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.
Hello Dr Sher,
I recently completed an IVF cycle, I was prepped for a fresh transfer, i.e. progesteron was taken immediately following egg retrieval (and for a number of days following). However, it was decided not to do a fresh transfer because I had mild OHSS symptoms, thus the cycle resulted in a “freeze all” cycle. I wondered if there’s an optimal wait time before at FET is attempted. Shortly after stopping the progesterone suppositories I got my period and am due my next soon, but wondered if it made sense to wait till the next one, given this next one/2nd post IVF period is likely to be late/disrupted.Is it better to wait till at least the 3rd post IVF period?
Many thanks !!
I see no reason tho delay!
Geoff Sher
Hi Geoff,
I think I have been put through two ‘one size fits all’ protocols by my doctor. Rather than having protocols specifically designed to address my low reserve and age range.
My stats:
-36.5 yrs old
-AMH level of 10 at last test (6 months ago)
-Normal bloodwork
-Healthy, active and taking supplements for months
Cycle #1 – Antagonist Cycle
-FSH: Gonul f 300 IU daily (starting day 2)
-FSH/LH: Menopur 150 IU daily (starting day 2)
-Letrozole 5mg from day 2 to day 6
-Antagonist: Orgalutran 250mcg daily starting day 6
-Trigger: Synarel 8 nasal sprays
Scan #1 on ‘day 7’ showed 9 follicles. The largest was 13mm. The rest less than 9mm.
Scan #2 on ‘day 10’ showed only 6 follicles worth mentioning; sized 17, 15, 13, 9, 6 and 6mm.
I was told to trigger at midnight on day #12 at 12pm.
Surgery on day #14.
4 eggs collected. 0 were mature.
Cycle #2 – Flare Cycle
-Puregon 450 units (starting day 3)
-Decapeptyl 100mcg daily (starting day 3)
-Trigger: Pregnyl 10,000 (which occurred on day 11 at 6.40pm.
Scan on day #10 indicated follicles; 19, 17, 14, 13, 12, 11.
Egg collection on Day #13 at 7.40am.
11 eggs retrieved. 0 mature. (2 were apparently close.)
In Summary:
– My first protocol included menopur and letrozole. You say these are bad for egg quality and should be omitted from protocol for women over 35 with decreased reserve as indicated by low AMH levels.
– My second protocol was a Flare cycle. The drugs apparently in patients with my profile do the following; the increased androgen production early on in the stimulation has a deleterious effect on egg development and thus on subsequent embryo quality.
My cycle length is usually 34 days or so. I told the doctor I thought she was either triggering me too early or not leaving me for long enough post trigger to have mature eggs. She told me cycle has nothing to do with it.
Would it be fair of me to suggest that these protocols were not tailored to my specific circumstances? Or am I being too harsh?
Another patient of hers indicated that her next protocol recommendation is likely to be;
“I have just started my third cycle with the doctor. I have been on a long long down reg this time taking Synarel for 6 weeks and now on Gonal f & Pergoveris. My doses have been lowered, I will be taking a double trigger of pregnyl & Ovidrel (I think) I also will be having a 38hour trigger time.”
I am concerned that this next cycle is going to leave me with 0 mature eggs again but am less familiar with the approach her other patient refers to above. (My guess is she will put me on the same as we are approx the same age and similar reaction to her other 2 protocol recommendations for our first 2 cycles.)
If you have thoughts or recommendations I would be so incredibly grateful.
Thanking you in advance for your wise input.
Hi Doc,
I am 11 weeks and 3 days and my HCG came in today as > 270,0000. I know I am not carrying multiples because I have had several ultrasounds so far. Also, this embryo is supposed to be euploid. Should I be concerned about my high HCG level?
Thanks,
Micha
I do not believe so, but discuss this with your OB!
Good luck!
Geoff Sher
Hi Dr. Sher – I’ve had 2 failed cycles and both suggest an egg quality issue (and potential male factor with high DFI at 20%). Cycle 1 retrieved 9 eggs, 4 matured, 1 day 6 blastocyst and it was aneuploid; used antagonist protocol with dual trigger shot. Cycle 2 retrieved 15 eggs, 6 matured, 3 day 5 blastocysts and 2 day 6. All 5 were aneuploid; same antagonist protocol with a mid luteal phase estrogen priming start and added omnitrope from priming through the entire stimulation phase. Should I continue with a 3rd cycle at this point? I am hesitant to proceed if the underlying issue is egg quality as I am not sure there’s much that can be done to improve this. I was very pleased to see an improved number of highly graded blastocysts in the 2nd cycle but pretty devastated with the PGTA results. Thanks in advance for your insight.
I would need much more information in order to comment authoritatively. I suggest we talk. Consider calling my assistant, Patti (702-533-2691) to set up an online consultation with me.
One of the commonest questions asked by patients undergoing IVF relates to the likelihood of their eggs fertilizing and the likely “quality of their embryos. This is also one of the most difficult questions to answer. On the one hand many factors that profoundly influence egg quality; such as the genetic recruitment of eggs for use in an upcoming cycle, the woman’s age and her ovarian reserve, are our outside of our control. On the other hand the protocol for controlled ovarian stimulation (COS) can also profoundly influence egg/embryo development and this is indeed chosen by the treating physician.
