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.
Dr. Sher,
Can you please enlighten me on how to go about hormone replacement therapy fet? Is it shorter than the natural transfer fet? Are the success rates for the two types of transfer comparable?
Thank you and more power.
Until about 15 years we believed that the best and safest way to cryopreserve embryos was by using a slow freezing method. What we subsequently learned was that the slow freezing process caused the formation of intracellular ice and that this, by damaging embryos and compromised their post-thaw survival as well as IVF outcome, significantly. The introduction of ultra-rapid embryo freezing (vitrification) has changed all that. With vitrification, embryos are frozen so fast that ice cannot form and as a result embryos are hardly damaged. In fact, about 90% of pre-vitrified embryos survive the freeze thaw in at least the same state of health as the day they were frozen and upon being transferred to a receptive uterus, have at the very least the same ability to propagate a viable pregnancy as they would have done, had they been transferred fresh. In fact there are many who believe that the post-FET pregnancy rate is now, perhaps even better than with fresh transfers. This is probably due to the fact that optimal hormonal preparation for FET provides the opportunity to better prepare the uterine lining for implantation than when fresh embryo transfers are done where unpredictably erratic levels of steroid hormones along with other potentially harmful byproducts of ovarian stimulation endometrial development might compromise endometrial development and receptivity. Against this background, and in the absence of prejudice, more and more IVF practitioners are freezing embryos for subsequent dispensation in FET cycles.
There are different ways to prepare the uterus for FET. Some authorities favor the use of commercially available oral estradiol products (e.g. Estrace, Progynova), while others recommend transdermal, transvaginal, or subcutaneous/intramuscular estradiol injections. The problem with oral estradiol administration is firstly that anything taken orally will upon gastrointestinal absorption, first pass through the liver (via the venous portal system) before being delivered into the systemic circulation and to the uterus. It is processed in the liver so what reaches the uterus is an altered substance and is substantially watered down. Secondly, the most commonly used form of estradiol, namely Estrace, readily metabolizes into both estradiol and estrone which could be prejudicial to optimal endometrial development. Trans-vaginal (suppositories) and trans-dermal (skin patches) administration also have drawn-backs that relate to erratic and unpredictable absorption issues. In my opinion, the optimal way to administer estrogen for endometrial development in preparation for embryo reception (FET), egg donor-IVF and gestational surrogacy) is through the twice weekly intramuscular administration of (slow release) estradiol (e.g. Delestrogen). This method of estradiol delivery allows for even absorption and is delivered directly to the uterus via the systemic circulation without having first to pass through the liver. I have advocated the use of
Delestrogen for uterine preparation exclusively for more than 20 years. Results are excellent and I see s no reason to change. Here is how I implement the treatment:
It starts with administering an oral contraceptive (OC) to the recipient. This is later overlapped with Lupron daily for 5-6 days. The oral contraceptive is then withdrawn, but the daily Lupron injections are continued until the onset of menstruation at which point the Lupron dosage is reduced and intramuscular (IM) estradiol valerate (Delestrogen) is administered every 3 days. The objective of the estradiol is to achieve and sustain an optimal plasma E2 concentration of 500pg/ml-1,000pg/ml and a 9mm endometrial lining as assessed by ultrasound examination. Intramuscular and/or intravaginal progesterone is administered daily starting about 6 days prior to the FET and continued along with twice weekly IM Delestrogen until the 10th week of pregnancy or until it has been confirmed that the patient is not pregnant.
Daily oral dexamethasone commences with the Lupron start and continues until a negative pregnancy test or until the completion of the 8th week of pregnancy. Then it is tapered down and discontinued. The recipient also receives prophylactic oral antibiotics starting with the initiation of Progesterone therapy, until the day after ET. Usually we would thaw vitrified blastocysts with the objective of having 1, 2 or 3 for transfer; depending on a couple’s stated preference. Commencing on the day following the ET, the patient inserts a vaginal progesterone suppository daily and this is continued until the completion of the 8th week of pregnancy or until a negative pregnancy test.
