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.
Is it okay to be on birth control prior to an IVF cycle if you are a poor responder? I take that I am a poor responder having had 10 follicles, 7 mature and 4 fertilized.
One often hears the expressed opinion that the BCP suppresses response to ovarian stimulation. This is not the case, provided that the BCP is overlapped with administration of an agonist (e.g. Lupron, Buserelin, Superfact) for several days leading up to the start of menstruation and the initiation of ovarian stimulation cycle with gonadotropin drugs. If the latter precaution is not taken, and the cycle of stimulation is initiated coming directly off the BCP the response will often be blunted and subsequent egg quality could be adversely affected.
The explanation for this is that in natural (unstimulated) as well as in cycles stimulated with fertility drugs, the ability of follicles to properly respond to FSH stimulation is dependent on their having developed FSH-responsive receptors . Pre-antral follicles (PAF) do not have such primed FSH receptors and thus cannot respond properly to FSH stimulation with gonadotropins. The acquisition of FSH receptor responsivity requires that the pre-antral follicles be exposed to FSH, for a number of days (5-7) during which time they attain “FSH-responsivity” and are now known as antral follicles (AF). These AF’s are now able to respond properly to stimulation with administered FSH-gonadotropins. In regular menstrual cycles, the rising FSH output from the pituitary gland insures that PAPs convert tor AF’s. The BCP (as well as prolonged administration of estrogen/progesterone) suppresses FSH. This suppression needs to be countered by artificially causing blood FSH levels to rise in order to cause PAF to AF conversion prior to COS commencing, otherwise pre-antral-to –antral follicle conversion will not take place in an orderly fashion and the follicles will not readily respond to gonadotropins (FSH) , thereby delaying follicle development by up to 7 days and compromising egg quality. GnRH agonists (e.g. Lupron, Buserelin, Superfact) , cause an immediate surge in release of FSH by the pituitary gland thus causing conversion from PAF to SAF. This is why, women who take a BCP to launch a cycle of COS need to have an overlap of the BCP with an agonist.
By overlapping the BCP with an agonist for a few days prior to menstruation the early recruited follicles are able to complete their developmental drive to the AF stage and as such, be ready to respond appropriately to optimal ovarian stimulation. Using this approach, the timing of the initiation of the IVF treatment cycle can readily and safely be regulated and controlled by varying the length of time that the woman is on the BCP.
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.
• 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
•Optimizing Response to COS in Poor Responders (DOR): A Personal Approach!.
•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
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.
Between fresh and frozen embryo transfers, which ones tend to have a higher success rate typically and why? The Nka issue I see you referring to often in your posts, is there anything medically that can be done to correct or help this (medications)? Is it possible for someone with this issue to ever have a successful pregnancy or is it just more challenging?
Frozen transfers do at least as well as fresh…in some cases better! This is probably becauase we can better fine tune the endometrium with hormone therapy than with ovarian stimulation.
As for treatment of immunologic implantation dysfunction (IID), please see below.
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
•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
•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
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.
Geoff Sher
Hello. Sorry if this is a duplicate. Not sure first went through. I am 39 yrs old, (40 in Sept,) husband is 42. We have been ttc for 10 mths. Got preg on our own at 7 mths, but had a miscarriage at 6 weeks. My TSH- 2.030, Estradiol – 56.3 pg/ml, LH – 6.5 miu/ml, FSH 8.2 miu/ml, AMH 2.8 ng/ml. Will have Progesterone test and semen analysis soon. Rubella, 2.18 index, Varicella 484 index. Ultrasound in April 2016, after miscarriage, shows: I have an enlarged retroverted uterus containing a myopia, 6.1 in size and left fundal, intramural in position. Endometrial lining is 12mm. Ovaries were imaged and appeared unremarkable. Do you think the fibroid will prevent me from getting preg/carrying to term and/or be a reason I would not be a good candidate for iui or ivf? And should we consider fertility treatments now or keep trying on our own. Nervous about approaching 40 but don’t want to jump the gun $$$. My ob/gyn said after 3 more cycles (which would be 6 cycles after miscarriage,) that she would possibly prescribe clomid. Haven’t spoken with any RE yet. You’re the first. Thank you in advance for any advice!
I have previously responded to this post!