First; it should be understood that the most important determinant of fertilization potential, embryo development and blastocyst generation, is the numerical chromosomal integrity of the egg (While sperm quality does play a role, in the absence of moderate to severe sperm dysfunction this is (moderate or severe male factor infertility a relatively small one). Human eggs have the highest rate of numerical chromosomal irregularities (aneuploidy) of all mammals. In fact only about half the eggs of women in their twenties or early thirties, have the required number of chromosomes (euploid), without which upon fertilization the cannot propagate a normal pregnancy. As the woman advances into and beyond her mid-thirties, the percentage of eggs euploid eggs declines progressively such that by the age of 40 years, only about one out of seven or eight are likely to be chromosomally normal and by the time she reaches her mid-forties less than one in ten of her eggs will be euploid.
Second; embryos that fail to develop into blastocysts are almost always aneuploid and not worthy of being transferred to the uterus because they will either not implant, will miscarry or could even result in a chromosomally abnormal baby (e.g. Down syndrome). However, it is incorrect to assume that all embryos reaching the blastocyst stage will be euploid (“competent”). ). It is true that since many aneuploid embryos are lost during development and that those failing to survive to the blastocyst stage are far more likely to be competent than are earlier (cleaved) embryos. What is also true is that the older the woman who produces the eggs, the less likely it is that a given blastocyst will be “competent”. As an example, a morphologically pristine blastocyst derived from the egg of a 30 year old woman would have about a 50:50 chance of being euploid and a 30% chance of propagating a healthy, normal baby, while a microscopically comparable blastocyst derived through fertilization of the eggs from a 40 year old, would be about half as likely to be euploid and/or propagate a healthy baby.
While the effect of species on the potential of eggs to be euploid at ovulation is genetically preordained and nothing we do can alter this equation, there is unfortunately a lot we can (often unwittingly) do to worsen the situation by selecting a suboptimal protocol of controlled ovarian stimulation (COS). This, by creating an adverse intraovarian hormonal environment will often disrupt normal egg development and lead to a higher incidence of egg aneuploidy than otherwise might have occurred. Older women, women with diminished ovarian reserve (DOR) and those with polycystic ovarian syndrome are especially vulnerable in this regard.
During the normal, ovulation cycle, ovarian hormonal changes are regulated to avoid irregularities in production and interaction that could adversely influence follicle development and egg quality. As an example, small amounts of androgens (male hormones such as testosterone), that are produced by the ovarian stroma (tissue surrounding ovarian follicles) during the pre-ovulatory phase of the cycle enhance late follicle development, estrogen production by the granulosa cells (that line the inner walls of follicles), and egg maturation. However, over-production of testosterone can adversely influence the same processes. It follows that COS protocols should be individualized and geared toward optimizing follicle growth and development time while avoiding excessive ovarian androgen (testosterone) production and that the hCG “trigger shot” should be carefully timed.
In summary it is important to understand the influence species, age of the woman as well as the effect of the COS protocol can have on egg/embryo quality and thus on IVF outcome. The selection of an individualized protocol for ovarian stimulation is one of the most important decisions that the RE has to make and this becomes even more relevant when dealing with older women, those with DOR and women with PCOS. Such factors will in large part determine fertilization potential, the rate of blastocyst generation and indeed IVF outcome.
I strongly recommend that you visit http://www.SherIVF.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.
•The IVF Journey: The importance of “Planning the Trip” Before Taking the Ride”
•Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
•The Fundamental Requirements For Achieving Optimal IVF Success
•Use of GnRH Antagonists (Ganirelix/Cetrotide/Orgalutron) in IVF-Ovarian Stimulation Protocols.
•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)
•Ovarian Stimulation in Women Who have Diminished Ovarian Reserve (DOR): Introducing the Agonist/Antagonist Conversion protocol
•Controlled Ovarian Stimulation (COS) in Older women and Women who have Diminished Ovarian Reserve (DOR): A Rational Basis for Selecting a Stimulation Protocol
•Optimizing Response to Ovarian Stimulation in Women with Compromised Ovarian Response to Ovarian Stimulation: A Personal Approach.
•Egg Maturation in IVF: How Egg “Immaturity”, “Post-maturity” and “Dysmaturity” Influence IVF Outcome:
•Commonly Asked Question in IVF: “Why Did so Few of my Eggs Fertilize and, so Many Fail to Reach Blastocyst?”
•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?
•Staggered IVF
•Staggered IVF with PGS- Selection of “Competent” Embryos Greatly Enhances the Utility & Efficiency of 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.
•IVF: Selecting the Best Quality Embryos to Transfer
•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
•IVF outcome: How Does Advancing Age and Diminished Ovarian Reserve (DOR) Affect Egg/Embryo “Competency” and How Should the Problem be addressed.
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ADDENDUM: PLEASE READ!!
INTRODUCING SHER FERTILITY SOLUTIONS (SFS)
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).
PLEASE SPREAD THE WORD ABOUT SFS!
Geoff Sher
UPDATED QUESTION
I transferred a single 5AA euploid embryo in a FET on 7/1 and 11dp5dt my HCG was 995, and 13dp5dt it was 3444. Is there any reason to be concerned that this is too high? Can it be indicative of a problem? Thanks in advance.
Could be a multiple pregnancy! However, if it is, it would be a uni-ovular (identical twin pregnancy. Let me know after an US in about 2 weeks time.
Geoff Sher