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 Dr Sher,
I hope this email finds you well and happy!
I am 41 and have completed one round of IVF with a donor sperm and I have 3 euploid embryos that have been cryopreserved.
I decided to undergo another round of IVF, to hopefully collect some further genetically balanced embryos and to try different sperm. I’ve since learned that there are donors that don’t simply donate for the money but in fact want to meet the offspring in the future and will welcome them into their families (in the UK, this is 18 years of age). This sort of donor is more appealing to me, hence the reason I’ve opted to try IVF again.
I have started the IVF process again, having had my baseline scan 4 days ago and am due for next scan tomorrow. However, something has urgent come up in work life which means I need to cancel this cycle. My question is, will this potentially impact negatively on outcomes of IVF, i.e. I have taken 4 days of 150ml of Menopur (same dose as last time) and I’m wondering if aborting now will have an negative impact on follicles next time/next month ? If the answer is, yes, possibly, then maybe I should proceed with IVF now rather than delay by a month.
I’m very grateful for your time and help in advance.
Best wishes and kindest regards!
Casey
In my opinion, it should in no way impact IVF in future cycles.
Good luck!
Geoff Sher
I am hoping you can answer for me . When I had a baby a few years ago, the catheter they used on me in labor and delivery was very uncomfortable. I could feel it the whole time and it made me feel like i frequently had to urinate. Ever since then, I can’t get rid of that feeling in my bladder. I have to urinate 5-6 times an hour at night and at least two times an hour during the day. When I am sleeping is the only time I get a break and if I even slightly wake up at night , have to pee or else it will keep me up all night. It doesn’t feel like a bladder infection. I have had them as a teenager and one in the last year. It’s not the same. It’s not a burning or painful sensation or feeling like I can’t completely empty my bladder. I just have to go all the time and it’s just feels like an urgency to pee all the time. I do drink a lot of water and always have but it still shouldn’t be that I have to pee all the time. But any few sips I have I feel like it goes right through me. Sometimes I’m in disbelief that I am able to urinate so much back to back. Like sometimes I expect just a sprinkle because I just went 15 minutes ago and it’s a full pee. What could be wrong? And could the catheter have caused this? I’ve done a lot of ivf and am still doing so, so I’ve been tested all the time for infections,, stds… and take routine antibiotics for transfers. Please help.
You need to see a Uro-gynecologist. It is possible that your bladder was traumatized with the birth of your child. This can sometimes lead to what we call Bladder Dyssynergia. It can be treated and it should be.
Good luck!
Geoff Sher
Hello Dr. Sher
I have a frozen embryo protocol that is very similar to yours. The main difference is I stay on 10 units of lupron until progesterone is started . Braverman also added letrozole for 5 days starting 12 days before transfer to address the lack of protein adhesives in the uterus in women with endometriosis. This worked for me and for the first time in my life I became pregnant and had a baby. He also treated my immune system with the usual, IVIg, prednisone, lovenox. Everything else seems to be the same as your protocol.
My question is what is the difference between the 10 units of lupron and 5 like in your protocol? I don’t think I had a period for this but maybe i did. It was so long ago I can’t remember.
If you were to do this protocol and not take birth control would stopping the lupron when you start progesterone induce a period?
10U Lupron is unnecessary, but is is OK. I would stop the Lupron when progesterone therapy is inotiated.
Until less than a decade ago, most women undergoing IVF would have embryos transferred to the uterus in the same cycle that the egg retrieval was performed (“Fresh” Embryo Transfer). This was because embryo cryopreservation (freezing) was a hazardous undertaking. In fact, it resulted in about 30% not surviving the freezing process and those that did, having about one half the potential of “fresh embryos to implant and propagate a viable pregnancy. The main reason for the high attrition rate associated with embryo cryopreservation is that the “conventional” freezing” process that was done slowly and this resulted in ice forming within the embryo’s cells, damaging or destroying them. The introduction of an ultra-rapid cryopreservation process (vitrification) freezes the embryos so rapidly as to avoid ice crystals from developing. As a result, >90% survive the freeze/thaw process in as good a condition as they were prior to being frozen and thus without being compromised in their ability to propagate a viable pregnancy.
