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.
I have read much on your blogs about your opposition to using agonist/antagonist in older women & those with DOR. I am 37 with low amh & have had 3 cycles using this type of protocol however I have gotten good mature eggs numbers. Only one of the cycles I am concerned with since it only got 6 eggs using Menopur/orgalutron and I got just one 5day blastocyst from those 6 eggs. Is that a poor/good/average blastocyst number from 6 mature eggs? I have many other eggs frozen which came from the agonist/antagonist protocol but were produced using Puregon at much better numbers. Could it be that I should just avoid Menopur and stitck to Puregon or should I ask my doctor to change the protocol all together? I’m worried now that my frozen eggs will be of poor quality because they came from an agonist/antagonist style stimulation, or if I am getting good numbers using Puregon should I stick to what is working?? Sorry for all the questions, my doctor isn’t very informative. Thanks in advance!!
Jessica,
You have it wrong. I favor the A/ACP strongly, specifically for older women and those with DOR. I do not use it in younger women with good ovarian reserve.
Geoff Sher
I am 36 soon to be 37 live in the uk and have a low ovarian reserve it is not very low but falls below the expected range for my age. I have had one failed ivf on a short protocol which produced only 3 follicles 2 were retrieved both fertilised and a 3 day 10 cell good quality embryo was transferred but sadly no pregnancy. The other embryo did not develop beyond 3days 4 cell . I am an army vetran who was given vaccines including anthrax prior to deployment to Iraq following 9/11. I was told by my ivf team that studies are showing evidence that the anthrax vaccine is now showing premature menapause in some women. My blood profiles over several months and clomid treatment show that I do not ovulate apart from one month. Could the vaccines given to me be a factor in my ovulation problems ? I am due to see my ivf consultant in 2 weeks where he will discuss the audit of my failed ivf cycle and if there are to be any changes to my treatment as I will be having one further and final ivf cycle. I would appreciate your thoughts and any advise you can offer. The one other question I have is my first cousin aged 23 has been diagnosed with factor v leiden following a brain haemorrhage 4 months after delivering her second daughter and within 2 weeks of starting birth control. She is thankfully making a slow recovery and enjoying being a mum her parents are due to be tested for the mutated gene and my own mother has not as yet been tested depending on the outcome of her sister’s test. I have had many different blood tests performed prior to starting my ivf treatment my question is would a test for the factor v leiden been performed as routine screening, and should I mention this at my next appointment as I do not want to appear foolish.
Many thanks for your valuable time I am most grateful.
Regards. Janet Barker
I am unaware of the Anthrax vaccine hastening the menopause. And yes we do routine thrombophilia testing in all our patients doing IVF and this includes testing for Factor V-Leiden.
As women age beyond 35Y there is commonly a progressive diminution in the number of eggs left in the ovaries, i.e. diminished ovarian reserve (DOR). So it is that older women as well as those who (regardless of age) have DOR have a reduced potential for IVF success. Much of this is due to the fact that such women tend to have increased production of LH biological activity which can result in excessive LH-induced ovarian male hormone (predominantly testosterone) production which in turn can have a deleterious effect on egg/embryo “competency”.
While it is presently not possible by any means, to reverse the age-related effect on the woman’s “biological clock, certain ovarian stimulation regimes, by promoting excessive LH production (e.g. short agonist/Lupron- “flare” protocols, clomiphene and Letrozole), can make matters worse. Similarly, the amount/dosage of certain fertility drugs that contain LH/hCG (e.g. Menopur) can have a negative effect on the development of the eggs of older women and those who have DOR and should be limited.
I try to avoid using such protocols/regimes (especially) in older women and those with DOR, favoring instead the use of the agonist/antagonist conversion protocol (A/ACP), a modified, long pituitary down-regulation regime, augmented by adding supplementary human growth hormone (HGH). I further recommend that such women be offered access to embryo banking of PGS (next generation gene sequencing/NGS)-selected normal blastocysts, the subsequent selective transfer of which by allowing them to to capitalize on whatever residual ovarian reserve and egg quality might still exist and thereby “make hay while the sun still shines” could significantly enhance the opportunity to achieve a viable pregnancy
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 Approach
•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.
•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.
Hi Dr Sher.
I had my first ivf round last year antagonist protocol 32yo with pcos and hashimotos, 34 follicles – 11 eggs and 5 blasts. We became pregnant on our fresh but sadly lost our pregnancy at 17weeks due to chromosomal abnormality. Sine then we have tried 2 FETS both times my lining wouldnt thicken well on 12mg a day estrogen, vaginal estrogen and patches. We did 1 transfer with lining over 7 which took longer to get it that thick and i had an early miscarriage. My progesterone was very low despite 3 x a day support. We are now trying a fresh cycle antagonist again same protocol but without the pill to start and i have developed 5 follicles only ive been instructed to trigger, my clinic still want me to have collection. Since the late pregnancy loss i seem to not be responding to the hormones as well and I cannot understand what has changed when my blood tests and scans are normal. Do you think i need to change protocols? Is it normal to have issues with lining and ovarian response to meds after a late loss? Thanks
Alas, in my opinion, both the follicle/egg response and the lining issue could have to do with protocol selection. Please review the articles listed 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
•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.
