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 have 2 grade A blastocysts and 2 3-day embryos. After retrieval, I proceeded with the next cycle for the transfer. My doctor used a natural transfer as protocol but , unfortunately it was cancelled because my progesterone on the day of the transfer was 3.44 when it should be at least 11. It was still low even if I took duphaston and utrogestan for 5 days. The doctor said it might be that my corpus luteum was not good that cycle and it changes from cycle to cycle. We tried the same protocol the following cycle but it was cancelled again since my progesterone is low again at 5.24. Now, we will be changing protocol next cycle and he will do a medicated transfer. What might be the cause of my low progesterone? Do you think a medicated transfer is suitable for my case? What supplement can I take to help increase my progesterone? I hope you can enlighten as a second opinion will be a great help. Thank you in advance Dr. Sher.
The cause can be due to dysfunctional ovulation which can be sporadic and is why I strongly favor hormone replacement cycles for my FET patients.
Geoff Sher
Dear Dr Sher,
I am 28 years old with pcos. My AMH level is 20. My free testosterone level is normal. My LH:FSH ratio is 3:1, though my LH is only 14. I am and always have been of normal weight.
In March we went to an endocrinologist for assistance with ovulation induction. To my knowledge, I have never had a period without help.
We tried one round of clomid at 100mg. A day 21 check of progesterone showed I didn’t ovulate. The doctor suggested menopur. At 75iu I didn’t respond so the cycle was canceled. Dr suggested menopur again with 75iu of Follistim. I overstimulated and we converted to IVF. We retrieved 17 eggs, 13 fertilized, and 5 were frozen after a Lupron trigger (my e2 levels were over 6,000 two days before triggering). A month later we transferred 2 blastocysts–BFN–using oral estrogen and PIO.
Not wanting to jump into another cycle, I requested trying femara. I was on 5mg cd 6-9. On cd12 I had an ultrasound showing one follicle of 10mm. Dr said that was unacceptable and cancelled the cycle, suggesting we do another FET.
I’m feeling very discouraged. Starting at 27, of normal weight, the doctor seemed very confident. Now, after a failed round of IVF, I’m doubting if I’ll ever have a baby.
How does this course of treatment sound to you? We are considering changing doctors. Would you have suggested other steps before ivf? Should I be asking about immune testing or endometrial receptivity? I know women with pcos can have poor egg quality, but for eggs retrieved at age 27, it seems like more should have made it and be genetically viable.
Thanks for your time.
Renee
I doubt your issue is immunologic and I do not believe in the value of endometrial function testing…period.
Your issue is PCOS-related egg quality and the fact that the method used for ovarian stimulation has a critical influence on egg quality. In addition, when adequately stimulated, women with hypothalamic-pituitary-ovarian PCOS run re risk of developing critically severe ovarian hyperstimulation syndrome (OHSS) with its incumbent risks. In such cases, in my opinion, the use of a Lupron trigger while reducing the maternal risks, does so at the expense of egg/embryo quality.
When it comes to addressing ovarian stimulation in women like yourself, my approach is consistently to use a long pituitary DR protocol with an agonist (e.g Lupron/buserelin), coming off 1-2 months on the BCP. The latter is intended to lower LH and thereby reduce stromal activation (hyperthecosis) in the hope of controlling ovarian androgen release. I then stimulate with low dosage FSHr to which I add a smidgeon of LH/hCG (Luveris/Menopur) from the 3rd day and watch for the # of follicles and [E2] starting on the 7th day of COS. If there are > 25 follicles, I keep stimulating (regardless of the [E2] until 50% of all follicles reach 14mm. Then, provided the [E2] is >2500pg/ml, I stop the agonist and the gonadotropin stimulation and follow the E2 (only) daily, without doing further US examinations. The [E2] will almost invariably climb and I watch it go up (regardless of how high the concentration of E2reaches) and track it coming down again. As soon as the [E2] drops below 2500pg/ml (and not before then ever), I administer 10,000U hCGu or hCGf (Ovidrel/Ovitrel-500mcg) as the “trigger” and perform an egg retrieval 36h later. ICSI is a MUST because “coasted” eggs usually have no cumulus oophoris and eggs without a cumulus will not readily fertilize on their own. All fertilized eggs are cultured to blastocyst (up to 6 days). And up to two (2) are transferred transvaginally under US guidance.
