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 Dr. Sher,
I am 41 years old and just had my IVF cycle cancelled. This would have been my second IVF cycle. My first cycle produced 15 follicles, 11 fertilized and only 3 made it to PGD testing. All 3 were chromosomally abnormal so there was no transfer. I was overstimulated from that cycle and experienced sharp pain to my shoulder, extreme bloating and my ovaries were very enlarged. My protocol was 225 iu Gonal F and 75 iu menopur and ganerilix. Since I had a pretty good response during my first cycle (minus the overstimulation) my doctor prescribed the same protocol. On day 7 of my second cycle, I had about 12 follicles ranging from 11-18mm and about 8 follicles that were less than 11 mm. At that point, my doctor thought 2 more days of medication and then egg retrieval. Unfortunately Day 7’s blood work came back and indicated that my estrogen had crashed going from 1400 to 400! Day 8 ultrasound showed the follicles were getting smaller instead of larger – hence my cycle was cancelled and my doctor said that it was due to poor response to the medication. I was obviously disappointed but still not sure how this could happen when my response to the medication in my prior cycle and every day leading up to Day 7 in my second cycle seemed really good. I still don’t understand it. My doctor mentioned putting me on Lupron for my next cycle but needed to give some more thought to what my protocol would be since I did respond well to meds (she mentioned my AMH is comparable to AMH of a 30 year old). Do you think this is the right course of action? Do you have any other explanation as to why my estrogen had crashed?
Thanks so much!
Kristina
Clearly what you experienced was premature luteinization. What you need is a careful review and drastic revision of the stimulation protocol. I would be happy to discuss this with you.
Older women and those who have diminished ovarian reserve ( DOR) tend to have increased LH activity and are thus more likely to produce excessive ovarian testosterone. It follows that sustained, premature elevations in LH or premature luteinization (often referred to as a “premature LH surge”) will prejudice egg development. Such compromised eggs are much more likely to end up being complex aneuploid following the administration of the hCG trigger, leading to fruitless attempts at retrieval and the so called “empty follicle syndrome.”
The developing eggs of women who have increased LH activity (older women, women with diminished ovarian reserve, and those with PCOS) are inordinately vulnerable to the effects of protracted exposure to LH-induced ovarian testosterone. Because of this, the administration of medications that provoke further pituitary LH release (e.g., clomiphene and Letrozole), drugs that contain LH or hCG (e.g., Menopur), or protocols of ovarian stimulation that provoke increased exposure to the woman’s own pituitary LH (e.g., “flare-agonist protocols”) and the use of “late pituitary blockade” (antagonist) protocols can be prejudicial.
The importance of individualizing COS protocol selection, precision with regard to the dosage and type of hCG trigger used, and the timing of its administration in such cases cannot be overstated. The ideal dosage of urinary-derived hCG (hCG-u) such as Novarel, Pregnyl and Profasi is 10,000U. When recombinant DNA-derived hCG (hCG-r) such as Ovidrel is used, the optimal dosage is 500mcg. A lower dosage of hCG can, by compromising meiosis, increase the risk of egg aneuploidy, and thus of IVF outcome.
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
•Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•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.
•Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
•The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
•Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
•Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice..
•Implications of “Empty Follicle Syndrome and “Premature Luteinization”
I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
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, today was the day I went in for my BETA HCG. I am on day 12 after a 4-day transfer. My HCG came out to a 6. My nurse said the results are inconclusive as it’s low for a full positive and high for a negative. They want me to take another test in 2-days to see if it goes up. Any thoughts on this? I’m so nervous and just can’t focus on anything else right now.
Sadly, this does not look good. Repeat the beta in 2 days on the off chance of things turning around.
G-d bless!
Geoff Sher
Hello,
I just had my 4th IVF failure. And I am really at a crossroad & would like your professional advice.
– I just turned 35 (2) weeks ago, my highest FSH was 11 & AMH 1.7 (3) years ago. I am so confused as to why my eggs are so bad, I have never had any eggs to freeze, all 3 day transfers. Could something be wrong with the protocol or is my egg quality that poor, that I have NO good eggs?
– My last cycle was a Natural IVF cycle. No Meds besides HCG boost in small amounts prior to retrieval, ganarelex for 3 days leading up to retrieval & Trigger shot. My estrogen dropped a lot to 50 2 days leading up to retrieval. The dr actually thought I may have ovulated due to my #s but I didn’t. Could I be suffering from some kind of hormonal issue? Is this something to further look into? Possibly causing quality issues?
– My husband has major sperm issues? Could Thisbe the cause as well? What tests should he do?