Recently, there have been several articles that have appeared in the literature suggest that an altered hormonal environment may be the reason for this effect. There have also been reports showing that when singletons (pregnancy with one baby) conceived naturally are compared to singletons conceived through a “fresh” embryo transfers they tend to have a greater chance of low birth weight/prematurity. This difference was not observed in babies born following FET. Hence, there is a suspicion that the altered hormonal environment during the fresh cycle may be the causative factor.
Available evidence suggests that FET (of pre-vitrified blastocysts) is at least as successful as is the transfer of “fresh” embryos and might even have the edge. The reason for this is certainly unlikely to have anything to do with the freezing process itself. It more than likely has to do with two factors:
a)An ever increasing percentage of FET’s involve the transfer of PGS-tested, fully karyotyped, euploid blastocysts that have a greater potential to propagate viable pregnancies, than is the case with “fresh” ET’s where the embryos have rarely undergone prior PGS selection for “competency”…and,
b) With targeted hormone replacement therapy for FET, one is far better able to better to optimally prepare the endometrium for healthy implantation than is the case where embryos are transferre3d following ovarian stimulation with fertility drugs.
There are additional factors other than method used for embryo cryopreservation that influence outcome following FET. These include
•An emerging trend towards selective transferring only advanced (day 5-6) embryos (blastocysts).
• (PGS) to allow for the selective transfer of genetic competent (euploid) embryos
•Addressing underlying causes of implantation dysfunction (anatomical and immunologic uterine factors) and
• Exclusive use of ultrasound guidance for delivery of embryos transferred to the uterus.
Against this background, the use of FET has several decided advantages:
•The ability to cryostore surplus embryos left over after fresh embryo transfer
•The ability to safely hold embryos over for subsequent transfer in a later frozen embryo transfer (FET) cycle (i.e. Staggered IVF) in cases where:
1.Additional time is needed to perform preimplantation Genetic testing for embryo competency.
2.In cases where ovarian hyperstimulation increases the risk of life-endangering complications associated with critically severe ovarian hyperstimulation syndrome (OHSS).
3.To bank (stockpile) embryos for selective transfer of karyotypically normal embryos in older women or those who are diminished ovarian reserve
4.The ability to store embryos in cases of IVF with third party parenting (Egg Donation; Gestational Surrogacy and Embryo donation) and so improve convenience for those couples seeking such services.
Preimplantation Genetic Sampling with FET:
The introduction of preimplantation genetic sampling (PGS) to karyotyping of embryos for selective transfer of the most “competent” embryos, requires in most cases that the tested blastocysts be vitribanked while awaiting test results and then transferred to the uterus at a later date. Many IVF programs have advocated the routine use of PGS in IVF purported to improve IVF outcome. But PGS should in my opinion should only be used selectively. I do not believe that it is needed for all women undergoing IVF. First there is the significant additional cost involved and second it will not benefit everyone undergoing IVF, in my opinion.
While PGS is a good approach for older women and those with diminished ovarian reserve (DOR) and also for woman who experience recurrent pregnancy loss (RPL) or “unexplained” recurrent IVF failure recent data suggests that it will not improve IVF success rates in women under 36Y who have normal ovarian reserve, who represent the majority of women seeking IVF treatment. Nor is it needed in women (regardless of their age) undergoing IVF with eggs donated by a younger donor. This is because in such women about 1:2/3 of their eggs/embryos are usually chromosomally normal, and in most cases will upon fertilization produce multiple blastocysts per IVF attempt, anyway. Thus in such cases the transfer of 2 blastocysts will likely yield the same outcome regardless of whether the embryos had been subjected to PGS or not. The routine use of
It is another matter when it comes to women who have diminished ovarian reserve and/or DOR contemplating embryo banking and for women with unexplained recurrent IVF failure, recurrent pregnancy loss and women with alloimmune implantation dysfunction who regardless of their age or ovarian reserve require PGS for diagnostic reasons.
