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 been reading your blog for so long. Very informative, thank you. I am about to embark on IVF cycle 2. I have no problem getting pregnant but doing IVF in order to PGD for a genetic issue with my DH. Below are my stats:
Age: just turned 37 a week ago 🙂
All the tests below are taken on CD2 last month:
AFC: 5-6 on left side. Big cyst on right ovary so they didn’t count on that side at all
FSH:2.2 U/L
LH: 2.2 U/L
AMH: 1.5ng/L (10.71 pmol/L)
Prolactin: 22.2 ng/mL (3.4 – 24.4)
E2: 30.2 ng/L (111 pmol/L)
TSH: 3.25 uiU/mL
I had my first IVF cycle 2 weeks ago (ANTAGONIST protocol with Letrozole for the first 5 days and Gonal-f (300 iu) + Menpur (150 iu) starting from day 3). I responded poorly to this. By day 4 my E2 was on 53 ng/L. By day 6 I had only 5 measureable follices and 2 were far ahead.
I will like to know what protocol will you recommend that I try next for my cycle 2? Thank you so much in advance!
In order for any organism to attain an optimal state of maturation (ripening) it must first undergo full growth and development. A fruit plucked from a tree before having developed fully or a poorly developed fruit might still ripen (mature) on the shelf and might even appear as enticing as one that had previously undergone proper development, but it will lack the same quality. The same principles apply to the development and maturation of human eggs. Proper development as well as precise timing in the initiation of egg maturation with LH or hCG is no less crucial to optimal egg maturation, fertilization and ultimately to embryo quality. In fact, in cases where egg maturation is improperly timed (LH or hCG is released/given too early, i.e. prematurely or too late, i.e. post-maturely) there is an increased risk of aneuploidy (structural and numerical chromosomal abnormalities) leading to compromised reproductive performance.
The potential for a woman’s eggs to undergo orderly maturation, successful fertilization, and subsequent progression to “good quality embryos” that are “competent” (capable of producing healthy offspring), is in large part, genetically determined. However, the expression of such potential is profoundly susceptible to numerous extrinsic influences, especially to intra-ovarian hormonal changes during the pre-ovulatory phase of the cycle.
During the normal ovulation cycle, ovarian hormonal changes are orchestrated to avoid irregularities in production and interaction that could adversely influence follicle development and egg quality. As an example, while small amounts of ovarian male hormones (predominantly testosterone) are essential to enhance egg and follicle development, over-exposure to excessive amounts of the same hormones can seriously compromise egg (and subsequently, also embryo) quality. It follows that protocols for ovarian stimulation should be geared towards optimizing follicle and egg development while avoiding overexposure to ovarian male hormones. The fulfillment of these objectives requires a very strategic and individualized approach to ovarian stimulation and precise timing of the human chorionic gonadotropin (hCG) “trigger.”
It is important to recognize that the pituitary gonadotropins, LH and FSH, while both playing a pivotal role in follicle development, have different primary sites of action in the ovary. The action of FSH is mainly directed at the cells that line the inside of the follicles (i.e. granulosa cells). LH, on the other hand, acts primarily on the connective tissue that surrounds the follicles (i.e. the ovarian stroma or theca) to compel the production of male hormones.. Some LH is essential because it is the androgens (mainly testosterone) that serves as th building block upon which FSH acts to promote follicle growth, estrogen production and egg development. Without some LH-induced testosterone production egg and follicle development would indeed be compromised. However, only a small amount testosterone is necessary for optimal development. Over-exposure to such androgens has a detrimental effect on granulosa cell estrogen production, follicle growth/development, egg maturation, fertilization potential and subsequent embryo chromosomal integrity (“competency” Furthermore, excessive ovarian androgens can also compromise estrogen-induced endometrial growth and development leading to a thin and unreceptive uterine lining, sometimes seen in women with PCOS who usually have excessive ovarian LH-induced testosterone production..
