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.
Dear Dr Sher
I am expecting babies, twins.I am in week 16.Baby A was diagnosed serious illness so doctor offered selective reduction because baby B is healthy.Baby A now is very sick she has more problem which will cause death.The reduction was delayed 3 weeks ago because the ultrasonic examination showed that baby A is worser and worser. We want to rescue baby B who is farer the cervix and we don’t know what will happen.We understood that A baby won’t alive and we have to decide if we wait for the nature or we ask the reduction.Can you give your advise how we can increase B baby chance to stay alive?We heard that baby A is closest to cervix so the risk is big regarding the reduction process.What we can do?
Me and my husband are very sad and we are really wanted the babies (it was possible with IVF) but in that case this is unpossible…..
Thank you in advance if you can give a quick response.A mother.
A selective reduction of Baby-A, in the right hands, has an excellent chance of leaving baby B unaffected, provided that these are binovular (fraternal twins) and not uniovular gtwins. It is a tough choice, but on balance, I would probably advise that course of action!
Geoff Sher
Dear Dr. Sher,
I am in a resting cycle between egg banking cycles. My first cycle in December I think was a success. 11 eggs retrieved, 9 frozen (1 post and 1 premature). My doctor was very happy with the results. It was a minimal stimulation protocol (bcp and then 150 Gonal-f, 1 menopur nightly, ganirelix added and then HCG trigger). I know you are not a proponent of minimal stimulation, but it seems to have done the job at least for this cycle.
I am just turned 40 with previously 2 miscarriages that were naturally conceived – one tested and found to be aneuploidy.
My plan now is to do another similar banking cycle as soon as I can. My concern now is the egg banking vs embryo banking. I went with egg banking this first cycle because of the lower cost compared to embryo banking. I’m wondering if I should seriously consider embryo banking despite the higher cost because of increased success. Not sure how to weight the pros and cons between the two choices. Can you offer some insight on this issue?
Thank you very much.
Emily
I forgot to mention my protocol also included letrazole. 2 tablets daily
Frozen eggs do NOT do as well as frozen embryos (blastocysts). The baby rate per frozen egg is on average about 7% but at 40Y is probably significantly lower. …for frozen blastocysts it is several times higher…and if the embryos frozen are subjected to PGS testing prior to g=freezing the results would be even higher. So with the former (frozen eggs) you are in the dark where as with frozen, PGS-selected blastocysts you have a better idea as to what you have.
Good luck!
Geoff Sher
I have just miscarried following my first ivf at 40. I had UK AMH 15.3 (think that is about 2.1 in US terms of measurement) a couple of months before my cycle. On my cycle 11 follicles, 9 eggs but only 5 mature and 2 fertilised. A couple of months before my ivf cycle I was advice to take dhea as “it would not cause any adverse effects but might help” No tests were done to check my dhea levels before I started taking 100mg daily. Having read info on your page could the dhea dosage have increased my levels to too high a level and led to high levels of immature eggs? I was on gonal f 300iu which was increased to 350iu and triggered on pregnyl 10,000iu
I hope you can give me some advice.
Thanks
Carole
This alone, probably will not explain the loss! At 40y of age the miscarriage rate approaches 25-30%…largely due to an age-related rise in egg numerical chromosomal egg abnormalities (aneuploidy). One way to get around this is to try and minimize the chance of egg aneuploidy by using a strategically contsructed and individualized approach to ovarian stimulation and by considering Staggered IVF with embryo banking and blastocyst PGS testing….
In my opinion, the protocol used for ovarian stimulation, against the backdrop of age, and ovarian reserve are the drivers of egg quality and egg quality is the most important factor affecting embryo “competency”.
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.
•The IVF Journey: The importance of “Planning the Trip” Before Taking the Ride”
•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
•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.
•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.
•IVF: Selecting the Best Quality Embryos to Transfer
•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
•IVF: The first Choice for Infertile Women 40 to 43 Years of Age!
•Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
•A personalized, stepwise approach to IVF
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.
My wife had an E2 of 2500 on Day 13 of stims (bit of a slow responder) with 21 follicles with leading around 17mm. Day 14 her E2 dropped to 2390 so they decided to trigger. Day after trigger her E2 stayed the same. RE said this could mean poorer egg quality but of course with everything in IVF, it’s unpredictable. What do you think? My research is inconclusive – some say a drop day after trigger could mean reduced egg quality but others say it’s not really a factor (in our case the E2 plateaued day after trigger). Any thoughts would be appreciated. ET is tomorrow but would appreciate your insight! Thanks!
If the E2 had dropped by >20% on day 14, I would have been more concerned as it might have pointed to premature luteinization. That did not happen so I am somewhat optimistic.
Good luck!
Geoff Sher
Hi – I was wondering if you could shed some light on my recent Ivf. My fsh was 9 at the start of it and I am 43 years old. On all of my monitoring ultrasounds, they saw 8-10 follicles. At retrieval, I got only 5 eggs, 4 of which fertilized normally. Is it possible the follicles were empty or immature? I ended up transferring four embryos on day 3 graded as follows: 6B, 9B, 10BC, 10BC. My protocol included Clomid 100 mg for five days and Gonal F 450 iu for 8 days. Is there any chance of success with these embryos or should I look into donor eggs? I am in the two week wait. I have two living children that I had in my late thirties.
First, clearly you have an advancing biological clock both with regard to your age and to DOR. No doubt you would do far better with Egg donation. However, it might not be your only alternative. In my opinion, it is not optimal to use clomiphene in older women. It causes increased pituitary LH and LH-induced ovarian testosterone with potentially adverse effects on egg/embryo competency…some of which in my opinion could help also explain the so called “empty follicle syndrome”.
In my opinion, the protocol used for ovarian stimulation, against the backdrop of age, and ovarian reserve are the drivers of egg quality and egg quality is the most important factor affecting embryo “competency”.
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