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 an AB embryo is un-frozen, laser assisted hatching is performed, and then it is re-frozen, is there any data to suggest its chances of surviving the process? We needed to have this done yesterday, due to a last-minute change of circumstances on the scheduled transfer date. Twice-frozen embryos seem to do well in the in studies that we have read, but we haven’t found studies pertaining to freezing after assisted hatching. What are your thoughts about post-assisted-hatching, twice-frozen embryos?
Thanks for your expertise and a very helpful blog.
In my opinion, it is not ideal to have to thaw–biopsy–refreeze…and then thaw later for an FET. Pregnancies do occur but the rate is reduced in my experience.
Hopefully all will be well in your case.
Geoff Sher
Hello Dr. Sher,
I was prescribed .5 dexamethasone in preparation for upcoming FET transfer (donor). He said it was to bring my DHEA levels down (I tested 3oo+ and 400+ on two separate blood tests) as well as high testosterone level. He said I was to stay on it during the pregnancy. I have researched the effects of dexamethasone on the developing fetus and found conflicting reports, none of them good. I am very hesitant to take it. What would you recommend? Thank you for taking time to answer my question! (BTW I am mid forty –if that matters)
Taking it up to the 8th-10th week and then tailing it off over 1-2 weeks of pregnancy is NOT a problem in my opinion. To continue into the second trimester is only justified for a good medical indication. I rarely so advocate to my patients.
Geoff Sher
Dear Dr Sher,
As I understand the trigger shot of HCG10,000 is given when E2 starts to come down just below a level?? In this case, if LH surge automatically happens when E2 is increasing and if E2 is still increasing, does it mean that it is better to wait even after LH surge till E2 falls below a certain level to give trigger shot?
That is not accurate. Unless you are hyperstimulated and coasting (where you wait for the E2 to come down before the trigger), it is not advisable to let that happen conventionally because a falling E2 can suggest premature luteinization and that is bad for egg/embryo competency.
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
•Ovarian Stimulation in Women Who have Diminished Ovarian Reserve (DOR): Introducing the Agonist/Antagonist Conversion protocol
•Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
•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
Dear Dr Sher,
A)My LH after taking Menopur is 8 on CD6. Is it bad to have LH of 8 after administration of Menopur 75iu daily since CD2?
B)After taking Menopur does LH still have to be under 4?
Your forum is really appreciated!
Best regards,
Melissa
No! The LH usually goes up with Menopur. This is why I limit the dosage of Menopur for my IVF stims.
Geoff Sher
I am writing to find out if progesterone dosage could make the difference in a miscarriage or not? I went to the pharmacy to pick up my progesterone. I was given capsules instead of my normal suppositories. The clerk looked it up to make sure this was correct and said that was what was sent over and noted that my previous prescription was for 100mg and this one was for 200mg and advised I contact my doctors office to make sure this was correct. When I called I spoke to the NP because my doctor is on vacation. She looked and the 200mg capsules was what was ordered. I was confused on why the change because the doctor and I had discussed not changing the plan because it had already worked once in March. I lost it at 9weeks was measuring 6weeks. However, she stated she wasn’t sure why I was on 100mg anyway, as they always do the 200mg capsules. So, my question is….obviously someone has messed up, the pharmacist said that the difference in the progesterone could lead to a miscarriage and I want a doctor’s perspective to see if this is in fact true….
I do not think that the dosage would have prejudiced outcome, but oral progesterone in my opinion is much less effective than intramuscular or vaginally administered progesterone.
Ovulation occurs within 38-42 hours of initiation of the spontaneous luteinizing hormone (LH) surge (which can be detected in the blood or urine prior to this event) and/or hCG administered following controlled ovarian stimulation (COS) with gonadotropins.
One or more eggs are released with spontaneous or induced ovulation. Those follicles that ovulate and many of those emptied at egg retrieval, then undergo “luteinization”, converting to one or more a yellow bodies or corpora lutea (CL) that produces both progesterone and estrogen. The greater the original number of mature follicles, the greater the progesterone/estrogen production is likely to be. Accordingly, women on fertility drugs have higher luteal phase progesterone/estrogen levels.
The effect of the pre-ovulatory hCG injection is usually sustained for 1-2 weeks exerting a protracted influence on ovarian progesterone/estrogen production. A few days later, provided that embryo implantation takes place, the early trophoblast (root system of the conceptus) begins to produce its own progesterone/estrogen as well as hCG, in ever increasing amounts. By the 8th week of pregnancy the early placenta provides for all hormonal needs of the developing conceptus. There is compelling evidence to show that hCG augments ovarian (corpus luteum) progesterone release while also promoting growth and development of the trophoblastic “root system” of the conceptus (which eventually will develop into the placenta) as well as estrogen and progesterone production. Since, at the same time, hCG probably also promotes the production of more hCG, it might be considered to be a self-propagating hormone.
By the 8th-9th week of pregnancy, the trophoblast has replaced the ovaries as the dominant source of progesterone and estrogen production. Thereafter there is probably little or no benefit in supplementation with progesterone/estrogen It follows that a low blood progesterone blood level is much more likely to be the consequence rather than the cause of a failing pregnancy. Thus in such cases the administration of progesterone/estrogen in an attempt rescue a failing pregnancy is tantamount to “shutting the gate after the horse has left the stable.”
An obvious situation where progesterone/estrogen supplementation is required is in cases where the woman is an embryo recipient (i.e., ovum donation, embryo adoption, gestational surrogacy and frozen embryo transfers-FET).
By the 8th to 10th week of pregnancy, conversion from reliance upon the corpus luteum to sustain the pregnancy has occurred and further fetal development, supported by the hormonal production of the placental trophoblast. Thus thee is in my opinion little or no benefit in estrogen/progesterone supplementation beyond the 10th week.
While progesterone /estrogen supplementation likely has benefit in cycles involving pituitary down-regulation with GnRH agonists (e.g. Lupron, Buserelin, Superfact, Decapeptyl) or antagonist (Ganirelix, Orgalutron, Cetrotide) where luteal phase hormonal deficiency is more prevalent, there is no conclusive evidence that patients undergoing gonadotropin stimulation without the use of a GnRH agonist or an antagonist would derive benefit from such hormonal supplementation.
Hormonal supplementation usually involves the daily intramuscular administration of progesterone +/- vaginal suppositories (comprising estradiol and micronized progesterone) until a blood pregnancy test is performed approximately eight days later (the chemical diagnosis of pregnancy). If the pregnancy test is negative or the plasma hCG levels fails to rise appropriately in the ensuing days, such hormonal support is discontinued. For those that cannot tolerate daily intramuscular progesterone, Crinone or Endometrin vaginal application
Geoff Sher