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 there,
So I’m coming off my first failed IVF cycle. Want to stay encouraged for our next try but I guess I’m looking for hope.
I’m 37, husband is 37. Neither of us have known fertility issues and have a 4 year old son who was conceived naturally. I also had a pregnancy a little over two years ago that ended at 6 weeks.
After no pregnancy since we decided to try IVF. I was taking suprefact to down regulate… Then started 150 each of menupur and gonal f. After 10 days of stims I had 7-8 follicles measuring 17/18. I took my trigger shot and 36 hours after had my retrieval. 12 eggs and out of the 12, 9 fertilized. No ICSI.
Out of those 9, 5 made it to day 5. Three full blasts graded 19, 19 and 20. Also two early blasts that could possibly make it to extended blasts but probably won’t have the 19/20 grading. We transfered grade 19 (and the time of transfer the 20 wasn’t a 20 yet) and they called that afternoon to say they froze 4. I should also note that they said during my checks that my uterus was thickening up beautifully.
I waited until 6 days post my 5 day transfer… Took a urine test.. Positive. Took another test two days later, more positive (darker line). Took ONE more test two days later again ( now 10 days post 5 day transfer) still positive. I then waited 4 days and took another. Nothing. I was scheduled to get my beta blood in 2 days which would have been 16 days past transfer but the clinic knew I was upset and said go one day early if I liked and get it checked. Sure enough.. Nothing. I’m assuming I had a chemical pregnancy?
Also.. Since retrieval I had been taking estrace , one pill twice a day… And three times a day taking two progesterone balls as a suppository. Also in this mix is my low dose aspirin I had been taking for a few months.
So to me… So many positives. Or at least I thought so, yet it didn’t work. We are going to attempt a FET using our grade 20 embryo. The clinic said for me to call them when I get my second bleed which will probably be late July.
We are just devastated and I want to try this next cycle doing all I can. What could I eat or avoid to eat that is helpful. I have been doing acupuncture… I had an appointment 3 days before transfer. Should I book a appointment on the day of transfer or the day after? Does my situation sound encouraging? I just don’t know what to think. We are just so desperate to add one more member to our family.
Thank you for any advice you can offer.
I would not read too much into your 1st attempt. In fact the very fact that you had a chemical pregnancy suggests that the embryo (s) started to attch and while the outcome was negative it could still represent a “dark cloud with a silver lining”. Your stimulation went well and the yield of blastocysts was excellent…thus I am optimistic.
I have no dietary recommendations and accupuncture might be a good idea shortly before or after the FET.
I wish you good luck!
Geoff Sher
PH: 702-533-2691
Dr Sher,
I have undergone one failed IVF cycle. I am a 33 yo female with an AMH of 1.45, Day 3 FSH 8.1 LH 4.0 Estradiol 50 Prolactin 14.5. I started BCP on 5/5/16 until 5/11/16 and on 5/12/16, a cyst was noted with an estradiol of 151. By 5/15/16 the cystic structure was largely gone and estradiol dropped to 60 and I started Lupron 1mg x 3 days, Gonal-F 225 and Menopur 225 through 5/23; Labs were as follows 5/20 E2 252 LH 8.4, 5/23 E2 436 LH 0.9 and 5/24 Es 536 and LH 1. At this point only had follicles measuring 16×13, 14×14 and two that were 10×9. Gonal F was increased to 300 =, Menopur remained 225 and cetrotide was added for 2 days. This resulted in 2 large follicles 25×26, 24×19 and a smaller 14×13 and 12×11 and I took the trigger shot late 5/25/16. on 5/26 my estradiol was 786 and progesterone was 7.67. Day of ER, 3 follicles were collected but only one contained a mature egg that did not make it past day 3. I have just met with my doctor regarding a second IVF cycle and his proposed approach is to not take BCP and to start stimulation medications on Day 2 which would include a similar “flare” approach of Lupron x 3 days and GonalF 150 and Menopur 75, as well as adding growth hormone as an adjunct. I am not convinced this is the best protocol but he is concerned about possible over-suppression by starting Lupron prior to the onset of menses? Would love to get your opinion regarding the proposed protocol for a second cycle of COH. Thank you for having this blog. It truly helps during such a difficult and complex process.