Embryo Banking: Some IVF centers are doing embryo banking cycles with Preimplantation Genetic Screening (PGS). With Embryo Banking” several IVF cycles are performed sequentially (usually about 2 months apart), up to the egg retrieval stage. The eggs are fertilized and the resulting advanced embryos are biopsied. The biopsy specimens are held over until enough 4-8 blastocysts have been vitribanked, thus providing a reasonable likelihood that one or more will turn out to be PGS-normal. At this point the biopsy specimens (derived all banking cycles) are sent for PGS testing at one time (a significant cost-saver), the chromosomally normal blastocysts are identified and the women are scheduled for timed FET procedures….. with a good prospect of a markedly improved chance of success as well as a reduced risk of miscarriage.
Standard (proposed) Regimen for preparing the uterus for frozen embryo transfer FET) is as follows:
The recipient’s cycle is initiated with an oral contraceptive-OC (e.g. Marvelon/Lo-Estrin; Lo-Ovral etc) for at least 10 days. This is later overlapped with 0.5 mg. (10 units) Lupron/Lucrin (or Superfact/Buserelin) daily for 3 days. Thereupon the OC is withdrawn and daily 0.25 mg (5 units) of Lupron/Lucrin/Superfact injections are continued. Menstruation will usually ensue within 1 week. At this point, an ultrasound examination is performed to exclude ovarian cyst(s) and a blood estradiol measurement is taken (it needs to be <70pg/ml). The daily Lupron/Lucrin/Superfact is continued until the initiation of progesterone therapy (see below).
Four milligram (4mg) Estradiol valerate (Delestrogen) IM is injected SC, twice weekly (on Tuesday and Friday), commencing within a few days of Lupron/Lucrin/Superfact-induced menstruation. Blood is drawn on Mondays and Thursdays for measurement of blood [E2]. This allows for planned adjustment of the E2V dosage scheduled for the next day. The objective is to achieve a plasma E2 concentration of 500-1,000pg/ml + an endometrial lining of >8mm, as assessed by ultrasound examination done after 10 days of estrogen exposure i.e. a day after the 3rd dosage of Delestrogen. The twice weekly, final (adjusted) dosage of E2V is continued until pregnancy is discounted by blood testing or an ultrasound examination. Dexamethasone 0.75 mg is taken orally, daily with the start of the Lupron/Lucrin/Superfact. This is continued until the 10th week of pregnancy or until pregnancy is discounted, at which point it is slowly tailed off over a 2 week period and stopped. Oral folic acid (1 mg) is taken daily commencing with the first E2V injection and is continued throughout gestation. Patients also receive Ciprofloxin 500mg BID orally starting with the initiation of Progesterone therapy and continuing for 10 days.
Luteal support commences 6 days prior to the ET, with intramuscular progesterone in oil (PIO) at an initial dose of 50 mg (P4-Day 1). Thereupon, (from the following day) , progesterone administration-Day 2, PIO is increased to 100 mg daily continuing until the 10th week of pregnancy, or until a blood pregnancy test/negative ultrasound (after the 6-7th gestational week), discounts a viable pregnancy.
Also, commencing on the day following the ET, the patient inserts one (1) vaginal progesterone suppository (100 mg) in the morning + 2mg E2V vaginal suppository (in the evening). This is continued until the 10th week of pregnancy or until pregnancy is discounted by blood testing or by an ultrasound examination done at the 6-7th gestational week. Dexamethasone 0.75mg is continued to the 10th week of pregnancy (tailed off from the 8th to 10th week) or as soon as pregnancy is ruled out. With the obvious exception of the fact that embryo recipients do not receive an hCG injections, luteal phase and early pregnancy hormonal support and immuno-suppression is otherwise the same as for conventional IVF patients. Blood pregnancy tests are performed 13 days and 15 days after the first P4 injection was given.