•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 Ovarian Stimulation in Women who Have Compromised Ovarian Response to Ovarian Stimulation in Women who Have Compromised Ovarian Reserve: 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?
•Blastocyst Embryo Transfers Should be the Standard of Care in IVF
•Thyroid autoantibodies and Immunologic Implantation Dysfunction (IID)
•Intralipid and IVIG therapy: Understanding the Basis for its use in the Treatment of Immunologic Implantation Dysfunction (IID)
•Intralipid (IL) Administration in IVF: It’s Composition; How it Works; Administration; Side-effects; Reactions and Precautions
•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
•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
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.
Hello Dr. Sher,
I am a 33yo about to do my first egg retrieval and IVF. I have been diagnosed with adhesions and endometrial hypoplasia following a D/C after the miscarriage of my first pregnancy (natural pregnancy). While use of my uterus has not been entirely ruled out, it needs some work, so at this time we will be doing a fresh transfer to a GC, a family member. I have 2 questions – one about a drastic change in my labs and one about the protocol selected based on these labs. I had my labs drawn by a local RE I am no longer seeing on 5/25. After that I was put on estrogen to prepare for a diagnostic hysteroscopy in June by an out-of-town Asherman’s expert. I used progesterone to induce a period and then was restarted on estrogen for hysteroscopic lysis of adhesions in July. For 30 days after that procedure I was on estrogen 2 mg BID vaginally and took progesterone day 26-30 (day 30 was 8/11). I started my period on 8/13 and had labs drawn on 8/15 by a new local RE. I did not really want to repeat these labs as I had been taking hormones basically everyday since they were last drawn. The 8/15 labs make me look like I’m in ovarian failure, but I think it has do do with the hormones. The labs were fine less than 3 months earlier when I was not taking medication. Both the local RE and the out-of-town Asherman’s expert cannot explain why my AMH has dropped so much. My concern is that my protocol (300 units Gonal-F, 150 units Menopur, and 0.25 mg cetrotide for 9 days with a possible lupron trigger) is based on erroneous lab results. I just asked my RE about dosages and he said I will be closely monitored and they can be adjusted based on my response. Now after reading on your site, I see the the entire protocol not just the dosages might be different, based in part on my labs. My AFC was 22. Would this protocol be appropriate based on my 5/25 labs? Is it a good protocol for egg quality? Can you explain the change in labs based on taking lots of estrogen and progesterone and then stopping those meds just prior to the drawn? Thanks for your input!
FSH
5/25/16 – 8.3
8/15/16 – 19.6 (drawn 3 days after stopping 2 mg estrogen vaginally BID for 30 days and progesterone CD 26-30)
8/29/16 – 2.8 (on BCP)
Estradiol
5/25/16 – 90
8/15/16 – 46 (after hormone therapy)
8/29/16 – <11 (on BCP)
AMH
5/25/16 – 5.02
8/15/16 – 1.25
8/29/16 – 1.27
Prolactin
12/10/12 – 8.1
8/15/16 – 6.3
LH
8/15/16 – 2.9
There is an inverse relationship between E2 and FSH. Administration of E2 either alone or in conjunction with progersterone (as in a BCP) will dramatically (falsely reduce the FSH). It is possible that it will rapidly rebound after stopping the estrogen. That could have happened with you. The same hormonal regimes can also falsely reduce AMH. Clearly with an AFC of 22 and an original AMH of >5 (]when you were not receiving estrogen augmentation)…rules out DOR. To the contrary, you are probably a high responder and as such (in an effort to reduce the frisk of OHSS), you are being prescribed a Lupron trigger. Indeed, this will reduce risk to you associated with OHSS but in my opinion, this comes at the expense of egg quality being compromised….see the relevant articles 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
•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.
•The Role of Nutritional Supplements in Preparing for IVF
•Preventing Severe Ovarian Hyperstimulation Syndrome (OHSS) with “Prolonged Coasting”
• “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?
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
Dr. Sher,
My husband and I have had a trying year. I am a 31 and my husband is 32. We have been TTC for 2 1/2 years with 1 1/2 years of those under the treatment of an RE in MN. We have done 3 IVF transfers (1 Fresh, 2 Frozen) all resulting in a chemical pregnancy. I want to note that every cycle I always start spotting brown around 6dpt. Its odd and I dont know why it keeps happening.
