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 there. I had Icsi in November 2012 due to low ovarian reserve and low sperm on my husband. The cycle was successful and I have a healthy boy now 3 years old. In December 2015 we decided to try again for a 2nd child. My amh in 2012 was 7.8 and in 2015 had gone down to 6.5. I was told my chances of conceiving were low 20%. I had Icsi in 2012. I had 15 eggs collected but they only went to 2 cell on day 3. I had two 2 cells but back but unfortunately the cycle was unsuccessful. I tried again in August 2016 but after testing amh it was 1.5. The cycle still went ahead. I had 6 eggs collected and one 4 cell and one two cell put back. Unfortunately this cycle failed also. Is it worth a third attempt? We are desperate for a second child and would do anything. If you could offer any advice would appreciate it. Many thanks
Women who (regardless of age) have diminished ovarian reserve (DOR) tend to produce fewer and less “competent” eggs, the main reason for reduced IVF success in such cases. The compromised outcome is largely due to the fact that such women tend to have increased LH biological activity which often results in excessive LH-induced ovarian testosterone production which in turn can have a deleterious effect on egg/embryo “competency”.
Certain ovarian stimulation regimes either promote excessive LH production (e.g. short agonist/Lupron- “flare” protocols, clomiphene and Letrozole), augment LH/hCG delivered through additional administration (e.g. high dosage menotropins such as Menopur), or fail to protect against body’s own/self-produced LH (e.g. late antagonist protocols where drugs such as Ganirelix/Cetrotide/Orgalutron that are first administered 6-7 days after ovarian stimulation has commenced).
I try to avoid using such protocols/regimes (especially) in older women and those with DOR, favoring instead the use of a modified, long pituitary down-regulation protocol (the agonist/antagonist conversion protocol-A/ACP) augmented by adding supplementary human growth hormone (HGH). I further recommend Staggered IVF with embryo banking of PGS (next generation gene sequencing/NGS)-normal blastocysts in such cases. This type of approach will in my opinion, optimize the chance of a viable pregnancy per embryo transfer procedure and provide an opportunity to capitalize on whatever residual ovarian reserve and egg quality still exists, allowing the chance to “make hay while the sun still shines”.
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.
•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?
•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
•Implications of “Empty Follicle Syndrome and “Premature Luteinization”
•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
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
Hi, I am 8 weeks pregnant after a 4th ivf. I am homozygous MTHFR plus homozygous factor V Leiden. I am very confused about which dose of folate is right for me. I keep hearing conflicting views. My clinic said I should keep taking 5mg of folic acid but everywhere else I read that folic acid is not good for MTHFR. What is your opinion? I am presently taking 3mg of methylfolate, 33.8mg of B6 and 1000mcg of Methyl-B12… am I overdosing? Also i read somewhere that overdosing on folate and b12 can lead to autism, is that so? Thank you!
I think you should stay the course with your folate, but with a homozygous MTHFR mutation I would probably add daily Clexane or Lovenox throughout pregnancy.
Thrombophilia (Hereditary Clotting Defect) is defined as the genetic predisposition to developing intravascular thrombosis. It is due to hypercoagulability of blood leading to impairment of initial vascularization that takes place during implantation.
Thrombophilia affects as many as one in five people in the United States and is responsible for pregnancy loss (most particularly after the 1st trimester) and “unexplained” infertility, as well as being a factor in some cases of “unexplained” IVF failure. Whether (and/or the extent to which) thrombophilia causes 1st trimester recurrent pregnancy loss (RPL) is the subject of debate and is controversial. In fact, first-trimester RPL is far more likely to be due to immunologic implantation dysfunction (IID) and/or irregularities in the contour of the uterine cavity or insufficient thickness of its lining (a thin endometrium). Thrombophilia has also been associated with late pregnancy-induced complications such as preeclampsia, premature separation of the placenta (abruptio placenta), placental insufficiency with intrauterine growth retardation, and in “unexplained” intrauterine death.
This having been said, it is a fact that most women with a thrombophilia go on to experience healthy pregnancies.
Diagnosis of Throbophilia
Thrombophilia is diagnosed when one or more of the following is detected:
•Mutational defect involving methylenetetrahydrofolate reductase (MTHFR), which occurs in at least 20% of affected cases. Homozygosity for a common C677T mutation in the MTHFR gene that is associated with hyperhomocysteinemia is the most common form of hereditary thrombophilia leading to a 3-fold increase in risk of complications.
