery and treatment with fertility agents has proven to be unsuccessful. We anticipate that approximately 75 percent of such women will achieve the birth of one or more babies within three IVF attempts performed at SIRM.
6.
?suppresses pro-inflammatory cellular (Type-1) cytokines such as interferon gamma and TNF-alpha. In-vitro testing has shown that IL successfully and completely down-regulates activated natural killer cells (NKa) within 2-3 weeks in 78% of women experiencing immunologic implantation dysfunction. In this regard it is just as effective as Intravenous Gamma globulin (IVIg) but at a fraction of the cost and with a far lower incidence of side-effects. Its effect lasts for 4-9 weeks when administered in early pregnancy.
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.
•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 Aproach
•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.
•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?
•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!
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF
Please call or email Julie Dahan, my patient concierge. She will guide you on how to set up an in-person or Skype consultation with me. You can reach Julie at on her cell phone or via email at any time:
Julie Dahan
•Email: Julied@sherivf.com
•Phone: 702-533-2691
?800-780-7437
Geoff Sher
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
I am 45 and trying to conceive. I have 2 children already 12 and 19 from a previous relationship. My husband (40years old) has no children and we would love to have a baby. I fell pregnant naturally 8 months ago but miscarried at 8 weeks. We tried one cycle of IVF which failed. We have decided to just try again naturally. My question is – does it give us a greater chance of conceiving because I already have 2 children? Also, I am taking prenatal vitamins, eating healthy and exercising everyday – is there annoying else I can do to increase our chances?
HiKisa,
Of course having had babies before makes you as fertile as a woman of 45 can be…but alas that does mean that you are likely to be successful. The reason is that at b45y of age about 90-95% of you eggs will be chromosomally abnormal and thus highly unlikely to propagate a viable pregnancy. Of course you can try on your own, but even IVF (unless donor egg is used) is very unlikely to succeed….sorry!
More and more women are deciding based upon personal preference and professional necessity, to postpone having a family to a later age. In fact, very recently, Janet Jackson (49Y) was in the news stating that she was cancelling her tour to prepare for treatment needed to have a baby. This prompted me to write this article on IVF in women of more advanced age.
The truth is that hardly a day goes by when I am not asked the question of “How old is too old to do IVF? The standard answer is that for women under 43Y provided that they have an adequate number of eggs (ovarian reserve) IVF with own eggs is definitely an option. After 43y the percentage chance that an IVF cycle (where the woman uses her own eggs) will result in a live birth, declines to the single digit range and after age 45Y it falls to well under 5% per cycle, making the use of an egg donor, the only rational choice.
Any decision of when/ whether a woman’s age should affect a medical decision on whether or not to proceed to IVF, should also take into consideration: 1) the increasing incidence of pregnancy complications with advancing age 2) The risk to the baby k of poor intrauterine development and premature birth …both with their risks,3) ethical factors such as age and its effect on projected life span as well as the physical, emotional and financial ability to provide for the needs of the child.
BUT it is not as simple as that! I will never forget a couple that travelled from Munich Germany to consult with me re IVF with Egg Donation about 20 years ago. The lady, who will here be referred to as (JS) was 53 years of age and her husband (PL) was 44. At that time we had a general policy not treat women over 50 years of age. When I informed her of this, she became very agitated. She responded that she was in perfect health, while her husband suffered from moderately severe hypertension and type 2 diabetes. She asserted that had the ages been reversed (i.e. if she were 44Y and he, 53Y) we would never have rejected them. She went on to insist that the ruling amounted to sexual discrimination….and you know what? She was right! I suggested that the couple personally present their argument to our Ethics Advisory Board…which they did. The board authorized me to perform IVF with egg donation. I did so and subsequently transferred two embryos to PL’s uterus. She conceived and gave normal vaginal birth (at full term) to two healthy girls. I have since heard regularly from this couple, receiving family photographs, virtually every year. The two girls are now both in college in. Sadly PL passed away about 3 years ago and JS very recently got remarried. The new family is thriving.
Any woman, regardless of age, given access to “competent” eggs/embryos whether own egg or donor-derived, who has a receptive uterus (her own, or that of a gestational carrier), is, capable of achieving motherhood through IVF. This ability is of course predicated upon the patient having access to a full spectrum of options.
