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.
Hello Dr Sher, if you are tested for DHEA what is this for? If you are in your mid 30s what should the result be for it to be good or normal? I am not trying to get pregnant right now but my doctor tested for it since I have acne and she gave me a drug called spironolactone to control it. Would this drug alter my ovary reserve and make it less for the future? I would like to start trying in maybe 6 months so wondering if this drug would make my eggs bad. I plan to stop taking it before we start trying as she said it can be dangerous to a foetus but will control the acne in the meantime. Help please!
The measurement is for DHEAS not DHEA. The former level helps determine if there is an adrenal gland (rather than ovarian) cause for increased male hormone (androgen production). The spironolactone (if indicated) should not significantly affect egg quality in my opinion.
Geoff Sher
Hi Dr Sher,
Earlier this year my doctor sent me for bloodwork which tested my cycle day 3 FSH several times about 6 months apart. First in February it was 5.4IU/L, (estrodial not tested.) Next in April it was 7.0IU/L and Estrodial was 139pmol/L. Last was in June it was 5.4IU/L again and estrodial was 116pmol/L. He also tested day 3 FSH back in 2014, 2 years ago and it was 6.1IU/L so very similar. Is this good or bad? should it go up or down? My doctor didn’t explain what this means. I am 37yrs of age. Can you please interpret for me in regards to my fertility status & chance for success either naturally or with IVF if needed? I am very grateful! Thank you, Tatiana.
This is a good level, suggestive of normal ovarian reserve (remaining eggs in the ovaries) and suggests that you should respond well to ovarian stimulation. More helpful is the AMH which can be tested any time in the b cycle. If it is >15pmol/L it would confirm normal ovarian reserve.
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)
•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?
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
hi. Today was my day 3 after egg retrieval and my embryo grades were 4-8A, 2-10A and 1-10C. what is survival rate of these embryos until day 5 . I am.going to do PGD and scared.
I was on gonal f 300 and hcg 10 units from second day of menses until 12th day and then triggered with Pregnyl… I had 14 eggs retrieved, 14 mature, 7 fertilized without icsi and all 7 made it to day 3 with cell grade memtioned above.. Now just want to understand my chance with day 5 and then they gonna freez and again do PGS and insert the embryo after my next periods. But afraid that atleast 2 shouls survive until day 5 else it is really unpredictable to just jave 1 embryo pgs tested. please answer
There are many factors other than the grade of embryos on day 3 that will affect the rate of conversion to blastocyst. But as a generalization younger women (under 35 years of age should see +/- a 40% conversion rate.
Good luck!
Geoff Sher
Dear Dr. Sher,
Does this sound like an agonist protocol? Taking birth control for 18 days then, 2 days of lupron prior to starting stims, continuing lupon while on stims 2 times a day. What is the purpose of taking dexamethasone while on stims. What does the 2 days of lupron before stims do? My AMH is 3 ng and follicle count was 18 last. I am 42 years old.
thanks,
Ashley
No that is not an agonist/antagonist protocol. See below….
The dexamethasone is thought to immmunomodulate the uterine lining to improve implantation.
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)
•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?
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
Dear Dr. Sher,
I am posting this for the 3rd time due to an apparent technical glitch.
I have a 5 yo son from ICSI2 (eggs were 33) and a 2 yo old daughter from ICSI4 (eggs were 36). I had one chemical pregnancy prior to my daughter but otherwise had BFN (recurrent implantation failure). We have MFI and I have a very high AMH but do not meet criteria for PCOS. Earlier this year my AMH had dropped to about 6 on the US scale (40-ish here, previously I had been at 80) and my FSH had increased to 8. I am now 40. We discovered that I am heterozygous for MTHFR and PAI-1 and I was started on high-dose folate (and given a prescription LMWH after transfer). I had an endometrial scratch prior to restarting treatments. For ICSI5 we did a natural start (no BCP) agonist cycle and I was stimulated initially with Gonal 150 which was decreased at day 5 to 112.5 (E2 562 or 2067 on the European scale) and we added some LH later in the cycle. My E2 was around 10K (35K in Swiss units) on CD13, I believe. The follicles were mostly large (perhaps 22-24 mm if memory serves me right) when we triggered with a 1/2 dose of HCG. We retrieved 39 follicles on CD 15 which led to 20 zygotes, 3 PGS normals and 3 indeterminate (Swiss law permits only polar body testing). There was no fresh transfer due to OHSS (E2 around 10K or 36K on CD13). FET1 (natural start medicated) was a 3dt of 2 polar-body PGS normals and had excellent betas but I lost the pregnancy at 5wk3d with hemorrhaging while on LMWH, estrogen and progestin (2h after a beta of 6K). FET2 (1 normal, 1 indeterminate) was a BFN. We have 2 indeterminates left to transfer and I am trying to plan the next step. My husband is not willing to do DE and I am running out of steam. I know I make lots of eggs but the quality has always been limited and age is not on my side. I have heard of human growth human improving egg quality but I worry about worsening OHSS. Do you have any evidence-based ideas on how to improve my egg quality without increasing the number of eggs retrieved or the risk of OHSS? Thanks in advance!
