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,
Are you aware of any connection between estrogen and increased TSH. I am in the middle of a FET cycle and am due to transfer a PGD tested AA D5 embryo on Monday, however my TSH level has jumped from 2.24 at the beginning of my cycle to 4.62 on D11 of my cycle. I noticed this occurred on my last unsuccessful cycle too and as soon as I stop estrogen my TSH returns to normal. My fertility specialist isn’t aware of such a connection but I am certain that it is the estrogen causing it and am not sure if it is something that should be treated or not, given the time period it takes for thyroid medication to work and the fact that it isn’t needed at the outset of my cycle. I obviously don’t want to transfer a good quality PGD normal embryo if this may be a concern. I am starting to think I have some kind of pituitary gland dysfunction. What do you think? Thanking you in advance 🙂
I know of no such connection. However, the raised TSH could be providing a hint of impending hypothyroidism which in women is commonly associated with an autoimmune disease where in 50% of cases there will be an immunologic implantation dysfunction (IID) due to activation of uterine nattural killer cells (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
•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!
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to 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.
Dr. Sher,
I was diagnosed with endometriosis stage IV when I was in my early twenties. Was put on bcp until age 38 when my husband and I decided to TTC. After 6 months of no luck, we consulted with an infertility specialist. Tests revealed FSH 21, AMH 0.25. Sperm count was good but showed poor motility. Also the dye test revealed dye collected around ovaries and did not flow beyond. IVF was determined as the best protocol. I was immediately advised to take 81mg aspirin, 75mg DHEA everyday, 200-400 Coq10 (I did 400), 2000 IU of Vitamin D, pre-natal vitamins (had been taking these for 8 months already). I also chose to continue taking fish oil (1200mg daily) and probiotics a few times a week. Prior to IVF, my physical revealed low Vitamin D level of 19.4. A month later they were at 31 (after taking Vitamin D supplements). After these results, I was advised by infertility clinic to continue taking 2000 IU of Vitamin D and here we are in June and I am still taking 2000 IUs of Vitamin D. I was placed on an aggressive fast-track IVF protocol after it was discovered that I had just ovulated. On 5/17, I was on Cetrotide injections for 3 nights and Vivelle 0.1mg patch every other day until Day 1 cycle of my period. Then after baseline ultrasound and bloodwork, I began stims on 5/23: 450 IU of Gonal-F, 2 vials of Menopur (75IU each) and 100mg of Clomid (for 5 days). Day 6 revealed estrogen level of 75. Day 7 (5/29) I began omnitropin injection 2.9ml (50 units) daily until Day 12. Day 8 revealed estrogen level of 195 and small growth of follicles. Cycle was continued even though doctors were discouraging—I was told I should have estrogen levels closer to 1000. Day 10 revealed estrogen levels of 401 and showed 6 follicles (3 on each ovary with at least 3 on the right at 16). Doctor said I am behaving as if it is day 6. Left ovary growth revealed 3 around 10 size. Day 12 revealed estrogen levels of 636 and progesterone was at 0.9. Ultrasound showed 6 follicles continuing to grow with 3 on the right at 19. Day 13 ultrasound showed only 4 follicles: 1 on the right at 16 and 3 on the left around 10. These numbers made no sense to me nor my husband. How could 2 of my follicles disappear within 24 hours? Doctor could not explain. Also progesterone was 1.9 on this day so trigger was done that night (10,000 of pregnyl). Today was my retrieval (6/6) and was told there were no eggs in my follicles. None were retrieved. We were told this is no surprise as my FSH was so high and yet the doctors did not prepare us for this possibility. I hope you can provide some insight.
Clearly you have diminished ovarian reserve (DOR). Your “empty follicles” is probably due to “prematureluteinization (see below). You in my opinion, requires a very individualized and strategic ovarian stimulation protocol.
Women who have diminished ovarian reserve (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.
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
•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!
•Endometriosis
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF
•Implications of “Empty Follicle Syndrome and “Premature Luteinization”
•Premature Luteinization (“the premature LH surge): Why it happens and how it can be prevented
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.
Dear Dr. Sher,
I just went through my first failed ivf cycle. I was put on birth control pills for almost two months to address my cysts. After the failed ivf cycle, the doctor concluded that I may have been over suppressed. I will be doing a second round starting July 23rd. I will be doing estrogen priming and adding Human Growth Hormones to this cycle. My insurance does not cover any of the costs, so I’m nervous about spending so much on medication and having another failed cycle. My doctor already started me on estrogen (4mg a night). Since I will be on estrogen for a month and a half before staring stims meds, is there a risk of over suppression with estrogen priming for a month and a half? I’m nervous that the estrogen will over suppress me just like the progesterone only bcp did a couple months ago. I should mention that I cannot do the June cycle because I’m traveling for work and could for three weeks out of state which is why I’m doing the second cycle in July.