As an alternative regimen for women who cannot tolerate intramuscular Progesterone (PIO), we prescribe either Crinone vaginal gel or Endometrin vaginal inserts according to protocol. If you’d like to explore one of these options, talk to your physician. For blastocyst FET’s, the blood pregnancy tests are performed 13 days and 15 days after the first progesterone administration is commenced.
I hope this helps!
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 – thanks for providing this service!
I have been offered two options regarding persistent bleeding from potential retained placenta (inconclusive ultrasound -I had small spots that the radiologist said could be blood clots, retained placenta or calcification) from my delivery 7 weeks ago: D&C or “wait it out”. I have been doing research and seen studies that cite the risk of Asherman’s to be 25% after a D&C for retained placenta between 2-4 weeks postpartum, but nothing about specific numbers after the 4-week point.
In your opinion, what is a greater risk to future fertility – a D and C at 8 weeks postpartum or leaving fragments of (potential) retained placenta? The bleeding has been somewhat lighter and even nonexistent for a few days over the past week, so I’m hesitant to go through a procedure unless it would be the safer option in terms of future fertility.
Thank you!
In my opinion, it is not the D&C that causes the adhesions (“Asherman’s). Rather it is the inflammation associated with endometritis starting in the products themselves. So I would advise a hysteroscopy and D&C.
Good luck!
Geoff Sher
Hi, My husband and I have been seeing a fertility specialist. We already have a 3yr old daughter who was conceived very quickly naturally. My periods however stopped and have only just come back after nearly a year. I have been put me on Clomid which I have just started. My husband sperm results came back with a Morphology % of 1, his concentration was 44.8, count 165.76 and rapid progression 33. Do you think there is a chance we will be able to conceive with his results the way they are? Have you any recommendations to increase his levels especially in relation to Morphology.
I would really appreciate any advice you could give me.
Regards
Laura
It hard to say with so little detail provided. The issues are whether ovulation has returned and is normal and whether or not there are any other factors involved. A low sperm morphology alone can be erroneous as it could be the result of a misreading or temporary. I would repeat the analysis na month or two later, if I were you.
Feel free to 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.
Dr. Sher,
You have answered several of my questions already in the recent past but now I have one more. I am in the BCP pill part of my IVF process of egg banking (in hopes of obtaining 6 good embryos for transfer). I just received my schedule. RE told me she was doing Teremoto protocol? of minimal stimulation in hope of obtaining best quality eggs. This is my schedule.
BCP for two weeks (on my second week now) until 10/29. Break until 11/4 then start again until 11/19. 11/24 start 2 tablets Letrazole, 150 units Gonal F, 1 Menopur plus baby aspirin and doxycycline daily. Day 6 possible start of Cetrotide injection. Planned egg retrieval on Day 13, 12/6.
I’ve been reading your blog about use of certain protocols in older women with DOR. (I’m about to turn 40 in a few weeks.) Not sure if this protocol is following your view on the way to handle someone in my situation.
I have a u/s thursday afternoon to see how i’m looking right now. I hope to ask some questions now. But not sure how to approach it as I don’t want to seem like I’m questioning the doctor’s expertise as I believe she is very good at what she does. She tailors protocols to each individual very carefully.
Thank you as always for you replies.
Very Respectfully, I do not believe in Mini-IVF (as described above)…especially not for olfder women. For reasons cited below, success rates are VERY low and in my opinion, egg quality is poorer.
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.
• 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
•Optimizing Response to Ovarian Stimulation in Women who Have Compromised Ovarian Response to Ovarian Stimulation in Women who Have Compromised Ovarian Reserve: A Personal Approach.
•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
•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 there,
On Saturday 15th October I had a 5 day blast transferred and on Monday 24th I had Hcg levels of 140, today is Thursday 37th and I have had some red bleeding. It started off as brown discharge this morning and has progressively changed colour throughout the day. I cannot get into my doctor until next week and I am just wondering what to do. The nurse I spoke with today, told me to just monitor it and call back in the morning and let them know if the bleeding continued?
What questions should I be asking and what should I do?
Feeling very emotionally and unsure at this point, would love some hope?
Kind regards- B