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. Our clinic only offers CGH, not NGS. Wife just turned 40 and has had two miscarriages (April 2016, August 2016.) Now moving to ivf for the first time. I know we need to do pgs, and I keep reading that ngs is superior. Should we switch to a clinic that does offer NGS? Or roll the dice with CGH? She did an u/s on Day 2 of her cycle and had 11 follicles. We will start stimming when she gets her next period. Thank you.
Not necessarily. CGH is also reliable. I would not switch for that reason alone…especially if you like and have confidence in the team there.
Good luck!
Geoff Sher
I am on a mini ivf protocol using letrozole, gonal f and menopur. On cycle day 1 I went in for baseline labs. My estrogen was 23. On cycle day 2 (stim day 1) I started 5 letrozole, 75 gonal f in am and 1 menopur in pm. On am of stim day 4 (cycle day 5) I went in for labs and sono. Had 4 follies on right and 4 on left of which only 1 was measurable on left. Estrogen came back at <5. They then increase my gonal f to 150 which i took stim day 5 and am of stim day 6. I went back on am stim day 6 (cycle day 7) for labs and sono. 4 follies on right and left all measureable with largest being about 12 and smallest about 8 or 9. Estrogen came back at 43. I am a bit concerned with these estrogen levels being so low. As I understand it estrogen levels corrolate to follicle growth amd maturation, correct? How can the follicles be growing and estrogen not increase. One of my REs associates said that the estrogen levels are probably low due to the letrozole and to continue taking meds as normal (letrozole 5, gonal f 150 and 1 menopur). This doesn't make sense to me and I am starting to worry being that ER is only 5-6 days away. I emailed the nurse this morning and askee her to ask my RE for a course to correct this. He said not to take the letrozole anymore. Are there any other ways to increase estrogen? Am I at risk of cycle cancellation? Do I have cause to worry? Any advice would greatly help.
Thank you
Respectfully,
I do not believe in mini-IVF using Letrozole or Clomiphene. Results are terrible in my opinion. I do offer micro-IVF which if used in an eligible patient works well. Please read 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
•The “Biological Clock” and how it should Influence the Selection and Design of Ovarian Stimulation Protocols for IVF.
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF
•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 Dr. Sher,
I am a patient at your NY clinic. I am 32, healthy and went to your clinic to do embryo banking. I was not ready to start a family and have never tried, but wanted to have embryos stored and ready for when it was time. All of my blood work was normal, my husband’s labs and sperm analysis were good as well-so it was assumed that I would have success. First cycle- 8 retrieved, 6 fertilized, 1 made it to freeze, grade 2. I did the Lupron suppression followed by stims for the first cycle. Doctor was surprised at results, so we tried again last month with shorter protocol with just stims and 12 were retrieved, 10 fertilized( I was happy at the higher number) and none made it to blast! I was devastated. He said it is most likely an egg quality issue but he is doing a test on my husband’s sperm for dna fracturing this week. So now I am in a strange predicament-I pursued this not ever having tried to conceive naturally and stumbled upon what appears to be a problem? I feel like I opened Pandora’s box and am not sure how to proceed- are these 2 cycles showing that there is a problem I never knew about and that I would have a really hard time conceiving naturally? I’m trying to figure out what to do- I really wanted to bank embryos, but at the rate I am going I would have to do a dozen cycles or more to get enough that make it to blast and then have to do pgd which cuts it all down by 50 percent mostly. I am just not sure what the best thing to do is to ensure my chances of having my own children any advice from your experience?
Hi Siobhan,
I sympathize with your predicament and I wish I could help, but to do so I would need a great deal more information. Personally, I doubt that at 32Y of age you would have an intractable egg issue. Rather, this sounds to me like it could be a stimulation issue.
Without much more knowledge about you I cannot advise authoritatively.
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
•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
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 Dr. Sher,
I wanted to get your opinion. I am 41 years old. A brief history for you first. At 38 years old, I froze my eggs at a local clinic. At the time, they used a protocol including BCP for 2 weeks prior to start of stims, then, stims were at 75IU of Menapur and 225 units of gonal F along with ganirelex. I stimmed for 8 days on the 8th day, they triggered. They retrieved 15 eggs, 8 of which were mature and of good enough quality to freeze through verification. Fortunately, I met my husband that same year (coincidentally). We got married when I was 39 and 4 months old. A few months later, we went to the clinic I froze my eggs at and had all kinds of fertility screenings done. The verdict by that RE was that everything looked good and I just needed to remove a polyp, which I did. But, he recommended we try naturally for a couple of months. Which we did. Then, we proceeded to IUI when I was 40 and 4 months. Then, at 40 and 7 months, we did an IVF round. He used 150 IU of menapur and 275 IU of Gonal F. I stimmed for 8 days and on the 8th day they triggered (I respond quickly). They retrieved 17 eggs, 10 of which were mature. They also thawed the frozen eggs from age 38 and of the 8, 5 survived. So, there were a total of 13 eggs to work with. Of those, 11 fertilized normally with ICSI and 5 grew to blast stage and were biopsied for PGS testing. 1 came back normal, day 5 grade 5AA. What is interesting is that was from the 40 year old bunch. We decided not to transfer this because we wanted a chance at a larger family. We also changed clinics. We went to CCRM in Denver. The baseline testing they did showed the following: AMH = 1.2, AFC = 9, FSH = 10.8. The doctor recommended we do back to back retrievals to bank and then PGS test then transfer. The following were the treatment protocols:
1st round: priming for a month before stims with testosterone gel and estrogen pills from CD1 through Ovulation. Then, switch to Testosterone patches, stay on estrogen, and start prometirium in the luteal phase of the cycle. This lasted for 25 days, then stopped all and waited for a period. Did baseline and then started stims. Note: When they checked my testosterone levels during this priming cycle, they said they were lower than they like and had me double the dose of the testosterone patches.
