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.
Dr.Sher, I recently had a FET with a 5 day blast. My beta level yesterday which was 8dpt was <1. I have been told that there are rare instances where there could still be a pregnancy and to stay on meds and repeat in 3 days. I was wondering your opinion on this? Thank you
Sadly it does not look hopeful Jen!
Geoff Sher
Thanks in advance for answering my questions. I desperately need a second opinion.
*Two part question, stims and embryos.
I just finished my first cycle of 2-cycle banking. I am 38 (39 in August) with low of AMH 0.63
Baseline AFC 6, CD9 count 3.
Last Friday, 3 eggs retrieved, only from my right ovary, don’t have problem with my left ovary but for some reason there were no follicles. 2 of the eggs were mature and were fertilized. I was told that my stims were “pretty high” but I have doubts.
I was on:
Day1-3 Gonal-f 375iu
Day 4 Gonal-f 300iu
Day 5 Gonal-f 225iu, Menopur 75iu
Day 6 Gonal-f 300iu
Day 7 Gonal-f 225iu, Menopur 75iu
Day 8-9 Gonal-f 150iu, Menopur 75iu, Cetrotide 0.25mg (am)
Day 10 Gonal-f 75iu, Cetrotide 0.25mg (both am), triggered with 10,000 units of Novarel PM
Do you think my doses were high enough? What kind of dosage do you recommend for my second cycle?
And I got the call today from the clinic on Thursday (Day 6). They were not able to do neither biopsy (PGS was going to be done) nor freeze the embryos. The embryos actually made it blastocyst stage but for some reason they did not continue to grow or do what they were suppose to do.
Both me and my husband wondered what caused blastocysts to stop growing and if they were somehow mishandled since the same thing happened to both embryos??
What is the likelihood of Day 5 embryo to stop growing? Is this nortmal or do you think something went wrong?
Sorry for the long message. Hope you answer my questions. Thank YOU so much!
Hi GG,
No doubt you have significantly diminished ovarian reserve (DOR).Older women as well as those who (regardless of age) have 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
Hello Dr. Geoffry. I just turned 29 years this May, husband is 30 , no sperm issues met with a doctor May 2015 after trying for 2 months just to check things were okay. Doctor saw beginning cysts on unltrasound suspecting endometriotic cysts. In October 2015, I underwent a diagnostic & therapeutic laproscopy associated with a disgnostic hysteroscopy & a blue test, the result is endometriosis, doctor mentioned it was mild to moderate , there were many chocolate cysts, very very small but many. There were significant adhesions found between both ovaries & the posterior surface of the uterus which has been treated, both ovaries had significant micro-cysts containing follicular fluid, all of which were treated (or emptied for the time for that matter). Both tubes were clear & open although having a post-inflammatory appearance. As per doctor , he advised us to start with ivf, because the chances for normal pregnancy if not impossible but difficult since we wanted to have babies sooner. I had my first ivf in December having Merional, Gonal F. It was a long protocol, i wasnt responding as quick as i should (i am guessing because it was too soon after laproscopy) i ended up producing 18 follicles , 10 were fertilized, 3 made it to day-5 transfers, one was grade 1 & 2 were grade 2. I ended up with a chemical pregnancy. My doctor asked for a long list of tests that included: Anticardiolipin IgM & Anticardiolipin IgM, Natural Killer Cells, Homocysteine, Free T3, Free T4, TSH, DRVV for Lupus Anticoagulant, Protein C, Protei S, Antithrombin III Level. All of which came back normal & my doctor was content with the exception of the Protein S level that came back border line normal at 66% (with normal range between 70-130). I started my second IVF in March 2016 with a short protocol of high dosed stimulation drug, i responded much better in 1 week producing 10 great follicles, 6 of which were fertilized, 4 made it to day 5transfer all of which were Grade 1, 2 were frozen & 2 transferred. I was put on Clexane 60 to address the Protein S levels. No pregnancy resulted. In May 2016 i had an FET for the 2 frozen embies, 2 survived the thaw & their quality was not changed, no pregnancy as well, i was put on Clexane 80 this cycle. It is worthy to mention that in the next 2 IVF cycles i rode a plan shortly after transfer & had some pelvic pains, but not sure if that is the reason, I still did not meet my doctor for the next ivf cycle, before the frozen embryo cycle, he had assured me that he has never seen such good quality embryos production that never resulted in a successful pregnancy & it is just an issue of trail & error, however i am concerned that there might be an issue that we are all missing & that it never happens. My next cycle i will definitely not ride a plan & take it easy as i believe i am too much of an active person to truly slow down in the 2WW. Any thoughts that you might have will be helpful. Thanks a lot for all your help before hand.
Hello, i need to adjust the name in the profile please, i was not aware it will be public, can you direct me how please.
I am concerned that your immune tests might not be representative. Unless the correct tests were done and were performed in a good reproductive immunology reference laboratory, they could be meaningless. There are only a handful of laboratories in the world that can do these tests reliably. I use Reproductive Immunology Associates in Van Nuys, CA (you can Goole them). In your cas, you need proper measurement of all antiphospholipid antibodies (APA), a reproductive immunophenotype (RIP) and most importantly, an The NK activity (NKa) test…i.e. the K-562 target cell test (note that the blood concentration of NK cells is totally irrelevant, it is the activvation as measured by the K-562 test and/or by uterine cytokines that matters. I suspect that this needs to be addresses.