Geoff Sher
I am 33 years old and have been through 2 rounds of IVF. First cycle I was on BCP, Suprefact and 225 units of Menopur. We got 12 eggs, 10 mature, 5 fertilized ICSI, 2 transferred on Day 3 resulting in miscarriage, 1 blast frozen (FET failed). Second cycle I was on BCP, Suprefact and 300 units of Menopur. Retrieved 15 eggs, 14 mature, 5 fertilized ICSI, 1 blast frozen – we could not do a fresh transfer due to high progesterone levels.
We are looking to a 3rd cycle to bank embryos as we have been advised there were egg quality issues in the second cycle. Dr has advised new protocol of 150 units Gonal F and 150 units Menopur
1) What are your thoughts on the new protocol?
2) Should we be continuing to use Menopur at all?
3) Was my elevated progesterone in our second cycle a result of our protocol (300 units Menopur) and did the higher progesterone have an effect on egg quality?
4) I have hypothyroidism (but have low thyroid antibodies) and B12 anemia. I have tested negative for all of the immunologic dysfunction blood tests (however have not had a Natural Killer cell bloodtest). Would you recommend the use of prednisone? Our dr. is against it as I’ve only had one miscarriage and has no reason to believe we need it as we had negative bloodwork.
I would like to add that I have AMH of 1.7 ng/ml, and have been informed by our dr that FSH and antral follicle counts are very good.
1The raised progesterone prior to hCG trigger is not a good sign as it suggests possible premature luteinization (see below). Also the issue pertaining to protocol selection is also covered in the articles on my blog, below.
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.
•Optimizing Response to COS in Poor Responders (DOR): A Personal Approach!.
•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?
•Why did my IVF Fail
•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
•
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. Sher,
Thank you for this blog! I’m 32y/F from India. I have suffered 3 MCs in the last 1.5 years of which 2 were natural pregnancies and last one IUI. First loss happened at 8 weeks after seeing fetal heart and last two happened at 6 weeks. After 2 losses that had normal karyotype we consulted an RE who ran a battery of tests (thrombophelia profiles – APA, MTfHR, factor V leiden, protein C&S etc that all came normal. My husband and I have no HLA match (dq alpha) and our karyotype are normal. There is no MFI. I tested positive for TAI (both TPO and ATG positive). We didn’t test for NK cells as these tests are not reliable in INdia. Before our last pregnancy attempt through IUI RE had treated me with IVIg infusions (50g every 21 days (my weight is 57kg, 3 infusions) and 10mg prednisolone. IUI worked and after my first beta (700 18dpo) I was given my 4th ivig infusion. I suffered my 3rd miscarriage at 6 wks. By this time I had taken 4 ivig infusions and was on 10mg prednisolone plus clexane 40mg along with metformin 500mg and 400mg of vaginal progesterone.
We are now being recommended IVF PGS (using NGS) and I am continuing ivig infusions (have taken 6- 50g every 21 days since mid march) we will restart prednisolone 10mg once cycle starts and clexane 40mg will be started after transfer.
Is this the best way forward for us or has IVIG failed for us and we should explore gestational surrogacy? Should ivig have worked in 4 infusions or it can take longer. Lastly last MC was spontaneous so we could not karyotype it. Should we try LIT?
Much appreciate your time.
Thanks
Would like to add that I am on 50mcg thyrox (have been on last two pregnancies) an TSH is around 2. Further last tested FSH was 5, LH 5.1 and prolactin 12 (limit <26) and AmH is 4.1
Very respectfully, you have not had a full and thorough immunologic assessment in my opinion. Your DQ alpha and HLA + NK activity and antithyroid antibody testing and an immunophenotype in my opinion should be repeated. I suggest that you contact Reproductive Immunology Associates (RIA) in Van Nuys, CA or ReproSource in Boston, MA (their contact information is available on Google) and have your and your husband’s blood sent there. This to me appears to more than likely be a case of Immunologic Implantation Dysfunction. I would be pleased to discuss this with you one on one via Skype, once the above mentioned tests have been repeated (as i recommended) and I have had the oportunity to review ALL available records.
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
•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
•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
•IVF-Gestational Surrogacy: An Overview
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.
Thank you for your response Dr. Sher! Last question- will the immunotherapy vary based on the results? Will ivig dosage/frequency or steroids dosage vary? Thank you again!