We had an amazing response to stims and our embryos are of amazing quality that all made it to blast at day 5 or 6, but are NOT PGS tested. We have 3 frozen embryos left and we will not be transferring anymore until I get some answers. This last cycle we did kerotype testing to see if we had any chromosome issues which we both didn’t. I haven’t done immune testing however I was on a low dose steroid and blood thinner 5 days before transfer until my beta this last cycle. I was also on 2 antibiotics for 2 weeks prior to transfer. We did an endo scratch added in vaginal Viagra even though my lining is always superb. We have no answers as to why. My uterus looks perfect under a saline sono but the only thing they have been able to find was during my HSG when the dye didn’t disperse correctly through my left tube. They are unsure if it was a spasm or something else. I also may have possible endo to do painful periods and mid-cycle spotting. We need help and are crushed that we haven’t had success with this yet.
Please any advice would be helpful.
Whenever a patient fails to achieve a viable pregnancy following embryo transfer (ET), the first question asked is why! Was it simply due to, bad luck?, How likely is the failure to recur in future attempts and what can be done differently, to avoid it happening next time?.
It is an indisputable fact that any IVF procedure is at least as likely to fail as it is to succeed. Thus when it comes to outcome, luck is an undeniable factor. Notwithstanding, it is incumbent upon the treating physician to carefully consider and address the causes of IVF failure before proceeding to another attempt:
1.Age: The chance of a woman under 35Y of age having a baby per embryo transfer is about 35-40%. From there it declines progressively to under 5% by the time she reaches her mid-forties. This is largely due to declining chromosomal integrity of the eggs with advancing age…”a wear and tear effect” on eggs that are in the ovaries from birth.
2.Embryo Quality/”competency (capable of propagating a viable pregnancy)”. As stated, the woman’s age plays a big role in determining egg/embryo quality/”competency”. This having been said, aside from age the protocol used for controlled ovarian stimulation (COS) is the next most important factor. It is especially important when it comes to older women, and women with diminished ovarian reserve (DOR) where it becomes essential to be aggressive, and to customize and individualize the ovarian stimulation protocol.
We used to believe that the uterine environment is more beneficial to embryo development than is the incubator/petri dish and that accordingly, the earlier on in development that embryos are transferred to the uterus, the better. To achieve this goal, we used to select embryos for transfer based upon their day two or microscopic appearance (“grade”). But we have since learned that the further an embryo has advanced in its development, the more likely it is to be “competent” and that embryos failing to reach the expanded blastocyst stage within 5-6 days of being fertilized are almost invariably “incompetent” and are unworthy of being transferred. Moreover, the introduction into clinical practice about a decade ago, (by Levent Keskintepe PhD and myself) of Preimplantation Genetic Sampling (PGS), which assesses for the presence of all the embryos chromosomes (complete chromosomal karyotyping), provides another tool by which to select the most “competent” embryos for transfer. This methodology has selective benefit when it comes to older women, women with DOR, cases of unexplained repeated IVF failure and women who experience recurrent pregnancy loss (RPL).
3.The number of the embryos transferred: Most patients believe that the more embryos transferred the greater the chance of success. To some extent this might be true, but if the problem lies with the use of a suboptimal COS protocol, transferring more embryos at a time won’t improve the chance of success. Nor will the transfer of a greater number of embryos solve an underlying embryo implantation dysfunction (anatomical molecular or immunologic).Moreover, the transfer of multiple embryos, should they implant, can and all too often does result in triplets or greater (high order multiples) which increases the incidence of maternal pregnancy-induced complications and of premature delivery with its serious risks to the newborn. It is for this reason that I rarely recommend the transfer of more than 2 embryos at a time and am moving in the direction of advising single embryo transfers …especially when it comes to transferring embryos derived through the fertilization of eggs from young women.
4.Implantation Dysfunction (ID): Implantation dysfunction is a very common (often overlooked) cause of “unexplained” IVF failure. This is especially the case in young ovulating women who have normal ovarian reserve and have fertile partners. Failure to identify, typify, and address such issues is, in my opinion, an unfortunate and relatively common cause of repeated IVF failure in such women. Common sense dictates that if ultrasound guided embryo transfer is performed competently and yet repeated IVF attempts fail to propagate a viable pregnancy, implantation dysfunction must be seriously considered. Yet ID is probably the most overlooked factor. The most common causes of implantation dysfunction are:
a.A“ thin uterine lining”
b.A uterus with surface lesions in the cavity (polyps, fibroids, scar tissue)
c.Immunologic implantation dysfunction (IID)
d.Endocrine/molecular endometrial receptivity issues
Certain causes of infertility are repetitive and thus cannot readily be reversed. Examples include advanced age of the woman; severe male infertility; immunologic infertility associated with alloimmune implantation dysfunction (especially if it is a “complete DQ alpha genetic match between partners plus uterine natural killer cell activation (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
•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.
•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): A Rational Approach to Hormonal Preparation and How new Methodology is Impacting IVF.
•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)
•Intralipid (IL) Administration in IVF: It’s Composition; How it Works; Administration; Side-effects; Reactions and Precautions
•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
•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
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.