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.
What is the role of post FET beta HCG booster shot.When it is given ? How to do follow up beta HCG levels for pregnancy progression in such cases ?
The decision of whether to administer supplemental parenteral progesterone or human chorionic gonadotropin (hCG), following embryo transfer, to support embryo implantation is by no means clear cut. 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 hyperstimulation (COH) with gonadotropins.
Usually, a single egg is released with spontaneous (normal) ovulation. Thereupon, each “empty” follicle collapses and converts into a corpus luteum (“yellow body”) which produces both progesterone and estrogen. A similar, but exaggerated response follows IVF where COH with hCG-induced ovulation results in the formation of numerous corpora lutea. The greater the original number of mature follicles, the greater the progesterone/estrogen production is likely to be.
Since COH in women who have absent or abnormal ovulation patterns [e.g., cases of polycystic ovarian syndrome (PCOS)] tends to result in the growth of many more follicles than when performed in controls (i.e., normally ovulating women), it follows that they develop many more corpora lutea and accordingly have exaggerated blood progesterone/estrogen concentrations. The effect of the preovulatory 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 also promotes the production of more hCG, it might be considered a self-propagating hormone. When hCG is administered following egg retrieval and embryo transfer, it is administered by intramuscular injection at a dosage of 5,000 units 3 times weekly, commencing after appropriately rising blood hCG levels signifies that implantation is taking place. Such administration of hCG promotes the release of ovarian and trophoblastic estrogen and progesterone which 6together promote exaggerated secretory changes (decidualization) of the uterine lining, trophoblastic growth, uterine relaxation and adaptation of the reproductive immune response.
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 administering either progesterone or hCG. 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 hCG or progesterone in an attempt rescue a failing pregnancy is tantamount to “shutting the gate after the horse has left the stable.”
Most advocates of hCG supplementation recognize that it is risky to administer hCG when a woman inadvertently becomes severely hyper-stimulated. Doing so could exacerbate the condition, placing her at inordinate risk of developing life-endangering complications associated with severe ovarian hyperstimulation syndrome (OHSS). In such cases, it is best to administer progesterone. Another obvious situation where progesterone (rather than hCG) supplementation is called for is in cases where the woman is an embryo recipient (i.e., ovum donation, embryo adoption, gestational surrogacy and frozen embryo transfers). In these cases, ovarian hormonal activity is dormant, rendering any attempt to try to promote ovarian steroid production with hCG, redundant.
Once conversion occurs from reliance upon the corpus luteum to sustain the pregnancy, to self maintenance of the pregnancy by the placental trophoblast, there is probably little benefit to either progesterone or hCG supplementation. This is why after the completion of the 9th week of pregnancy, supplemental hormonal therapy is discontinued.
Progesterone or hCG supplementation likely has significant value in cycles involving pituitary down-regulation with GnRH agonists (e.g. Lupron, Buserelin, Nafarelin, Synarel, Decapeptyl) where there is often luteal phase hormonal deficiency. However, there no conclusive evidence that patients undergoing gonadotropin stimulation without the use of a GnRH agonist or an antagonist would derive benefit from progesterone or hCG luteal phase supplementation. Hormonal supplementation usually involves the daily intramuscular administration of of progesterone and/or vaginal suppositories (comprising estradiol valerate 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 fail to rise appropriately in the ensuing days, all hormonal support is abruptly discontinued. In most cases Crinone or Endometrin vaginal applications can supplant daily intramuscular progesterone administration.
Hope this helps!
Geoff Sher
I have DOR and only one follicle a month on ivf. The last cycle resulted in one egg that fertilized abnormally. I was told it was a 3 pronuclei. Meaning that the egg was likely fertilized by two sperm or that’s as much as I gathered from doing my own research. I got a call that they were letting the embryo continue to grow. They didn’t tell me the cell count for today which is day 3. They also told me that they want to let it continue to grow to day 5, do a biopsy and send it out to get pgs tested. I am so confused. It is my understanding that a 3 pronuclei embryo cannot result in a viable pregnancy. Am I mistaken? Why would they continue to let an embryo grow that was abnormal at fertilization? That can be reversed.
Thank you in advance for your response,
Mercedes
You are not mistaken!
