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.
I wasn’t sure which blog was still active, so sorry if I double posted
Dr Sher,
I’m currently in cd6 and my first scan this morning showed I have a total of six follicles, three of which are already at 16mm. My RE plans on triggering me this Saturday on CD8. I’m concerned over egg quality/maturation. The trigger that he prescribed to me is ovidrel 250. Should I talk to him about adding on 10,000 hcg like noravel and trigger with both?
This is definitely the preferred site for me Melanie.
Obviously I cant tell your RE what to do, but I either use 500mcg of Ovidrel or 10,000U hCGu.
Good luck!
Geoff Sher
Dear Dr. Sher,
My husband and I are both 32. He was diagnosed with azoospermia as a result of undescended testicle and I was diagnosed with endometriosis. I had a laparoscopy to remove a right endometrioma and widespread nodules in 2013.
Our first cycle wasn’t successful and our second ended up being ectopic, it ruptured and I had my right tube removed.
We tried the agonist protocol on our first cycle using 300 IU Gonal F. On our second cycle we tried the antagonist protocol using a combination of Gonal F 100 IU and Menopur 150. Cycle one I had 6 retrieved, 4 was mature and 2 fertilised, we transferred a 6 and 8 cell embryo with some fragmentation on day 3. Cycle two I had 12 follicles, 6 eggs retrieved, 4 was mature and 2 fertilised, we transferred 2 compact morals with no fragmentation.
On both cycles both eggs and sperm where not of great quality.
I have a AMH < 4.0 pmol/L and FSH is 7.4 U/L.
Would you recommend trying the agonist/antagonist protocol? Or would you recommend switching to donor?
Also, would you recommend that I get immune testing done?
Thanks,
Donna
Thanks for posting, Donna,
First, you need to be aware that in 30% of cases, endometriosis is associated with an immunologic implantation dysfunction and this needs to be addressed in the ET cycle.
You have severely diminished ovarian reserve and no doubt, your biological clock is running out of time. You need toi be very proactive. i would use a modified long pituitary down-regulatuion protocol with estrogen priming (agonist/antagonist conversion protocol with estrogen priming) + human growth hormone supplementation. i would also seriously consider Staggered IVF with “Embryo banking” of PGS-selected embryos to try and make hay while the sun still shines and I would not waste a minute in starting.
Your husband’s issue probably mandates that you consider using donor sperm.
I urge you to access my new blog. When you get to the “home page” of the Blog on this website. Go to the home page of the blog and find the “search bar”. Typeype in any of the articles below by title, “click” and you will immediately be taken to these. While on this blog, please take the opportunity 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
•Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
•Ovarian Stimulation for IVF: Comparing “conventional” use of GnRH antagonists to the Agonist/Antagonist Conversion Protocol (A/ACP)
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?.
•Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
•IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
•The Role of Nutritional Supplements in Preparing for IVF
•Frozen Embryo Transfer (FET): What Does it Involve?
•Hereditary Clotting Defects (Thrombophilia)
•Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
•PGS-Biopsy for the Assessment of Embryo Numerical Chromosomal integrity (Ploidy): Should it be done on Day 3 or on Day 5-6 post fertilization?
•Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
•Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
•Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
•Male Factor Infertility
•The Sperm Chromatin Structure Assay (SCSA): A Measure of the Potential of Sperm to Help Propagate a Viable Pregnancy
•Endometriosis and Infertily
•Treating Ovarian Endometriomas with Sclerotherapy
•IVF Egg Donation: A Comprehensive Overview
Might I 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.
Call 702-699-7437 if you wish to discuss your case with me in detail via Skype.
Geoff Sher
@GeoffreySherMD what would you recommend after 3failed icsi. D2,D5,then D3 transfer.unexplained infertility both 30yrs old.had D&C ’07 With a previous partner
Lou, when confronted with “unexplained” IVF failures where morphologically good embryos were transferred, the question arises as to whether the problem is due to inherent egg/embryo “incompetence” (which usually equates with an irregular chromosomal configuration [aneuploidy]) or whether it is due to an implantation dysfunction.The younger the woman and the higher the quality of available embryos (preferably blastocysts), the less likely it is that the fault lies with embryo “incompetence” and the greater is the likelihood that it is due to underlying implantation dysfunction.
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)
Implantation dysfunction (anatomical or immunologic) is a common cause of repeated “unexplained” IVF failure with good embryos. 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.
I urge you to access my new blog on this website. When you get to the “home page” of the Blog, find the “search bar” and type in any of the articles below by title, “click” and you will immediately be taken to these.
•Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
•IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
•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)
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
•The Role of Nutritional Supplements in Preparing for IVF
•Frozen Embryo Transfer (FET): What Does it Involve?
•Hereditary Clotting Defects (Thrombophilia)
•Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
•PGS-Biopsy for the Assessment of Embryo Numerical Chromosomal integrity (Ploidy): Should it be done on Day 3 or on Day 5-6 post fertilization?
•Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
•Male Factor Infertility
•The Sperm Chromatin Structure Assay (SCSA): A Measure of the Potential of Sperm to Help Propagate a Viable Pregnancy
•Endometriosis and Infertily
I invite you to call 702-699-7437 or 800-780-7437 and set up a one hour Skype consultation with me to discuss your case in detail.