Note: Alternative progestational therapy in cases where intramuscular progesterone is not used: One (1) vaginal application of Crinone 8% is administered on the 1st day (referred to as luteal phase day 0 – LPO). On LP Day 1, they will commence the administration of Crinone 8% twice daily (AM and PM) until the day of embryo transfer. Withhold Crinone on the morning of the embryo transfer and resume Crinone administration in the PM. Crinone twice daily is resumed from the day after embryo transfer. Contingent upon positive blood pregnancy tests, and subsequently upon the ultrasound confirmation of a viable pregnancy, administration of Crinone twice daily are continued until the 10th week of pregnancy.
Regime for Thawing and Transferring Cryopreserved Embryos/Morulae/Blastocysts:
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ADDENDUM: PLEASE READ!!
INTRODUCING SHER FERTILITY SOLUTIONS (SFS)
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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.
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Geoff Sher
Hi Dr Sher,
I am 33. I have a 15 month old son from IVF (before this I tried for 2.5 years naturally and never had a positive Pregancy tests). I have partial DQ alpha match with my husband. And 5 HLA matches altogether. Before having my son I had K-562 done and it showed high NK cells. Uterine biopsy also showed high NK cells.
My first FET for my son worked with immune protocol (LIT, Intralipids, 1mg dexamethasone, clexane).
I have just attempted another FET with a PGS tested embryo and the same protocol as above but it ended in a brief chemical pregnancy.
I am wondering if I should stick to this protocol for next FET? Or add IVIG? I have two more PGS normal embryos and 5 untested.
What do you think my chances of conceiving a second child are now? I consulted with you in 2018 and you told me it was possible to conceive my first (but is it going to be harder for me now for the second?)
Thank you
I would stay with the same protocol because 1: 2 embryos will match and if you transfer one (see below), there is therefore a 50%v chance it will match with your DQalpha. Since there is no way of knowing which will match and given that if there is a match, that embryo will not establish a viable pregnancy regardless of treatment, it is likely that the last transfer was with a matching embryo.
Alloimmune dysfunction is diagnosed by testing the blood of both the male and female partners for matching DQ alpha genes and NK/CTL activation. It is important to note that any DQ alpha match (partial or complete) will only result in an IID when there both a DQa/HLA match exists along with NK cell activation. With the exception of cases where both partners have a total (absolute DQa match and treatment requires the use of sperm from a non-matching sperm donor, about 90% of cases alloimmune implantation will have a partial match where 1: 2 embryos will match the woman’s DQalpha genotype and half will not. In cases of an alloimmune dysfunction (with associated NKa), treatment with IL or IVIG will in my opinion, will not protect against a matching embryo being rejected. It can only clear the NK environment for an embryo that does not match the woman’s DQalpha genotype. For this reason, it is my opinion that only 1 embryo should be transferred at a time because, given the fact that i:2 embryos will match, transferring >1 embryo at a time creates a risk that the matching embryo will evoke a local NKa/’cytokine response that will “muddy the water” for both. Thus, in cases of a “partial” DQalpha match I recommend against transferring more than a single embryo at a time.
Good luck!
Geoff Sher
Hi Dr. Sher,
I am 34 years 9 months currently and had a failed first round of IVF in June. (Low AMH: 1.23, Protocol: 13 days down-regulation with birth control pills, 225 Gonal F and 300 IU Menopur for 12 days, 6 eggs retrieved, 5 mature, 3 fertilized, 2 Blastocysts but both PGS abnormal). Currently on Round 2 which was a Menopur only + HGH (Downregulation for 12 days, then 450 IU Menopur for first 3 days and 600 IU Menopur for 7 days. 25 units HGH for each of 10 days), 6 eggs retrieved, only 2 mature, both of which fertilized. Waiting currently to see what happens after 5 days. On Day 9 of stimulation, follicles showed uneven growth with a smaller group of three (less than 12 mm) and a larger group of two grown too much (greater than 22 mm). Would it be possible to tell why that might happen with this protocol?