The stims for this cycle were: 300 IU of menapur, 300 IU Gonal F, Ganirelex and Pregnyl HCG shot. They took the 300 menapur down to 150 after the day 5 check because I had huge lead follicles (I was actually quite annoyed because I told the doctor I didn’t need that high of a dose given my past history of quick response, but, he ignored me). I stimmed for 8 days and triggered on day 8. They had been tracking about 11 eggs and ended up retrieving 13 eggs, 9 were mature, and 7 fertilized normally with ICSI. They froze them on day 2.
The second cycle, he changed my protocol to have priming with testosterone gel and estrogen only (no patches and not prometirum in luteal phase). He also added ganirelex in last few days of luteal phase to “slow me down a touch” as he put it. The stims were 150 IU menapur, 300 Gonal, and ganirelex and pregnal for HCG. He had to take my gonal dosing down a few times in the tail end of the cycle. I stimmed for 9 days triggering on day 9. They retrieved 13 eggs, 8 were mature, and 5 fertilized normally with ICSI. They froze on day 2 again. His explanation for the reduced number of fertilized eggs was that every cycle is different. He said change in protocol had nothing to do with it. Even though I thought having me take ganirelex at end of priming before stims maybe over-supressed me. But, he said no.
Third and final cycle: this time, he recommended a micro flare lupron protocol. When I asked him why, he said for better quality. When I asked why he never recommended before if it is better quality, he didn’t really give me a satisfactory answer. My instinct was so against it, but, my husband told me we need to listen to the doctor as he knows more than we do. He had me prime again in the same way he had me prime on the very first cycle (testosterone gel, estrogen pills, then testosterone patches and promethium). Again, I had to double testosterone dose because I was too low. Stims were: micro flare Lupron (20 IUs) 2 times a day for CD2 through the rest of the cycle. Menapure at 150 and gonal at 300 were started on CD3. . I stimmed for 9 days and triggered on day 9. Again, I had a few lead follicles. They were tracking about 13 eggs on U/S but only retrieved 10 this time. When I asked embryologist why, they said it means some had no eggs in them. FIRST TIME this happened since I have done this ever in my life. I have always retrieved more than they were tracking. Then, they called later and said of the 10, 8 were mature but only 3 fertilized normally with ICSI. This is only 37% fertilization! I have always gotten between 62 and 80 % fertilization with ICSI. So, how could it drop that much? When I asked the embryologist for some insight, she said there was nothing noted off with the sperm or eggs from previous cycles and that I should ask my doctor if he changed anything. YES he did, that micro flare Lupron is what he did and I have never done it before. I feel like this is the culprit. I get saying every cycle is different and I understand variability. But, normal variability is within a tight range, not this much??
What are your thoughts? We have not gotten a blast report yet. They thawed all the day 2 ones from previous cycles and are growing them now to blast. So have no idea what we will end up with. He predicted this last cycle I would have 7 fertilize based on my U/S and blood work.
What are your thoughts on these protocols and especially this last one with lupron?
I feel like CCRM has not at all lived up to their name. I am so disappointed. I don’t feel he truly customized for my body. I think the back to back approach gave him leeway to just try things without any realy thought behind it as evident by his answers to me when I questioned why Micro flare. I wish I never listened and insisted we go back to the first cycle method since I do well on that.
Hi Ranya,
Very respectfully, I personally do not use the protocols you were on….especially not in women with diminished ovarian reserve (DOR) or in older women. I disagree with the use of “flare protocols” in women with DOR or the use of testosterone and additional hCG/LH supplementation (as with the hCG supplementation and high dosage Menopur) during the stimulation. In my opinion, your stimulation protocol needs to be reviewed critically and revised.
The older a woman becomes, the more likely it is that her eggs will be chromosomally/genetically “incompetent” (not have the potential upon being fertilized and transferred, to result in a viable pregnancy). That is why, the likelihood of failure to conceive, miscarrying and of giving birth to a chromosomally defective child (e.g. with Down Syndrome) increases with the woman’s advancing age. In addition, 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
my urine test came back positive
but i am having a hard time ready my blood test
its states
HI 452 Result <5
what does this mean ? pregnant or none
It is not possible for the urine test to be +ve if the blood hCG level was <5MIU/ml and if that blood test is correct, then alas you probably are not pregnant.
Geoff Sher