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 recently failed the Etegrity endometrial biopsy .. My lining came out poorly receptive and out of phase .. I am now doing embryo banking 3 cycles . I have since them been told I probably have silent endometriosis …,My plan is to do 3 months of lupron depot to fix lining and swing into a FET protocol —
What is the best fet protocol to subdue all the endo inflammation …
Also would you suggest a lap vs lupron depot?
I am NOT a believer in the Etegrity process at all…so I am really not the right one to advise you here.
Sorry!
Geoff Sher
Thank you for having such a wealth of information be so accessible, it has been so very useful to read your blog and responses to others’ questions.
I am 33 years old with a high antral follicle count (likely PCOS). I have a high AMH level (10-11) but my LH/FSH ratio is normal (4.5 and 5.3 respectively) and my testosterone/DHEA is not elevated. After taking 1500mg/day of metformin I began to ovulate on my own. My husband is also 33 and has male factor infertility which led us to recently complete our first IVF/ICSI cycle, which unfortunately did not go as we had hoped.
I was on the antagonist stimulation protocol. After BCP for 2 weeks, I was on 150 units of Menopur & 150 units of Gonal-F for 8 days at which time, Ganarelix was introduced to prevent ovulation. By Day 11 my estradiol (E2) level reached 4,500 but many of my follicles needed another day to reach the desired size for trigger. On Day 12 my estradiol level fell slightly to 4,200. I took my trigger that night (Lupron trigger with hcg co-trigger of 1,000 IU to avoid OHSS) and the second Lupron trigger in the morning. My progesterone was 25 the day before retrieval.
Thirty-two (30) eggs were retrieved, 24 were mature, and 22 fertilized successfully with ICSI. By day 3, we had 17 decent quality embryos and 5 poor. However, by Day 5 only one made it to blast and was of poor quality; the rest arrested.
Do you have any opinions on what could have gone wrong? Would you recommend a protocol change to address egg quality despite the initial good response I had (high # mature eggs, good fert rate, etc)? I have read your advice on the importance of individualizing protocol of ovarian stimulation in PCOS patients including that often times increased LH can compromise egg development. Would the same concern apply even though my blood LH level is not elevated as in the typical PCOS patient? Alternatively, could the Lupron trigger be to blame? Is there any hope of having a more successful outcome in a future cycle?
In my opinion this is almost certainly a stimulation protocol issue. My approach is consistently to use a long pituitary DR protocol with an agonist, 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.
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
•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 BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
•Why did my IVF Fail
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF
•The Role of Nutritional Supplements in Preparing for IVF
Understanding Polycystic Ovarian Syndrome (PCOS) and the Need to Customize Ovarian Stimulation Protocols.
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
Dr sher
If NK Cells are activated it is not possible to have a pregnancy then??
It is possible but the likelihood of a viable uncomplicated pregnancy is very much reduced.
Geoff Sher
Dr sher
Can someone with elevated Nk Cells get pregnant and stay pregnant??? Im afraid that i will never be able to have a baby since my test for elevated Nk Cells came back positive
It is not impossible, but also not likely if NK cells are activated.
Geoff Sher
I started this journey when I was 39, and am now 40. I understand they my age, and that I only have 1 ovary were against me but all testing was normal and I was told everything looked good. I am using donor sperm, and started with IUI, then moved to medicated IUI’s. This process was over about 6 months. Then in October my antral follicle count decreased to 2 (was 8) FSH which was always normal was over 30, and AMH dropped to 0.04 (was 1.5). I was then told I was in menopause even though my menstral cycle was normal every 27-28 days. I started an IVF cycle with BCP for 1 month, then Ganrelix, Menopur, and Follistim. I formed 6 follicles but my RE canceled ER because she said they were all cysts not follicles at day 7. I took 2 months interviewed several Dr’s and found a new one I am currently working with. My antral follicle count went up to 6 but has steadily been dropping every month. Its been 4 months since my AMH dropped. Last month I did another IVF round with Estrogen for 2 weeks, then Lupron, Omnitrope, DHEA, Follistim, Menopur. I had 4 eggs retrieved and 1 making it to day 5 to freeze and do genetic testing. Then I went right into another IVF round with the same protocol as before but only yielding 2 follicles, 1 egg, and nothing that survived. I have been told to not wait a month in between cycles as I could have no eggs if I give my ovary a month break. What are your thoughts? Are there any other protocols suggestions or am I just out of time? I know DHEA can increase testosterone which can also impede egg quality so I’m second guessing everything. I want to try 1 more cycle but don’t know if it is even worth it. I have looked into egg donor, embryo adoption, and adoption but would really like a biological child if at all possible. Any insight or thoughts would be appreciated to help me make my decision. Thanks
Hi Jessica,
I am so sorry you messed around trying IUI when based on your ovarian reserve, you were running out of time. Even women who have normal ovarian reserve have abouta 2% chance of a viable pregnancy per IUI cycle (medicated or non-medicated). At this point given your AMH it is my opinion that you need an eggdonor. Anything else is going to be emotionally and financially taxing and is unlikely to succeed, I am afraid..
However, if in spite of this advice, you decide to still try with own eggs, then you would urgently need a modified, robust, long pituitary down-regulation protocol. I would use an agonist/antagonist conversion protocol with human growth hormone (HGH) augmentation and would recommend Staggered IVF with embryo banking of PGS (next generation gene sequencing)-normal blastocysts, to make hay while the sun still shines.
Please visit my new Blog at o to http://goo.gl/4hvjoP , 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?
•Frozen Embryo Transfer (FET): What Does it Involve?
•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 Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
•IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
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