– Lastly, should I give up & go to doner eggs? I am at a breaking point, and can’t handle to disappointment? I just feel like if my doctor isent digging deep enough & maybe there is something being overlooked?
I truly appreciate your time & advice
I do not think you need donor eggs. Your drop in estradiol prior to ER points to premature luteinization and this in my opinion strongly suggests that the protocol used for ovarian stimulation needs to be reviewed/revised. If this is done, I suspect that you could have a much improved response…see below. I urge you to call and set up an appointment to do a Skype consultation with me.
Older women and those with diminished ovarian reserve (DOR) often have increased LH activity and are thus more likely to produce excessive ovarian testosterone. It follows that sustained, premature elevations in LH or premature luteinization (often referred to as a “premature LH surge”) will prejudice egg development. Such compromised eggs are much more likely to end up being complex aneuploid following the administration of the hCG trigger, leading to fruitless attempts at retrieval and the so called “empty follicle syndrome.”
The developing eggs of women who have increased LH activity (older women, women with diminished ovarian reserve, and those with PCOS) are inordinately vulnerable to the effects of protracted exposure to LH-induced ovarian testosterone. Because of this, the administration of medications that provoke further pituitary LH release (e.g., clomiphene and Letrozole), drugs that contain LH or hCG (e.g., Menopur), or protocols of ovarian stimulation that provoke increased exposure to the woman’s own pituitary LH (e.g., “flare-agonist protocols”) and the use of “late pituitary blockade” (antagonist) protocols can be prejudicial.
The importance of individualizing COS protocol selection, precision with regard to the dosage and type of hCG trigger used, and the timing of its administration in such cases cannot be overstated. The ideal dosage of urinary-derived hCG (hCG-u) such as Novarel, Pregnyl and Profasi is 10,000U. When recombinant DNA-derived hCG (hCG-r) such as Ovidrel is used, the optimal dosage is 500mcg. A lower dosage of hCG can, by compromising meiosis, increase the risk of egg aneuploidy, and thus of IVF outcome.
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
•Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•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.
•Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
•The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?.
•Male Factor Infertility
•The Sperm Chromatin Structure Assay (SCSA): A Measure of the Potential of Sperm to Help Propagate a Viable Pregnancy
•IVF for Women Who Have Previously Conceived (Secondary Infertility).
•IVF Egg Donation: A Comprehensive Overview
•IVF-Gestational Surrogacy: An Overview
I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
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
Dear Dr. Sher
Many thanks for the useful info on your blog. It answers all my questions and I am a daily reader of your blog. I attended a conference tonight and two of your papers were discussed which I had previously read good feedbacks about them. My questions is regarding people with endometrial polyps who are diagnosed with cervical stenosis. Some physicians have suggested the use of prostaglandins in order to surgically remove the polyps whereas others have contraindicated the use of such interventions. Since I am a clinical embryologist and don’t have enough information on this issue, I would kindly appreciate your opinion on this matter. As you are aware prostaglandins may have adverse effect on implantation of embryo and for this reason one may not want to utilise them. Can we start a new cycle immediately after using prostaglandins or do we have to wait for a while?
Many thanks
Soheil
Thanks
Thank you!
Endometrial polyps need to be surgically removed. the cervix needs to be dilated, whereupon a hysteroscopic resection or a sharp curettage with polypectomy should be done. Sometimes vaginal prostaglandins will help soften a stenotic cervix to allow dilatation and/or laminaria can be used.
Geoff Sher
Good luck!
Geoff sher
Hi Dr Sher
I live in London I am 30yrs old. Me and my boyfriend has been trying to conceive for 5months now but nothing has happened i know we are meant to be trying for 6-12months but i couldn’t wait and i was having mild pain and some times sharp pain in my lower left stomach so i went to have an ultrasound and it showed that i have 2 cyst on my left ovary not big and possible hydrosalpinx in the left tube and the right ovary and tube is fine so i have been referred to a gynaecologist at the end of March. My Dr and the technician who performed the ultrasound didn’t seem concerned and said i could still get pregnant but what i wanted to know is:
1) How would i know if the hydro fluid has leaked into my uterus? would i feel a sharp pain
2) could i really still get pregnant with this condition as I’ve read online that people miss carry and some don’t
3) could a normal self massage that is perfermed everyday help unblock my left tube.
4) does certain body positioning like lying on your side allow the hydrosalpinx fluid to leak out in to the uterus ?
Alas, if your tubes are blocked you would need IVF. The only surgery you would require would be in preparation for IVF and that would involve ligating the distended tubes where the leave the uterus or removing them because they are without function and could otherwise interfere with IVF outcome.
Geoff Sher