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.
Hi Dr. Sher,
I transferred a PGD-normal blastocyst (we have zero morphology issues, nothing on my side except my age: 39).
9 days post transfer, my quantitative HCG beta was only 52. Doctor said original number doesn’t matter as much as doubling time, however, I believe it is extremely low for viability.
2 days later it more than doubled to 132, two days after to 442, and 3 days to 2,072.
I understand I will only know when my 7 week ultrasound happens, but can there be viability with a pregnancy that starts at only 52 on 9 days post 5 day blast transfer?
Thank you!
Paula
(I forgot to mention this was a FET with ICSI)
Of course there can and this looks very good. It might even have split into to identicals…given this rise.
Good luck!
Please keep me updated.
Geoff Sher
Hi Dr. Sher
I’m 36 and husband 38. We have been ttc since the last 7 years and have 4 failed Ivf cycles. In all of the cycles about 8-12 eggs were retrieved and multiple embryos were transferred on day 2 and 3. My latest AMh level has decreased from 4.3 to 1.35 in two years. I am planning to go for another Ivf cycle in 3 months time and I was asked to take DHEA 75MG. My latest Dheas level is 246.18 ug/dl and Testosterone Total is 44.16.
I’m confused as to take the Dhea or not. My Dr. says its ok as long as I don’t have Pcos which according to the last ultrasound I don’t have anymore. What would you suggest?
Thank you..
I do not advocate DHEA for older women and for women such as you who have DOR. It gets converted to testosterone (T) in the ovaries and too much testosterone is harmful to egg development.
I would favor 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”.
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?
•Blastocyst Embryo Transfers Should be the Standard of Care in
•Why did my IVF Fail
•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?
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
Why shouldn’t dhea be used? What is the best protocol for DOR and POA?
DHEA is an androgen. It is converted to testosterone in the ovary. While a small amount oftestosterone is required, too much testosterone (especially in women with DOR and older women) gets into the pollicular fluid an compromises egg development.
Please read the articles below relevant to the agonist/antagonist conversion protocol + human growth hormone for DOR. Also rread about Staggered IVF, embryo banking and PGS.
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?
•Blastocyst Embryo Transfers Should be the Standard of Care in
•Why did my IVF Fail
•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?
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 Dr. Geoff,
I’m a 31-year-old female. My husband is 30-year-old. Married 4 year and been trying to conceive for almost 3 years now.
A little background. We’re both healthy weight, exercise regularly (but not anywhere close to fanatically), and eat fairly healthful balanced diets. We both used to drink a decent amount throughout college, but we are pretty tame with our drinking these days. My husband is 6’4 and 230 but very muscular. I’m 5’4 and was consistantly 123 for about 7 years (it just seemed to be where my body was comfortable). Since starting fertility treatment I’ve gained between 8 to 10 pounds.
Although I’ve been told it shouldn’t impact my fertility, I like to note that I hit puberty early starting my period in 5th grade. My cycles were never totally regular, and I suffered from horrible cramps for years. When I was 16 a doctor told me I had PCOS, even though all doctors since then have said that I do not. After being placed on oral contraceptives at 16, my period regulated and my cramps became much more manageable.
During my junior year of college I stopped having periods altogether. My ob said it was due to the birth control. However, later that year I was diagnosed with a pituitary micro prolactinoma when I started leaking milk from my breasts. It raises my prolactin level way beyond normal range. At the time I was advised to continue oral contraceptives and not to worry about the leakage (unless it got worse) until I was ready to get pregnant.
Since we embarked on this journey to have a child, I have been on bromocriptine to reduce my prolactin level. Once I started the medication, my periods returned like clockwork. When it seemed that was not enough to get us pregnant, I asked my obgyn if there was anything else we could do. She then had me use Clomid. We did three cycles with no success. After that I asked for a recommendation to a fertility specialist.
I love my clinic and generally feel very confident in them. They have great SART stats and seem very knowledgeable; however, in the age of Google I still seek more information… wondering if I’m just a less common case. We went through 2 failed UIU’s before deciding that IVF would probably be a better option. During the first IVF cycle I was prescribed gonal-f (225) for 5 days, then menopur (1 vial) along with gonal-f (150) for 1 day, then gonal-f (150) with 2 vials menopur along with cerotide for 3 days. I then triggered with Novarel. We had 15 follicles but only retrieved 6 eggs. Of those 3 fertilized. However, only 1 made it to being frozen on day 5. My doctor said she feels a FET will be best for us since we can minimize and hyper stimulation I might have and get my lining exactly where we want it.
Being that we’d like to transfer two embryos and also figure it would be a good idea to freeze a few now rather than possibly have to go through the stimulation cycle again later if we decided to have more children, we launched into a 2nd IVF cycle. At that time I asked my doctor to give me a glucose test (to help rule out PCOS) and check my vitamin D levels (since I’ve heard low levels can negatively impact fertility). The glucose test came back fine while my vitamin D was slightly low. So, I started taking D3 in addition to my regular prenatal.
Although I brought up all sorts of things about empty follicle syndrome and asked a million questions after my first retrieval, my Dr. seemed convinced we’d have better results simply changing up the protocol slightly. So, this go round we started me on both gonal-f (150) and menopur (2 vials) for 5 days, then increased the gonal-f to 225 while continuing the 2 menopur and adding cetrotide for 2 days. then for the last two days we increased the metopur to 3 vials while continuing the certitude and gonal-f. Again I triggered with Novarel. I’d been told I had 11 follicles. The largest were 30, 25, 24, 23 at my trigger day ultrasound, so I was excited. However, we only retrieved 7 eggs. That retrieval was this morning, so we don’t know yet how they will fertilize. I realize we did get some eggs in both of these retrievals, but I know if it is EFS that even the eggs retrieved could be poorer quality that desired.