In conditions such as polycystic ovarian syndrome (PCOS), which is characterized by increased blood LH levels, there is also an increased ovarian androgen production. It is therefore not surprising that “poor egg/embryo quality” and inadequate endometrial development are often features of this condition. The use of LH-containing preparations such as Menopur might further aggravate this effect. Thus we strongly recommend against the exclusive use of such products, in PCOS patients, preferring FSH-dominant products such as Follistim, Puregon and Gonal F. While it would seem prudent to limit LH exposure in all cases of ovarian stimulation, this appears to be more relevant in older women, who tend to be more sensitive to LH
Preparing for Ovarian Stimulation:
Before embarking on ovarian stimulation it is essential to try and define the woman’s ovarian reserve (i.e., the number of eggs still available in her ovaries). Determination of the ovarian reserve will assist in defining the protocol of ovarian stimulation that would most safely yield the optimum number and quality of follicles/eggs in a given case. The ovarian reserve can best be assessed by determining the woman’s blood FSH and estradiol (E2) measurement on the 3rd day of a spontaneous menstrual cycle and by evaluating the manner in which she responded to a most recent cycle of treatment. Other blood tests that can also be selectively used to assist in assessing ovarian reserve are measurement of blood antimullerian hormone and inhibin B levels.
Once the ideal stimulation protocol is selected, the next step is to choose a suitable time for IVF treatment. For women who require a repeated cycle it is advisable that at least one-month be allowed to elapse (“resting cycle”) between IVF treatments, in order to allow the ovaries to fully recover from the preceding stimulation. Since estrogen or a combined BCP suppresses LH, it is both clinically beneficial as well as convenient to launch IVF cycles with the woman having been on at least 10 days of combined birth control pill (BCP) such as Desogen, Low-estrin or Marvelon.
Does the BCP suppress ovarian response to COS? One often hears the expressed opinion that the BCP suppresses response to ovarian stimulation. This is not the case, provided that the BCP is overlapped with administration of an agonist (e.g. Lupron, Buserelin, Superfact) for several days leading up to the start of menstruation and the initiation of ovarian stimulation cycle with gonadotropin drugs. If the latter precaution is not taken, and the cycle of stimulation is initiated coming directly off the BCP the response will often be blunted and subsequent egg quality could be adversely affected. The explanation for this is that in natural (unstimulated) as well as in cycles stimulated with fertility drugs, the ability of follicles to properly respond to FSH stimulation is dependent on their having developed FSH-responsive receptors . Pre-antral follicles (PAF) do not have such primed FSH receptors and thus cannot respond properly to FSH stimulation with gonadotropins. The acquisition of FSH receptor responsivity requires that the pre-antral follicles be exposed to FSH, for a number of days (5-7) during which time they attain “FSH-responsivity” and are now known as antral follicles (AF). These AF’s are now able to respond properly to stimulation with administered FSH-gonadotropins. In regular menstrual cycles, the rising FSH output from the pituitary gland insures that PAPs convert tor AF’s. The BCP (as well as prolonged administration of estrogen/progesterone) suppresses FSH. This suppression needs to be countered by artificially causing blood FSH levels to rise in order to cause PAF to AF conversion prior to COS commencing, otherwise pre-antral-to –antral follicle conversion will not take place in an orderly fashion and the follicles will not readily respond to gonadotropins (FSH) , thereby delaying follicle development by up to 7 days and compromising egg quality. GnRH agonists (e.g. Lupron, Buserelin, Superfact) , cause an immediate surge in release of FSH by the pituitary gland thus causing conversion from PAF to SAF. This is why, women who take a BCP to launch a cycle of COS need to have an overlap of the BCP with an agonist. By overlapping the BCP with an agonist for a few days prior to menstruation the early recruited follicles are able to complete their developmental drive to the AF stage and as such, be ready to respond appropriately to optimal ovarian stimulation. Using this approach, the timing of the initiation of the IVF treatment cycle can readily and safely be regulated and controlled by varying the length of time that the woman is on the BCP.
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”
•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.
•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 with Compromised Ovarian Response to Ovarian Stimulation: 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?