It is not unusual for women who develop hyperstimulation to produce poorer quality eggs. In my opinion this has much tyo do with the following:
1. The cycle is often cut short by initiating the hCG trigger prematurely (before the follicles are fully developed) to try to arrest the stimulation process and avoid OHSS.In such cases the erggs are often forced into reproductive division (meiosis) prematurely.
2. Triggering with too low a dosage of hCG (5,000U rather than 10,000U or 250mcg Ovidrel rather than 500mcg. This is often insufficient to optimize the meiosis process, compromising the eggs.
3. Using a Lupron trigger rather than hCG in ordser to lower the risk of OHSS. It does lower the risk, but in my opinion, this often comes at the expense of egg quality.
My approach is consistently to use a long pituitary DR protocol with an agonist, coming off 1-2 months on the BCP. The latter is intended to lower LH and thereby reduce stromal activation (hyperthecosis) in the hope of controlling ovarian androgen release. I then stimulate with low dosage FSHr to which I add a smidgeon of LH/hCG (Luveris/Menopur) from the 3rd day and watch for the # of follicles and [E2] starting on the 7th day of COS. If there are > 25 follicles, I keep stimulating (regardless of the [E2] until 50% of all follicles reach 14mm. Then, provided the [E2] is >2500pg/ml, I stop the agonist and the gonadotropin stimulation and follow the E2 (only) daily, without doing further US examinations. The [E2] will almost invariably climb and I watch it go up (regardless of how high the concentration of E2reaches) and track it coming down again. As soon as the [E2] drops below 2500pg/ml (and not before then ever), I administer 10,000U hCGu or hCGf (Ovidrel/Ovitrel-500mcg) as the “trigger” and perform an egg retrieval 36h later. ICSI is a MUST because “coasted” eggs usually have no cumulus oophoris and eggs without a cumulus will not readily fertilize on their own. All fertilized eggs are cultured to blastocyst (up to 6 days). And up to two (2) are transferred transvaginally under US guidance.
The success of this approach depends on precise timing of the initiation and conclusion of “prolonged coasting”. If you start too early, follicle growth will stop and the cycle will be lost. If you start too late, you will encounter too many post-mature/cystic follicles (>22mm) that usually harbor abnormally developed eggs.
Use of the above approach avoids unnecessary cycle cancellation, severe OHSS, and optimizes egg/embryo quality. The worst you will encounter is mild to moderate OHSS and this too is uncommon.
I do not use antagonists in high responders (e.g., PCOS) because it interferes with the assay of E2 (often causing the value to be understated), a valuable index in assessing risk for the development of severe/critical OHSS. I also do not believe in the agonist trigger to prevent OHSS. The reason is that the magnitude of the induced LH surge varies and if too little LH is released, meiosis can be compromised, thereby increasing the egg aneuploidy index.
As for the endometrial “scratch” approach…in my opinion it is ineffective and I do not use it.
Finally, please read the article on Thrombophilia, referenced 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
•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
•Why did my IVF Fail
•Blastocyst Embryo Transfers Done 5-6 Days Following Fertilization are Fast Replacing Earlier day 2-3 Transfers of Cleaved Embryos.
•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.
•Hereditary Clotting Defects (Thrombophilia)
•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
•Preventing Severe Ovarian Hyperstimulation Syndrome (OHSS) with “Prolonged Coasting”
•Understanding Polycystic Ovarian Syndrome (PCOS) and the Need to Customize Ovarian Stimulation Protocols.
•“Triggering” Egg Maturation in IVF: Comparing urine-derived hCG, Recombinant DNA-hCG and GnRH-agonist:
•The “Lupron Trigger” to Prevent Severe OHSS: What are the Pro’s and Con’s?
ll 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.