With my retrieval history and my pituitary micro adenoma, would you think I should be classified as having EFS? And if so, if we don’t get the results we want from this cycle, should a long pituitary down-regulation protocol be used next?
Thank you for your feedback.
Hi Jennifer,
Respectfully, I strongly suspect that the problem is linked to the protocol used for ovarian stimulation, its implementation and the timing of the type/dosage/trigger. I would point out that it is not there anusually the type of drugs used but rather how thw cycle was launched (was it coming off a BCP and if so was there a terminal overlap with an antagonist?). I can tell you that follicles >22mm areusually over-developed and will yield “dysmature” eggs in most cases. I would be helpful to have more information on the exact stimulation and your ovarian reserve (AMH/basal FS, LH and estradiol level)
I think I can help you but to do so we would need to talk and I would need to review all your records.
Whenever a patient fails to achieve a viable pregnancy following embryo transfer (ET), the first question asked is why! Was it simply due to, bad luck?, How likely is the failure to recur in future attempts and what can be done differently, to avoid it happening next time?.
It is an indisputable fact that any IVF procedure is at least as likely to fail as it is to succeed. Thus when it comes to outcome, luck is an undeniable factor. Notwithstanding, it is incumbent upon the treating physician to carefully consider and address the causes of IVF failure before proceeding to another attempt:
1.Age: The chance of a woman under 35Y of age having a baby per embryo transfer is about 35-40%. From there it declines progressively to under 5% by the time she reaches her mid-forties. This is largely due to declining chromosomal integrity of the eggs with advancing age…”a wear and tear effect” on eggs that are in the ovaries from birth.
2.Embryo Quality/”competency (capable of propagating a viable pregnancy)”. As stated, the woman’s age plays a big role in determining egg/embryo quality/”competency”. This having been said, aside from age the protocol used for controlled ovarian stimulation (COS) is the next most important factor. It is especially important when it comes to older women, and women with diminished ovarian reserve (DOR) where it becomes essential to be aggressive, and to customize and individualize the ovarian stimulation protocol.
We used to believe that the uterine environment is more beneficial to embryo development than is the incubator/petri dish and that accordingly, the earlier on in development that embryos are transferred to the uterus, the better. To achieve this goal, we used to select embryos for transfer based upon their day two or microscopic appearance (“grade”). But we have since learned that the further an embryo has advanced in its development, the more likely it is to be “competent” and that embryos failing to reach the expanded blastocyst stage within 5-6 days of being fertilized are almost invariably “incompetent” and are unworthy of being transferred. Moreover, the introduction into clinical practice about a decade ago, (by Levent Keskintepe PhD and myself) of Preimplantation Genetic Sampling (PGS), which assesses for the presence of all the embryos chromosomes (complete chromosomal karyotyping), provides another tool by which to select the most “competent” embryos for transfer. This methodology has selective benefit when it comes to older women, women with DOR, cases of unexplained repeated IVF failure and women who experience recurrent pregnancy loss (RPL).
3.The number of the embryos transferred: Most patients believe that the more embryos transferred the greater the chance of success. To some extent this might be true, but if the problem lies with the use of a suboptimal COS protocol, transferring more embryos at a time won’t improve the chance of success. Nor will the transfer of a greater number of embryos solve an underlying embryo implantation dysfunction (anatomical molecular or immunologic).Moreover, the transfer of multiple embryos, should they implant, can and all too often does result in triplets or greater (high order multiples) which increases the incidence of maternal pregnancy-induced complications and of premature delivery with its serious risks to the newborn. It is for this reason that I rarely recommend the transfer of more than 2 embryos at a time and am moving in the direction of advising single embryo transfers …especially when it comes to transferring embryos derived through the fertilization of eggs from young women.
4.Implantation Dysfunction (ID): Implantation dysfunction is a very common (often overlooked) cause of “unexplained” IVF failure. This is especially the case in young ovulating women who have normal ovarian reserve and have fertile partners. Failure to identify, typify, and address such issues is, in my opinion, an unfortunate and relatively common cause of repeated IVF failure in such women. Common sense dictates that if ultrasound guided embryo transfer is performed competently and yet repeated IVF attempts fail to propagate a viable pregnancy, implantation dysfunction must be seriously considered. Yet ID is probably the most overlooked factor. The most common causes of implantation dysfunction are:
a.A“ thin uterine lining”
b.A uterus with surface lesions in the cavity (polyps, fibroids, scar tissue)
c.Immunologic implantation dysfunction (IID)
d.Endocrine/molecular endometrial receptivity issues
Certain causes of infertility are repetitive and thus cannot readily be reversed. Examples include advanced age of the woman; severe male infertility; immunologic infertility associated with alloimmune implantation dysfunction (especially if it is a “complete DQ alpha genetic match between partners plus uterine natural killer cell activation (NKa).
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
•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
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, My nurse has told me that Cetrotide will lower progesterone levels (1.6 at Stim day 4). How does this work? I can’t find any evidence that this Cetrotide is marketed for this purpose.
I apologize, I cross posted this with your old blog.
Not true!
Geoff Sher