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 in your many years of practice when using your agonist antagonist conversion protocol how much does the follicle count at baseline correlate with the number of eggs retrieved in patients?
Using this protocol, the correlation is often poor. What you are looking for is a steady rise in E2.
With the A/ACP, it is follicular size rather than absolute blood [E2] levels that is mainly used to determine developmental progress and the timing of the hCG “trigger”. While serial This is because with the A/ACP, E2 levels are often falsely understated. The possible explanation could be that when a GnRH-antagonist is administered for a protracted period of time, an isomeric variant of E2 is produced, one that is under-read by the standard E2 blood assay, resulting in under-reading of the true [E2]. This can often be misleading. Accordingly when the A/ACP is used, we rely much more upon ultrasound evidence of follicle growth, along with a progressive (albeit much slower) rise in E2 , to evaluate response t5o A/ACP stimulation.
Women who have elevated basal AMH levels, women with irregular or absent ovulation and those with PCOS, where the peak [E2] response to even low dosage gonadotropin stimulation tends who are often at risk of developing a life endangering condition known as severe ovarian hyperstimulation syndrome (OHSS). In such cases, it is critical that measured [E2] blood levels be accurate and truly representative of the degree of ovarian stimulation. Accordingly, I do not advocate the use the A/ACP in such cases.
Geoff Sher
Hello Doctor,
I had an IUI on 8-8-20. I had a positive pregnancy blood test on 8-24-20 (16dpo) hcg level 67. Two days later 18dpo hcg 108, 20 dpo hcg 219, 23 dpo 607. The doctor is concerned although my numbers are doubling my value is too low and indicates an ectopic. What do you think? Have you seen slow rising hcg turn in to a successful pregnancy?
Hard to say. Wait 2 weeks and do an US for a more definitive answer.
In the meanwhile, if you experience sudden abdominal pain with bleeding go straight to the nearest ER.
Good luck!
Geoff Sher
Hi Dr. Sher. I so appreciate your website and the wealth of information. I am writing and wondering if I am kind of out of protocol options. I did an IUI with donor sperm 1.5 years ago and ended up with a ruptured ectopic pregnancy, losing my left tube at the time they used 4 injections of methotrexate, to no avail. Prior to that I had no fertility issues, having a pregnancy earlier in life. After losing my left tube my right ovary was never the one to ovulate so I moved to IVF.
I am 35 with an AMH of 0.9.
First round-birth control, 150 gonal f 150 menupour, 12 eggs at baseline, four eggs took off, four retrieved, resulting in 2 day 5 morulas that didn’t implant with fresh trasfer.
Second round- birth control, 9 days of lupron, 300 gonal f, 300 meupour 13 at baseline, four eggs took off again, 3 retrieved resulting in 2 morulas on day five again and a chemical pregnancy with transfer.
I took off 3 months, added supplements, acupuncture currently in my 3rd round using estogen priming with a patch, 3 days of cetrotide then 300 gonalf 150 menopur (which has already been bumped to 300) and 8 days of omnitrope, basically seeing the same results even though this time I had 20 at baseline only 4 are growing.
It feels as though I have done every priming method and even though the follicles are there are baseline they are not growing. My doctor said that my body “doesn’t like IVF meds”. Its hard to understand since I have done every test available and all come back normal. I asked about “mini ivf” since maybe the drugs are too much, but my dr said that is not an option for me.
Any advice?
In my opinion, given that based upon your AMH, you have diminished ovarian reserve, you would likely benefit from a revised and individualized protocol for ovarian stimulation.
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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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.
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).
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Geoff Sher
Hi Dr Sher,
What is your view on HCG injection of 2000 IU twice (3 days post and 6 days post an embryo transfer)? Does it help with implantation/luteal phase support?
In my opinion, it does not help and it confuses interpretation of the blood quantitative pregnancy testb result. I do not do this.
Geoff Sher
Good morning Dr. Sher. Thank you for creating this blog and all the time you in for those of us in the world of IVF. Every time I have an IVF or fertility related question, I enter the question into a search engine and then write “Dr. Sher” after and always find an answer. This time I couldn’t find anything, so I hope you don’t mind answering. Is it normal to have scanty periods after coming off of birth control and lupron? I do not have a full flow when coming off the two for IVF so I am never sure which day is cycle day one. Thank you for your time.
Lynsey
Thanks Lynsey.
The amount of flow is usually irrelevant. Regular cyclicity is far more important
Geoff Sher