Thank you in advance!
Hi Sadie,
I know your RE is pulling out all stops for you. However, there is often a difference in approach from one IV doctor to another. So without criticizing what you are doing, I would prefer to give you some insight into my approach.
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
•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?
•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.
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 just went through a FET. My first HCG blood work was 65, second was 87, and the third was 196. The doctor was hoping the third blood work would be in the 300s. Does this sound like I am having a chemical pregnancy or does this sound like just a slow progressing pregnancy?
It is hard to say Morgan. This is an aberrant rise in hCG is however somewhat alarming. Alas only time willtell!
Geoff Sher
Hi Dr Sher, Would you recommend transferring embryos at day 3 or day 5? What are the advantages and disadvantages of each?
I am 44 years old. I have 7 top quality embryos frozen at day 3. I am on my second cycle and am looking to bank more embryos to do PGS testing on them all. I need to decide whether to take the embryos to day 3 or day 5 for PGS then do a frozen embryo transfer.
I would really value your opinion.
Kind regards,
Louise
Embryo transfer (ET) is undoubtedly a rate limiting factor when it comes to IVF outcome. In fact, in my opinion, it is the single most important procedural step in IVF. Optimal performance of ET takes practice, confidence, dexterity, timing, gentility and skill. Of all the hands-on procedures involved in the IVF process, embryo transfer is by far the most difficult to teach. In fact, any women fail to conceive simply because the practicing physician did (could) not perform this procedure optimally.
The issue of whether it is better to transfer early (day 2-3,post fertilization) cleaved embryos rather than (day 5-6) blastocysts continues to rage. Here I wish to focus on the reasons why I favor transferring blastocysts.
Not too long ago, it was believed that the sooner an embryo was transferred into the “natural environment” of the uterus, the greater would be the chance of it implanting and propagating a viable pregnancy. Thus most IVF physicians advocated day 2 or day 3 embryo transfers preferentially. About 20 years ago, we began to realize that there was no validity to the belief that an embryo would develop better and have a greater chance of propagating a baby by being inside the uterus earlier than it would by being allowed to first develop into a blastocyst in an incubator. About a decade later, it was realized that cleaved embryos that fail to develop into blastocysts are with few exceptions numerically chromosomally “incompetent” (aneuploid) such that had they been transferred earlier, they almost certainly would not have developed into blastocysts and would not have propagated a pregnancy anyway. Now most of us practicing in this field believe it to be preferential to selectively transfer blastocysts rather than earlier cleaved embryos. Don’t get me wrong! I am not saying that there is never a place for doing earlier pre-blastocyst transfers. Patients that only have one or two cleaved embryos available might as well transfer them early.
The recent popularization of full preimplantation genetic sampling (PGS) using methods such as comparative genomic hybridization (CGH), next generation gene sequencing (NGS) and SNP array, now allow us to identify those blastocysts that are the most “competent”. Selective transfer of such embryos improves the implantation rate per embryo by a factor of 2-3.
It is important to bear in mind that morphologically good looking day 3 embryos/blastocysts that are determined microscopically to be of a “high grade” , are by no means always numerically chromosomally “competent” euploid , and the likelihood of such embryos being “competent” diminishes progressively with advancing age of the woman. Only through the performance of full PGS can his age-related discrepancy be reduced.
While it would be acceptable to me to transfer 2 PGS-untested blastocysts to women under 39 years, and to transfer 3 to older women, I would not recommend transferring more than 2 PGS-normal embryos at any age.
The following are arguments in favor of performing blastocysts transfers:
•By waiting to day 5-6 many unworthy, many aneuploid and “incompetent” embryos can be culled out, thereby allowing for the transfer of fewer embryos and minimizing the risk of high order multiple pregnancies.
•Diagnostic Advantages:
o Failure of the expected number of cleaved embryos to advance to the blastocyst stage of development in culture, raises the suspicion of underlying inherent embryo “incompetence”, which is usually (but not exclusively) egg-related rather than due to a sperm factor. While age of the woman is the most important factor involved, it can also be due to the wrong protocol of ovarian stimulation being used).
oIt facilitates the performance of PGS to identify and then selectively transfer only most “competent” (euploid) blastocysts. In such cases, provided there is no underlying uterine implantation dysfunction implantation and pregnancy rate is enhanced significantly.
Of course, for the treating physician it is far less stressful not have to have to confront a patient with her having no surviving embryos to transfer. The avoidance of this has in my opinion, in the past, been one of the main reasons why IVF practitioners have elected to transfer cleaved embryos rather than blastocysts. But such a policy is usually not in the in the patients’ best interest. In my opinion, it is far better to advise the patient to do a blastocyst transfer since that is almost always in their best interest.
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
•Blastocyst Embryo Transfers Should be the Standard of Care in
•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.
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
•
•