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
Good Morning DR. Sher;
I am really hoping you can give me some insight as to what direction I should take. I have been trying to conceive for the last 15 years. The first 10 years of IVF’s we suffered repeated miscarriages. The last 5 I ended up with what they said was DOR. My Fsh varies from 5 -12. I was told to move onto donor eggs. My first donor egg cycle in June resulted in twin blighted ovum. We did a fresh cycle with a new donor in November that was negative. After being fed up, I took it upon myself to do immune testing with RMI in California. These tests showed a normal Nk assay result, Treg at 0.3. and my TNF-a-IL-10 was horrible at 45.9. I do have Hashimoto’s and am on Synthroid. I also did intralipids, 5mg of prednisone starting on the day of the donors retrieval as well as lovenox 40mg 1x a day. After my pregnancy in June for some reason another IL was not done. My RE’s office is suggesting that I move on to surrogacy. Since my embryo’s are in Europe, this is not possible. Is this something that is treatable so that I can use my last 4 blasts, or should I just call it quits?
Thank you so much for your time, and all that you do to help those of us that are in desperate need.
The TNFa result suggests that you do have NK cell activation, since activated NK cells are the main source of TH-1 cytokines. I thus suspect an error in interpretation. Remember also that NK cell concentration is irrelevant. Itis NK cell activity as measured by the K-562 Target cell test that matters. Also, taking IL on the day of ER is far too late for it to be effective. Finally, it is essential before going any further to determine whether you have autoimmune or allimmune implantation dysfunction and that requires that you and your partner be tested for DQ alpha/hHla matching.
I urge you to consider allowing me to review your case. For that to happen we need to consult. Please call 1-702-699-7437 or 1-800-780-7437 ASAP and ask Tina to arrange for us to interact via Skype.
Also, please read all the articles referenced below and which can be found on my blog on this very website,www.DrGeoffreySherIVF.com which also hosts the blog. From the home page of this website you can access the blog and the “search bar” where you can type in a topics (below) , click and you will be taken to the article of your choice.
•Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
•Ovarian Stimulation For Women with Diminished Ovarian Reserve (DOR) and in Older Women undergoing IVF
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
•Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
•Unexplained IVF Failure
•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)
•Recurrent Pregnancy Loss (RPL): Why do I keep losing my Pregnancies?
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
•The Role of Nutritional Supplements in Preparing for IVF
•Frozen Embryo Transfer (FET): What Does it Involve?
•Hereditary Clotting Defects (Thrombophilia)
•Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
•PGS-Biopsy for the Assessment of Embryo Numerical Chromosomal integrity (Ploidy): Should it be done on Day 3 or on Day 5-6 post fertilization?
•Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
•Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
•Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
Finally, perhaps you would be interested in accessing 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.
Geoff Sher
Hi Dr.Sher
I’m 28/f with unexplained infertility.I have pcos but regular with periods other than that my reports and my husbands are normal .I’m married for 5 years but took conterceptive pill for 2 years after that I was diagnosed with chronic vaginal infection .I took medicine several times for infection and now I think it’s fine.I took ovulation medicine 15 times but failed, iui but failed , ivf with icsi(agonist protocol) 4blastocyst were transfered but failed, fet 3 embryos 3 day embryo were transferred but failed.now I don’t know what to do I gave up hope .I’ll be grateful if u could help.
Hello Dr Sher,
I have pcos and I my situation is worsen by immune issues
I tested for various immune issues and my results are as follows:
[u][b]DQ Alpha Genotype[/b][/u]
Me HLA Genotype: 1.3, 2.0
Spouse HLA Genotype:1.4, 2.0
[u][b]NK Cells[/b][/u]: normal
[u][b]Anti-Paternal Leukocyte Antibody:(Negative)[/b][/u]
T-Cells : 0.3
B-Cells: 8.1
No Auto Nuclear Anitbody and Anit Phospolid antibody.
I would like to understand what these results mean. Please help.
In the absence of activated NK cels (NKa), the partial genotypic matching will not compromise implantation in my opinion. Both NKa+ and DQ alpa/HLA matching need to co-exist to create the problem. The absenece of paternal leukocyte antibodies is irrelevant.
PCOS is a separate issue that requires that the protocol used for ovarian stimulation be carefully selected. Please go to the article on PCOS, to be found on the blog in this website.
I am proud to announce the establishment of my new website, http://www.DrGeoffreySherIVF.com which also hosts my new blog which I will be servicing with articles on an ongoing basis and where I will be addressing your questions and comments.
From the home page of this website you can access the blog and the “search bar” where you can type in a topics (below) , click and you will be taken to the article of your choice. I will also continue to answer all questions you post on the “IVFauthority” blog but will no longer be contributing new articles on that site.
•Understanding Polycystic Ovarian Syndrome (PCOS) and the Need to Customize Ovarian Stimulation Protocols.Controlled Ovarian
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
•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)
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
•The Role of Nutritional Supplements in Preparing for IVF
•Frozen Embryo Transfer (FET): What Does it Involve?
•Hereditary Clotting Defects (Thrombophilia)
•Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
•PGS-Biopsy for the Assessment of Embryo Numerical Chromosomal integrity (Ploidy): Should it be done on Day 3 or on Day 5-6 post fertilization?
•Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
If you are interested in having a Skype consultation with me and discussing your case in detail, please call 1-702-699-7437 or 1-800-780-7437.
Finally, perhaps you would be interested in accessing 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.
Geoff Sher