•Effective Treatment to Help Thicken a Thin Uterine Lining
•Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
•A personalized, stepwise approach to IVF
•Ovarian Reserve Requiring IVF with Embryo Banking and PGS.
•Induction of Ovulation With Clomiphene Citrate: Mode of Action, Indications, Benefits, Limitations and Contraindications for its ue
•Clomiphene Induction of Ovulation: Its Use and Misuse!
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.
Thanks so much Dr, this was VERY informative. I am already going through all the articles on your blog as advised. Please can you tell me:
1. With my pretesting result (above) would you say I have DOR for my age (37 years)
2. WIth my low FSH and LH (both 2.2 U/L) would you recommend that I do a A/ACP protcol or I should stick with Antagonist with BCP?
3. If i were to inccorporate Somatropin (HGH) would you advice that I do so 5 weeks before stims (at 1iu per day) or I should do larger doses on stim days only?
4. Is there any benefit of Using Lupron (Lucrin) or Synarel (Nafarelin nose spray)?
Thank you so much for your willingness to answer our questions!
NB: I am in South Africa and I gathered you were here on holiday. I hope you had a swell time and I’m sure you found our weather quite pleasant! 🙂
Hi Dr,
We are married for 5 years now and ttc from more than 1 year, we are advised to for IVF because i am having OAT condition. due to this our RE suggested to pool embryos and get PGS done before transfer due to severe male factor.
Our first cycle yielded 1 B grade embryo and its forzen on 3rd day[6 eggs, 4 matured, 1 bgrade 7cell]
second cycle 4 embryos and all 4 frozen on 3 day[2B, 1c, 1D].
third cycle planned for march
could you please help us to understand how well PGS will help or is there any other tests to be done before we go for transfer as we don’t want to take any risk.
Regards
Oligoasthenospermia can be reversible in some cases. You need a thorough andr0-urologic investigation to be done. If irreversible, embryo banking of PGS-normal embryos is a good strategy, especially if, in addition to the OAT, you are a poor rfesponder with diminished ovarian reserve (DOR).
Good luck!
Geoff Sher
Hi sir,
In 2013 ectopic pregnancy and 2015 one misscarriage now planning from year but no luck.so planned for IVF .laproscopy was done and every test was done everything was good.last month done with first IVF My first bhcg is 23 after 15 days 5day ET. My dr told that it’s on negative side Do I have chance for viable pregnancy?all my reports were normal and quality is also good as per Doctor nothing is complicated in my case.Unable to find the reason of failure.If this cycle fails,then will I have more chances of success for second IVF ? (remaining only 2 FET) IVF failure caused severe dissapointment. And I want to know that in general how many cycles Max are needed to get successful pregnancy for a person who’s age is below 30 with all normal reports as per your experince
That is a low hCG. Repeat it. If pregnant it should double in 2 days.
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.
•IVF: How Many Attempts should be considered before Stopping?
•Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
•A personalized, stepwise approach to IVF
•How Many Embryos should be transferred: A Critical Decision in IVF.
•The Role of Nutritional Supplements in Preparing for 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.
Hi Dr. Sher. For my ivf cycle we had 13 blastocysts. (day 5) Of those 13, only 6 are PGS normal. If the remaining 7 are abnormal (trisomy 15 & 16, monosomy 18, trisomy 3, trisomy xxy) how did they make it to day 5? They’re all frozen. My RE was dumbfounded on it and didn’t shed light on it. What do you think? Thank you for the time.
In my opinion, that result is pretty good. Congratulations! that is a good yield of “competent” blastocysts .
Geoff Sher
Dr. Sher,
I have been trying to conceive for two years. I have had 7 iii’s and 2 IVF’s. With my second IVF, I had an unviable pregnancy. Every cycle after ovulation, I have bad cramping and pain off and on up to starting my menstrual cycle. It is usually focused on my left side. It usually starts about 7 days past ovulation. This happened this past month on a natural cycle. Nobody seems to have an answer for me as to why this pain occurs. I feel like if I am getting pain this early in the luteal phase it is preventing implantation from occuring.
Any ideas would be so helpful.
Thank you so much!
Kristina