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
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 keep trying to post but it keeps deleting. Not sure what I’m doing wrong. I will be starting ivf with my next cycle. My last cycle started September 23. (First cycle after a miscarriage.) I will be traveling across country to do IVF so my clinic suggested I start birth control so we know exactly when to expect my period and when to expect ovulation so that I can buy my plane tickets accordingly. My clinic said to start BC on Day 1, Day 5 at the latest. I just realized today is cycle Day 8 and now my clinic is closed of the wknd. Should I start the birth control today? or I have missed the window, and I should just guesstimate a date for the plane tickets? We will be at the clinic of 10 days. If we did just guess on the dates, I would hope the egg retrieval day would fall within that 10 days. They retrieve on Day 13 usually, Day 16 latest. My period is a bit unpredictable (usually Day 29-32,) which is why I asked my clinic about going on BC in the first place. Thank you so much.
Hi Berma,
In my practice I at times do allow the initiation of BCP up to day 8 of the cycle. However, I caution them that when you start the BCP so late, there can be some inter-menstrual bleeding but it should not compromise their IVF. This having been said, I cannot recommend that you do anything contrary to the advice of your treating RE.
Good luck!
Geoff Sher
Hello. I will be starting ivf with my next cycle. My last cycle started September 23. (First cycle after a miscarriage.) I will be traveling across country to do IVF so my clinic suggested I start birth control so we know exactly when to expect my period and when to expect ovulation so that I can buy my plane tickets accordingly. My clinic said to start BC on Day 1, Day 5 at the latest. I just realized today is cycle Day 8 and now my clinic is closed of the wknd. Should I start the birth control today? or I have missed the window, and I should just guesstimate a date for the plane tickets? We will be at the clinic of 10 days. If we did just guess on the dates, I would hope the egg retrieval day would fall within that 10 days. They retrieve on Day 13 usually, Day 16 latest. My period is a bit unpredictable (usually Day 29-32,) which is why I asked my clinic about going on BC in the first place. Thank you so much.
I wish I could help. However, I cannot advise you to do something your treating physician might disagree with. I personally will sometimes start my patients on a BCP up to day 8 but will warn them that they could experience some inconvenient bleeding in the ensuing weeks.
I wish you well!
Geoff Sher
good morning Dr Sher
i am in australia, just had my first (cancelled) round of IVF. i have a couple of questions that are probably really silly in comparrison to the ones above.
i have Hirshprungs discease that has left me with a large scar on my left side. as far as i can tell i have a left ovary however on all ultrasounds noone has been able to pick it up. i understand that if they cant see it, they cant reach it so they would not have been able to retreive any fluid from that ovary or follicles that could be there.
on my right side at my first scan they thought they counted around 3 at around 13mm however 2 days later scan showed only 1 at 19mm and couldnt see any others. due to this they cancelled my cycle. i was on dose 150 of puregon. the dr advised to cancel as my levels were fine for my age and we can increase the dose next time. i am also okay with this.
they advised i should still take the trigger injection and have timed intercourse which i am now doing in line with the 36 hours before and after.
my questions:
if i do have a left ovary and i had follicles that were able to be retrieved on right side, would the trigger release the left side also that i could get pregnant this way in the mean time of them doing IVF and then implanting?
by not being able to retrieve or see follicles on my left ovary (based on the fact that it hasnt been proven i dont have one) would one ovary respond better/worse to the stimulation that it could cause OHSS but they wouldnt be able to tell???
thank you again im hoping to go for a stronger dose in 6-7 weeks and see some decent follicles this time!
1. if i do have a left ovary and i had follicles that were able to be retrieved on right side, would the trigger release the left side also that i could get pregnant this way in the mean time of them doing IVF and then implanting?
A: The fact that they could not identify your left ovary might simply mean that it is due to dense post-surgical adhesions. It does not mean that the ovary is definitely absent. Nor does it mean that if they can get that ovary to respond to stimulation that eggs could mnot be retrieved from that ovary.
2. by not being able to retrieve or see follicles on my left ovary (based on the fact that it hasnt been proven i dont have one) would one ovary respond better/worse to the stimulation that it could cause OHSS but they wouldnt be able to tell???
A:If present, it would likely respond normally.
Good luck!
Geoff Sher