Herewith, a few basic considerations:
1.Access to at least one “competent” embryo. It is a fact that as women advance beyond their mid-thirties, both the number and chromosomal integrity of their eggs, will inevitably decline. At age 30Y about 1:2 are chromosomally numerically normal (euploid) and “competent”, upon fertilization to implant in the uterus and propagate healthy babies. By age 40Y about 1:6 eggs are euploid and by the 42nd year, only about 1:10 will be “competent”. By the time the woman reaches age 45, only about 1: 25 harvested eggs will be euploid
Simultaneously, as the woman reaches her 40’s, the number of eggs remaining in her ovaries (her ovarian reserve) will start to decline This diminishing ovarian reserve (DOR) will be reflected in her basal blood FSH level rising progressively and her blood antimullerian hormone (AMH) level dropping. What this means is that the woman’s pregnancy potential drastically declines as she emerges from her 30’s into her 40’s.
The combination of age-related egg “competency” and ovarian reserve is is defined as the “biological clock” By the time the average woman reaches 43y, both these component parts of the “biological clock” will usually have declined substantially such that after 43 years of age, she would be best advised to preferentially choose egg donation. The transfer of a single advanced embryo (blastocyst) to the uterus of a 43 year old woman, will likely yield less than a 10% chance of a baby. Conversely, a similar looking blastocyst found through chromosomal testing or PGS (using next generation Gene sequencing or NGS) to be euploid and “competent” could allow the same woman a 40-50% chance of a live birth. It thus follows that for women with such declining fertility potential, NGS embryo testing with “banking” (stockpiling) of several embryos over multiple IVF cycles will at the time of transfer to the uterus, dramatically improve the odds of success.
2.A receptive uterus: For an embryo to propagate a viable pregnancy the uterus needs to be as anatomically normal, its endometrial lining needs to develop normally in response to estrogen and any underlying immunologic implantation dysfunction must be identified and corrected. Conditions such as uterine fibroids and adenomyosis are more prevalent in older women. And post-menopausal women who are estrogen depleted will find their uteri shrinking and the endometrial lining becoming ever less responsive to estrogen. It is important in such cases to prescribe estrogen hormone replacement therapy for 2-3 months, prior to performing embryo transfer.
3.A healthy parturient, who is capable of carrying a baby to term. The Hippocratic Oath demands that physicians knowingly never put patients in harms way. Since pregnancy is inevitably associated with increasing maternal risk as the woman ages, it is important prior to embarking on fertility treatment in such cases, to perform a thorough physical examination and a barrage of tests that includes (but are not limited to) EKG; Chest X-ray; Blood chemistry (BUN, electrolytes, creatinine, liver enzymes, lipid profile, glucose etc..); mammogram and PAP smear. It is also important to explain to the patient/couple.
4.A medical and laboratory team with the necessary experience/expertise, and with ready access to the most advanced options such as:
a. Egg Donation
b.Gestational Surrogacy
c.Donor sperm (if needed)
d.Genetic embryo selection (using PGS)
e.Gestational surrogacy.
When it comes to a “cut off” for IVF eligibility, age is an important consideration and the risk/benefit of any particular course of treatment needs to be critically addressed with patients but there can in my opinion, not be any hard and fast rule. In the final analysis, each case must be considered on its own merit. As physicians we have the responsibility of providing patients with information needed to make a decision without imposing our will upon them.
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.
•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 Aproach
•Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
•IVF Egg Donation: A Comprehensive Overview
Please call or email Julie Dahan, my patient concierge. She will guide you on how to set up an in-person or Skype consultation with me. You can reach Julie at on her cell phone or via email at any time:
Julie Dahan
•Email: Julied@sherivf.com
•Phone: 702-533-2691
?800-780-7437
Geoff Sher
I have a unicornuate uterus. My current RE says the size is not really the issue but the shape of the uterus (it more canoe shaped rather than a triangle/pear). What kind of advanced FET protocal would you suggest? Last time we did Estradiol shots. My lining was about 7 or 8 at transfer. I thought we should have maybe waited a few more days before transfer. What about an endo scratch? I want to try all methods first before moving on to a gestational carrier. Also, does your clinic accept embryos?
The unicornuate uterus alone should not prevent you from carrying your own child. It would however be advisable to be checked for abnormalities of the kidneys and collecting system since there is an association between such uterine abnormalities and this. As for the precise protocol I would recommend…alas I cannot micromanage from here, but I will tell you that it needs to take into account that you developed an inadequate uterine lining. This must be evaluated and addressed too. Finally, your OB/GYN needs to assess the neck of your cervix to exclude cervical incompetence which can lead to mid-trimester miscarriages and which is associated with developmental uterine abnormalities such as a unicornuate uterus.
Please call or email Julie Dahan, my patient concierge. She will guide you on how to set up an in-person or Skype consultation with me. You can reach Julie at on her cell phone or via email at any time:
Julie Dahan
•Email: Julied@sherivf.com
•Phone: 702-533-2691
?800-780-7437
Geoff Sher