Women who (regardless of age) 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”.
In my opinion, 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).
Respectfully, I try to avoid using such protocols/regimes (especially) inwomen e 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.
• 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)
•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 IVF
•Frozen Embryo Transfer (FET) versus “Fresh” ET: How to Make the Decision
•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 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?
•PGS and Assessment of Egg/Embryo “competency”: How Method, Timing and Methodology Could Affect Reliability
•Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
•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
•Premature Luteinization (“the premature LH surge): Why it happens and how it can be prevented.
•Fertility Preservation (FP) Through Freezing/Banking Human Eggs
•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
I would like to ask this question, I have stage 4 endometriosis but I am still fertile, currently on the prostap injection, my last inj is on the 15th of July. Is there anyway possible to find out if the substance from the injection (or its effects) are still in my blood stream? If I can help it I would rather not be the cause of disability in my near future baby. Thank you very much in advance dr.
Prostap is a long-acting agonist. It can remain in your system for a month or longer. You will know when you are free of it once, after stopping, you start having regular menstruation again.
Geoff Sher
My wife had 3 day transfer on June 15. The Dr. office scheduled blood test on June 21, which seemed early to me, but I didn’t object at the time. The Dr. called my wife later that day and told her the results were negative, but then confirmed the day of the transfer and said we should schedule another test on the June 24. If we have to get potentially negative results again this week, I fear it is overly hard on my wife. Why would we have been asked to do the earlier test if it is not definitive? Was there some value?
I agree that with a day-3 ET on June 15th, doing a blood beta hCG on June 21st) is somewhat early. This having been said, we always do at least 2 tests for a trend.
I know of no medical announcement associated with the degree of emotional anticipation and anguish as that associated with a pending diagnosis/confirmation of pregnancy following infertility treatment. In fact, hardly a day goes by where I am not confronted by a patient anxiously seeking interpretation of a pregnancy test result.
Testing urine or blood for the presence of human chorionic gonadotropin (hCG) is the most effective and reliable way to confirm conception. The former, is far less expensive than the latter and is the most common method used. It is also more convenient because it can be performed in the convenience of the home setting. However, urine hCG testing for pregnancy is not nearly as reliable or as sensitive e as is blood hCG testing. Blood testing can detect implantation several days earlier than can a urine test. Modern pregnancy urine test kits can detect hCG about 16-18 days following ovulation (or 2-3 days after having missed a menstrual period), while blood tests can detect hCG, 12-13 days post-ovulation (i.e. even prior to menstruation).
The ability to detect hCG in the blood as early as possible and thereupon to track its increase, is particularly valuable in women undergoing controlled ovarian stimulation (COS) with or without intrauterine insemination (IUI) or after IVF. The earlier hCG can be detected in the blood and its concentration measured, the sooner levels can be tracked serially over time and so provide valuable information about the effectiveness of implantation, and the potential viability of the developing conceptus.
There are a few important points that should be considered when it comes to measuring interpreting blood hCG levels. These include the following:
•All modern day blood (and urine) hCG tests are highly specific in that they measure exclusively for hCG. There is in fact no cross-reactivity with other hormones such as estrogen, progesterone or LH.
•Post conception hCG levels, measured 10 days post ovulation or egg retrieval can vary widely (ranging from 5mIU/ml to above 400mIU/ml. The level will double every 48–72 hours up to the 6th week of gestation whereupon the doubling rate starts to slow down to about 96 hours. An hCG level of 13,000-290, 0000 mIU/ml is reached by the end of the 1st trimester (12 weeks) whereupon it slowly declines to approximately 26,000– 300,000 mIU/ml by full term. Below are the average hCG levels during the first trimester:
o3 weeks LMP: 5 – 50 mIU/ml
o4 weeks LMP: 5 – 426 mIU/ml
o5 weeks LMP: 18 – 7,340 mIU/ml
o6 weeks LMP: 1,080 – 56,500 mIU/ml
o7 – 8 weeks LMP: 7, 650 – 229,000 mIU/ml
o9 – 12 weeks LMP: 25,700 – 288,000 mIU/ml
•A single hCG blood level is not sufficient to assess the viability of an implanting embryo. Caution should be used in making too much of an initial hCG level. This is because a normal pregnancy can start with relatively low hCG blood levels. It is the rate of the rise of the blood hCG level that is relevant.