The success of this approach depends on precise timing of the initiation and conclusion of “prolonged coasting”. If you start too early, follicle growth will stop and the cycle will be lost. If you start too late, you will encounter too many post-mature/cystic follicles (>22mm) that usually harbor abnormally developed eggs.
Use of the above approach avoids unnecessary cycle cancellation, severe OHSS, and optimizes egg/embryo quality. The worst you will encounter is mild to moderate OHSS and this too is uncommon.
I do not use antagonists in high responders (e.g., PCOS) because it interferes with the assay of E2 (often causing the value to be understated), a valuable index in assessing risk for the development of severe/critical OHSS. I also do not believe in the agonist trigger to prevent OHSS. The reason is that the magnitude of the induced LH surge varies and if too little LH is released, meiosis can be compromised, thereby increasing the oocyte aneuploidy index.
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
•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?
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,
My husband and I are dealing with secondary infertility. We have a 4 year old son that we conceived naturally. We have been trying for #2 for a little short than 3 years now. I did get pregnant a year and a half ago naturally, but it ended as a ruptured ectopic pregnancy.
I just completed my first IVF cycle in August- both my husband and I are 28 and healthy. All tests with me were good; the only unfavorable result is that my FSH came back at 10.6 which was higher than we’d like to see for my age).
We went into IVF thinking our main issue for not being able to get pregnant was MFI (low count, under 1 million, low motility and morphology). We used antagonist protocol, but had to increase Menopur dosage half way through because of too slow of growth. My progesterone level was getting too high so I had to trigger a little earlier than the RE wanted. Nonetheless, they retrieved 30 eggs- 21 were mature, and 17 fertilized and looked good on day 2. On day 3, the clinic started getting worried because all the embryos were very bad quality. None of them made it to 5 day blast. This surprised both us and our doctor, so now we are thinking we have an egg issue, sperm issue, or combination of both. I started taking all the normal supplements for improving egg quality (DHEA, vitamin D, coQ10, fish oil), and we are talking about trying a second IVF cycle in February. Our RE suggests either trying a long lupron protocol, or trying antagonist again, and hoping for a better outcome this time (possibly tweak the dosages). The good thing about the antagonist protocol is that we have seen how I respond to it already. And the long lupron protocol would be an experiment. Do you have any insight on which protocol we should try for the second time around to possibly improve our embryo quality? This will most likely be our last attempt due to financial reasons.
Thank you, I really appreciate your response.
I have little doubt that the issue relates to the selection of an ideal long pituitary down-regulation protocol coming off a BCP,possible use of “coasting” to avoid OHSS and accurate timing with regard to triggering with at least 10,000U hCG and NOT 250 mcg of Ovidrel or Lupron, will go a long way towards addressing this problem …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
•Prolonged “coasting” to prevent OHSS
•“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?
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.
I had my baseline scan today for my natural FET. I am on day 4 and my lining is at an 11. Is this too thick?
As long as there is no endometrial pathology there is in my opinion no such thing as too thick a proliferative endometrial lining.
Geoff sher
Dear Dr. Sher,
I have questions about degenerated eggs right after RE. I am 41 years old and had 2 IVF cycles from a clinic in NY, and both protocols included injection of FSH, and oral pills of clomid and letrozole. During my first RE in June, I had 6 eggs of good size, two were degenerated per the embryologist. The rest 4 were mature and viable for fertilization. In my second cycle, I had about 8 eggs, 3 were degenerated, and the rest 5 were put under fertilization. In both cycles, my LH was well controlled under 5. I would like to get your insight about the following:
1. Is the large follicle more likely to degenerated? I am asking to understand if changing the trigger time can reduce the degenerate risk.
2. What are the possible reasons causing eggs degenerating, besides of age? I tried to google online but was not very successful.
Thank you so much for your time and help!
Best
May
Very Respectfully may,
I do not agree with the protocols used for ovarian stimulation in your case.
Older women as well as those 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