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.
Question about laparoscopic surgery- Dr. Sher I was diagnosed with endometriosis when a 6 cm endometrioma was found in my left over through a sonohystogram. After trying for two years, I discovered I was pregnant 6 weeks after the sonohysterogram. Now, at 34, I am trying for number 2 for another 2 years. My endometrioma is now only 2.5 cm as it shrunk or burst. I have done 2 ivfs which has resulted in many “empty” follicles in the first cycle as well as highly fragmented embryos. The second cycle, menopur was added as well as more hcg (dual tripper 2500 hcg and lupron). No empty follicles, but I got 7/8 highly fragmented follicles. Will surgery help my egg quality. My reserve is just average. (Fsh 7 and amh normal, but afc =8 both cycles). Looking for the best way to handle all these poor quality embryos!
Hi Laura,
The endometrioma is probably only part of the story and I believe it should be removed because it will in my opinion adversely affect the quality of uour eggs in the affected ovary. The other issue is the “empty” follicles. Please read the article below and you will understand that there is no such thing as an “empty follicle”. You have to have an egg in order to develop a follicle…it is just that the egg is trapped in the follicle and does not come out. This has to do with the ovarian hormonal environment in which the follicles develop and this in turn is affected primarily by age, ovarian reserve, the endometrioma and the protocol used for ovarian reserve . The two latter issues are the only ones you can influence and thus should be addressed.
Frequently, when following vigorous and often repeated flushing of follicles at egg retrieval they fail to yield eggs, it is ascribed to “Empty Follicle Syndrome.” This is a gross misnomer, because all follicles contain eggs. So why were no eggs retrieved from the follicles? Most likely it was because they would/could not yield the eggs they harbored.
This situation is most commonly seen in older women, women who have severely diminished ovarian reserve, and in women with polycystic ovarian syndrome (PCOS). In my opinion it is often preventable when an optimal, individualized and strategic protocol for controlled ovarian stimulation (COS) is employed and the correct timing and dosage is applied to the “hCG trigger shot.”
Normally, following optimal ovarian stimulation, the hCG “trigger shot” is given for the purpose of it triggering meiosis (reproductive division) that is intended to halve the number of chromosomes from 46 to 23 within 32-36 hours. The hCG trigger also enables the egg to signal the “cumulus cells” that bind it firmly to the inner wall of the follicle (through enzymatic activity), to loosen or disperse, so that the egg can detach and readily be captured at egg retrieval (ER).
Ordinarily, normal eggs (and even those with only one or two chromosomal irregularities) will readily detach and be captured with the very first attempt to empty a follicle. Eggs that have several chromosomal numerical abnormalities (i.e., are “complex aneuploid”) are often unable to facilitate this process. This explains why when the egg is complex aneuploid, its follicle will not yield an egg…and why, when it requires repeated flushing of a follicle to harvest an egg, it is highly suggestive of it being aneuploid and thus “incompetent” (i.e., incapable of subsequently propagating a normal embryo).
Older women, women with diminished ovarian reserve, and those with polycystic ovarian syndrome, tend to have more biologically active LH in circulation. LH causes production of male hormone (androgens, predominantly testosterone), by ovarian connective tissue (stroma/theca). A little testosterone is needed for optimal follicle development and for FSH-induced ovogenesis (egg development). Too much LH activity compromises the latter, and eggs so affected are far more likely to be aneuploid following meiosis.
Women with the above conditions 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.
There is in my opinion no such condition as “Empty Follicle Syndrome.” All follicles contain eggs. Failure to access those eggs at ER can often be a result of the protocol used for controlled ovarian stimulation.
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)
•Why did my IVF Fail
•Secondary Infertility: Addressing the Root Causes
•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)
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF
•Endometriosis and Infertily
•Treating Ovarian Endometriomas with Sclerotherapy.
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
Hi,
My doctor has promised to let me try the AACEP protocol, but we have some questions regarding the details:
* As Estradiol Valeriate is not available as IM and suppositories in Sweden (where I live), can i take it orally instead (Progynon)?
*When do the stimulation with gonadotropins begin, at the same time as the conversion from GnRH agonist to antagonist (which I guess it the first day of the second cycle of the treatment), or is it at some other point?
*Does the OC start day 1 of the “first” cycle and the GnRH agonist on day 21?
Somewhere you wrote that the RE could give you a call, is this still the case and which of the clinics should he then call?
Best regards,
Christina
1. As Estradiol Valeriate is not available as IM and suppositories in Sweden (where I live), can i take it orally instead (Progynon)?
A: Progynon is estradiol valerate. If estrogen priming is used then yes, it can be used but preferably IM and not orally.
2. *When do the stimulation with gonadotropins begin, at the same time as the conversion from GnRH agonist to antagonist (which I guess it the first day of the second cycle of the treatment), or is it at some other point?
A: If you use the estrogen priming protocol then it is started after 8-10 days of estrogen, injected twice a week.
3.*Does the OC start day 1 of the “first” cycle and the GnRH agonist on day 21?
4. The monophasic OC starts within the 1st 4-5 days of the period and must be continued for at least 10-14 days. The agonist is overlapped in the last 3 days on the OC.
Geoff Sher
Hello Dr. Sher,
I have had 2 IVF cycles where my E2 dropped drastically after taking ganirelix. Is this normal?
In my opinion…no! I think it points to “premature luteinization” and the need to revamp the protocol used for ovarian stimulation.
Women with increased LH activity and a more likely to produce excessive ovarian testosterone which compromises egg and follicle development. 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?
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 Dr. Sher,
I was thinking about doing initial NK testing at
ReproSource because they take insurance. And if the result would be positive and I would need more testing I would make an appointment and do testing at RIA… since they are the best.
However, ReproSource do NK Activity w/Suppression but they don’t test using K-562 target cell test.
Can you advise if NK testing by ReproSource is good enough to see if I have immune problems (few unsuccessful IVFs)
Thank you!
Zuza
Reprosource is a good lab, but you should know that in my experience, RIA takes insurance as well. Give them a call to make certain of this.
Geoff Sher
Thank you Dr. Sher for your valuable inputs ( reg the dominant follicle related protocol).
Unfortunately , I am on Day 7 and they start with the injections today. If you can tell me how we could tweak what they are already giving (Gonal / Follitism + Cetrotide), I could share that with my fertility specialist.
Since , I am in India and the stimulation starts today, it will be difficult to setup a Skype to talk to you before that.
Thanks as always Dr. Sher. Eagerly waiting for your inputs.
I really do not feel comfortable inserting myself into a treatment cycle in progress with another physician.
Sorry!
Geoff Sher