•In some cases the initially hCG level is within the normal range, but then fails to double in the ensuing 48-72hours. In some cases it might even plateau or decline, only to start doubling appropriately thereafter. When this happens, it could be due to:
oA recovering implantation, destined to develop into a clinical gestation
oA failing implantation (a chemical pregnancy)
oA multiple pregnancy which is spontaneously reducing (i.e., one or more of the concepti is being lost) or,
oAn ectopic pregnancy which will either absorb spontaneously (a chemical-tubal gestation), or evolve into a full blown tubal pregnancy continue and declare itself through characteristic symptoms and signs of an intraperitoneal bleed.
•The blood hCG test needs to be repeated at least once after 48h and in some cases it will need to be repeated one or more times (at 48h intervals) thereafter, to confirm that implantation is progressing normally.
•Ultimately the diagnosis of a viable pregnancy requires confirmation of the presence of an intrauterine gestational sac by ultrasound examination. The earliest that this can be achieved is when the beta hCG level exceeds 1,000mIU/ml (i.e., around 5-6 weeks).
•Most physicians prefer to defer the performance of a routine US diagnosis of pregnancy until closer to the 7th week. This is because by that time, cardiac activity should be clearly detectable, allowing for more reliable assessment of pregnancy viability.
•There are cases where the blood beta hCG level is extraordinarily high or the rate of rise is well above the normal doubling rate. The commonest explanation is that more than one pregnancy has implanted. However in some cases it can point to a molar pregnancy
•Finally, there on rare occasions, conditions unrelated to pregnancy can result in detectable hCG levels in blood and urine. They include ovarian tumors that produce hCG, such as certain types of cystic teratomas (dermoid cysts) and some ovarian cancers such as dysgerminomas.
Geoff Sher
hello dr.i have a history of 3 ectopic pregnancy and my tubes were tied and clipped,at 33 i went to ivf long lupron protocol overlap with ocp ,recagon 300 was used with 2 eggs and both transfered and fet 2 day transfer failed,at 34 2nd ivf menogon 450iu reduced to 300 iu on day 4 10 eggs retrieved only 3 fertilised and dr.told poor quality embryo AMH 1.8.FAILED.FRESH TRANSFER.THIRD IVF MINI IVF ONE EGG FERTILISED DAy 3 tranfer failed.4 th ivf gonal f 225 iu eith menopur 75 iu 6 oocytes 4 m2 and 2 fertilised i perfect day 3 and other with 20% fragmentation fresh trasfer failed.
now at 36 i am doing my fifth ivf after my natural periods dr kept me on ocp for 10 days and after 5 days day 2 of my period stated gonal f 225i.u,and growth hormone4 i.u daily and clomiphene 100 mg till day 10 from day 5 menogon 75 iu added to above ,afc was 4,with a cyst.my fsh is generally 6-7,but after 10 days ocp it was 14.98 on day 2 of stimulation now my query is on day 6 i have 1.1,0.9.0.4 in my left ovary and right ovary follicles didn’t grow.is it advisable to continue further .how can i have my own baby.all 4 cycles we did icsi.all the 4 cycles growth of egg was not a problem,but know i feel growth is not good,all 4 cycle sperm was oligoasthenoteratozoospermia and now after antiooxidant he got perfect sperm count and casa report.suggest a protocol to get a take home baby.please help me we don’t have insurance for ivf.what should i do in this cycle,do fsh raise after 10 days of ocp after periods?
Older women as well as those who (regardless of age) 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
•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.
• 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)
•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 IVF
•Frozen Embryo Transfer (FET) versus “Fresh” ET: How to Make the Decision
•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 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?
•PGS and Assessment of Egg/Embryo “competency”: How Method, Timing and Methodology Could Affect Reliability
•Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
•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
•Premature Luteinization (“the premature LH surge): Why it happens and how it can be prevented.
•Fertility Preservation (FP) Through Freezing/Banking Human Eggs
•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