Second is the need for your embryos to Karyotyped before being transferred.
Third is the protocol chosen for ovarian stimulation which needs to be reviewed
Fourth: Any endometriomas need to be addressed prior to IVF (see below).
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
•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?
•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!
•Endometrial Thickness, Uterine Pathology and Immunologic Factors
•Vaginally Administered Viagra is Often a Highly Effective Treatment to Help Thicken a Thin Uterine Lining
•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
•Endometriosis and Infertily
•Treating Ovarian Endometriomas with Sclerotherapy.
•Adenomyosis-Related Infertility: A Therapeutic Challenge!
•Implications of “Empty Follicle Syndrome and “Premature Luteinization”
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.
Hello! I am currently finishing my 3rd IVF cycle. I am 31 years old.. With PCOS! Amh was 5. First cycle, everything looked great … Bcp for 3 weeks…I stimmed with 150 follistim, then ganirilex… Then pregnyl 10,000.. Doc expected 10-12 eggs based on scans. He only retrieved 4 eggs 1 of which was mature. Some caught up over night. Only morulas at day 5. Cycle 2, pretty much the same.. Stimmed a day longer and upped follistim to 225. I switched clinics and he had me do 225 gonal f and a vial of menopur… Then added cetrotide… Then a double ovidrel trigger… I don’t have an exact count or E2 values but my doc was so confident and there was so many more follicles and they appeared much bigger! This time I only got 4 eggs… 4 mature but only 2 fertilized… Going tomorrow for a 3 day transfer.. Why does this keep happening?
Women with PCOS respond differently to ovarian stimulation that most other women do. In addition egg quality is often an issue. Thus the protocol used for ovarian stimulation is central to success and this needs to be very individualized.
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?
•Frozen Embryo Transfer (FET): A Rational Approach to Hormonal Preparation and How new Methodology is Impacting IVF.
•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
•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”
•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?
•Intrauterine Insemination (IUI): Who Needs it & who Does Not: Pro’s
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.
Hello Dr. Sher! Would really like your thoughts on my history…I am now 27 and had two IVFs done at age 24, tubal infertility, no sperm issues. First cycle used Follisitim, low dose HCG, and Ganirilex with Ovidrel trigger. 22 follicles retrieved, 12 immature and 10 mature, 6 fertilized (no ICSI) and all embryos arrested by day 5. Second cycle used Bravelle, Menopur, and Ganirilex with Lupron trigger. 16 follicles retrieved, 10 immature, 6 mature and fertilized with ICSI and again by day 5 all had arrested. This past month went to a new facility and stimmed with Gonal-f and Menopur and used Cetrotide and a Lupron trigger. 23 follicles were retrieved, 11 were mature and 8 fertilized with ICSI, by day 3 most had arrested and on day 5 they all had. I was told by every facility that my blood work was great and my egg quality was well so I’m so confused on the continued failures and would love your thoughts, thank you for your time!
Hi Tina,
First, in my opinion, with all those follicles, neither a 250mcg Ovidrel “trigger” nor a Lupron “trigger” are sufficient to initiate orderly optimal chromosomal reduction division (meiosis) and this could explain the egg/embryo incompetence you experienced. I think this is all about the protocol used for ovarian stimulation. You clearly are a high responder and your treating RE used these trigger approaches to try and avoid OHSS.
My approach is consistently to use a long pituitary DR protocol with an agonist, coming off 1-2 months on the BCP. The latter is intended to lower LH and thereby reduce stromal activation (hyperthecosis) in the hope of controlling ovarian androgen release. I then stimulate with low dosage FSHr to which I add a smidgeon of LH/hCG (Luveris/Menopur) from the 3rd day and watch for the # of follicles and [E2] starting on the 7th day of COS. If there are > 25 follicles, I keep stimulating (regardless of the [E2] until 50% of all follicles reach 14mm. Then, provided the [E2] is >2500pg/ml, I stop the agonist and the gonadotropin stimulation and follow the E2 (only) daily, without doing further US examinations. The [E2] will almost invariably climb and I watch it go up (regardless of how high the concentration of E2reaches) and track it coming down again. As soon as the [E2] drops below 2500pg/ml (and not before then ever), I administer 10,000U hCGu or hCGf (Ovidrel/Ovitrel-500mcg) as the “trigger” and perform an egg retrieval 36h later. ICSI is a MUST because “coasted” eggs usually have no cumulus oophoris and eggs without a cumulus will not readily fertilize on their own. All fertilized eggs are cultured to blastocyst (up to 6 days). And up to two (2) are transferred transvaginally under US guidance.
The success of this approach depends on precise timing of the initiation and conclusion of “prolonged coasting”. If you start too early, follicle growth will stop and the cycle will be lost. If you start too late, you will encounter too many post-mature/cystic follicles (>22mm) that usually harbor abnormally developed eggs.
Use of the above approach avoids unnecessary cycle cancellation, severe OHSS, and optimizes egg/embryo quality. The worst you will encounter is mild to moderate OHSS and this too is uncommon.
I do not use antagonists in high responders because it interferes with the assay of E2 (often causing the value to be understated), a valuable index in assessing risk for the development of severe/critical OHSS. I also do not believe in the agonist trigger to prevent OHSS. The reason is that the magnitude of the induced LH surge varies and if too little LH is released, meiosis can be compromised, thereby increasing the oocyte aneuploidy index.
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
•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
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF
•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?
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
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.