•Mutation of factor V Leiden (FVL),
•A mutation of prothrombin G20210A,
•Deficiency of antithrombin III
•Deficiency of protein C
•Deficiency of protein S
Risk Factors
•Pregnant women with predisposing factors such as:
•A personal or family history of thromboembolism (deep vein thrombosis), pulmonary embolism (blood clot in the lung), cerebrovascular accidents (i.e. strokes)
•A personal history of pregnancy complications such as unexplained intrauterine death, preeclampsia, abruptio placenta, intrauterine growth retardation, placental insufficiency, should be tested for the condition.
Treatment
Treatment should be initiated as soon as possible after pregnancy is diagnosed biochemically (blood or urine hCG test) and be continued throughout gestation.
Severe thrombophilias (e.g. homozygous MTHFR mutations, protein C deficiency, prothrombin G20210A mutation) as well as cases of mild thrombophilias associated with one or more of the pregnancy complications mentioned above, are best treated with low-molecular weight heparin (LMWH).
For other (milder) thrombophilias and no history of prior pregnancy complications: Low-dose aspirin with the B vitamins folic acid, B6 and B12.
Good luck!
Geoff Sher
HI
I had my APA/RIP/NKA tests done and I will like a second opinion in the type of treatment I need.
Thanks
TEST #1
The following were High:
CD8T-suppresor 15.2
CD19 B Cells 29.9
CD56+16+NK 12.3
CD19B Cells# 1.07
CD56+16+NK# 0.44
Rest were normal
TEST #2
Only
AntiPhosEth IgM was high 20.8
TEST #3
My NK Cell Activation is 5.6
NK IVIg Suppresion is 1.9
NK Intralipid Suppresion is 4.0
Reference Range <10
have responded above! I am particularly disappointed in the NK cell activity test report and Antiphospholipids..
Geoff Sher
Dear Dr Sher,
Thank you for this blog. I would like some general advice.
I’m 30 and husband is 36 and we’ve been ttc for 21 months. I started having investigations after a year and was told I had mild pcos. Following on from this I was then put on clomid/ metformin for 4 months which didn’t work. At this point, my husband also had a sperm test which concluded he has borderline/low sperm count and morphology of 3%. Thereafter, we tried stimulated iui ( 75 iu of gonal-f) every other day for about 10 days and then 250mcg ovidrel ). I produced 5 eggs of which 2 were aspirated prior to the transfer of washed sperm ( we had about 28 million post wash sperm). This didn’t work and I think it was largely down to the poor timing between trigger and transfer (less than 12 hours). We moved on to IVF and I was stimmed with 125 iu gonal-f for 7 days which was then increased to 150 iu for the final 3 days. I also used cetrotide to prevent premature ovulation and then 0.5 buselerin. No blood tests were carried out although I did have 3 or 4 scans during the period. I have clear tubes and testorone levels etc all fine. I had 35 eggs retrieved and sadly none fertilised -they were all immature even though at least 4 follicles were measured as 18-22 mm in size prior to trigger. I think the IVF protocol is to blame for this and needless to say we were both devastated. I am on 500mg metformin now for at least the next 6 weeks and looking to give IVF another go. What would you do differently? The doctor has suggested a lower dose of gonal -f and menopur for cycle 2. Is this adequate? Many thanks in advance
I cannot help but agree! This is likely na stimulation issue. We do need to talk…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
•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
•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?
•Intrauterine Insemination (IUI): Who Needs it & who Does Not: Pro’s & Con’s!
•Micro-IVF: Often Preferable to Ovarian Stimulation with or Without IUI
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,
I have had many IVF and FET cycles, one ectopic pregnancy, one miscarry after 13 weeks and five miscarries after 4-5 weeks.
We have found out that I have some immune problems and PCO. We tried FET with intralipids 3x with no luck.
Me and my husband had out DQ alpha checked, I am 102 and 103, my husband is 601 and 501. I have read that 501 can cause problems, but is that when one has it or just when both have it?
I guess the main question is, can I put two embryos in or should I put one at a time?
Thank you in advance.
Since you do not have an alloimmune cause, 2 embryos would be OK!
Good luck!
Geoff Sher