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.
My recently married son (44) and his wife (33) have found out they both carry the cystic fibrosis gene even though there’s no history of it in either family. They want to start a family and want do Pre implantation diagnostic testing. Since infertility isn’t the issue but CF is, do you recommend it? They said I should be tested also which I see as making no difference in the end. Please advise me since I want to do the right thing. Thank you!
I tend to agree with you!
Geoff Sher
Hi Dr. Sher,
I am 39 and have gone through 3 IVF cycles with 6 failed FETs. Our main reason for doing IVF was my husband’s vasectomy, but have had no success so far. On my fist IVF at 37, (225 Gonal and 75 Menopur), we got 42 eggs, 39 were mature. The embryologist was concerned about the frozen sperm we were using and talked me into fertilizing our eggs in 2 batches. The first try we used 21 eggs, 19 fertilized, 12 made it to day 3 and in day 6 we had 5 left. Of these, 3 ‘passed’ PGS. The quality of these were all BB or higher. These were all transferred one at a time and I took oral and vaginal estradiol, progesterone starting 5 days ahead. My lining had difficult reaching 7mm, but always had the three layers. Intermixed in these cycles, were 2 cancelled transfer cycles, one for thin lining and one for high progesterone. Those transfers failed, so we used my frozen eggs with fresh sperms. Of 19 eggs, 12 fertilized and 9 made it to day 3. Of these, only 1 ‘passed’ PGS, this time we did a day 3 FET, At this point I started on prednisone, lovenox, neupogen injections, aspirin, did an HCG wash, a neupogen wash and intralipids for all future transfers.The second round of IVF, we got 16 eggs, 12 fertilized with fresh sperm, 1 was ready On day 5, 4 were ready On day 6. One passed PGS. This time we used 75iu Gonal and my lining was over 8. Before transfer, I had IViG. I had a chemical pregnancy, with HCGs of 69, 82 and 73. The 3rd round’ my meds were increased to 300 Gonal and 150 Menopur, I also did HGH and estrogen for 2 months before my retrieval cycle. My retrieval cycle was delayed a month due an ovarian cyst. We got 24 eggs, 16 were mature and 9 fertilitized with fresh sperm. We had 3 ready in any 5, and 2 ready On day 6. 1 passed PGS. The FET was delayed in month due to the size of my varies. The next FET also used 75 in Gonal, neupogen injections, HCG wash, lovenox, predinisone, intralipids before. This cycle also failed. I don’t have a problem getting eggs, and my RE has never commented that my eggs look bad. In my last conversation with him, my RE said there wasn’t anything else he could think of adding and that I could either try another cycle with my eggs or to look at donor eggs. I’ve read about ERA, but my RE doesn’t do this test. Could this offer any useful information, is there anything else can I look into or am I just out of luck with my eggs? Thank you.
I left out, importantly, that I was diagnosed with endometriosis at 23 and have multiple ovarian cysts. I’ve had 4 laprascopies to remove endometriosis, most recrlu before my 3rd failed IVF. The dr also found during that procedure that both of my tubes are blocked. I have had an endometrial biopsy and that was normal. Thank you!
Hi dr Sher,
I did ICSI once and I got 52 eggs 40 MII and 10 MI and 2 E Zona . I got sever hyperstimulation. My eggs quality was bad and i got the trigger shot at E2 equals more than 7000 I guess. I hot 32 embryos and my dr froze them .but i did implantation once and it failed and nowadays iam going to try another one. My husband is sperm is good but speed rapid =0 and moderate=60%. Our embryos quality is degree 2 and 3 , there is no grade 1 at all which is highest grade. My quest is I am nerves and wonder if my bad oocytes quality may cause implantation faliure again? Also I have polycystic with multiple antra follicles so does the bad egge quality is becuase of polycysistic or because of stimulation protocole or probability of bad chromosome? And how can I improve my egges quality? Finally would IUI useful for us?
Iam 30 years old . I have no problems in my uterus. I just had a ervix small polyp but i removed it recently 3 weeks ago.
PCOS is associated with an increased propensity for poorer quality eggs. However, this can to a large extent be mitigated through use of an individualized protocol for ovarian stimulation. PCOS also sets you up for severe ovarian hyperstimulation syndrome (OHSS).
Yes, Severe Ovarian hyperstimulation syndrome (OHSS) is often associated with e poor egg/embryo quality. This is especially so in women with high ovarian LH-induced testosterone (e.g. those with PCOS). The often present with poorly developed (“dysmorphic”) eggs, with reduced fertilization potential and yielding “poor quality embryos”. However, in the author’s opinion (which admittedly runs contrary to popular opinion), this is unlikely to be due to an intrinsic deficit in egg quality. Rather, it more likely relates to intra-ovarian hormonal changes brought about by hyperstimulation and which compromise egg development. This effect, in my opinion, can often be significantly reduced through implementation of an individualized or customized ovarian stimulation protocols that minimize exposure of the developing follicles and eggs to excessive LH-induced ovarian androgens. This can be best achieved by limiting the use of LH-containing gonadotropins such as Menopur through selective institution of “prolonged coasting” (see below). Approaches to preventing OHSS include:
1.PROLONGED COASTING (My preferred approach) : My approach is to use a long pituitary DR protocol coming off up to 2 months on the BCP, overlapped in the last 3 days with the agonist, Lupron. The BCP is intended to lower LH and thereby reduce stromal activation (hyperthecosis) in the hope of controlling ovarian androgen (predominantly, testosterone) production and release. I then stimulate with low dosage FSHr (Follistim/Gonal-F/Puregon) to which I add a smidgeon of LH/hCG (Luveris/Menopur) from the 3rd day. Then, starting on day 7 of ovarian stimulation, I perform serial blood estradiol (E2) and ultrasound follicle assessments, watching for the # of follicles and [E2]. If there are > 25 follicles, I keep stimulating (regardless of the [E2] until 50% of all follicles reach 14mm. At this point, provided the [E2] reaches at least >2,500pg/ml, I stop the agonist as well as gonadotropin stimulation and track the blood E2 (without continuing US, follicle measurements) ) daily. The [E2] will almost invariably increase for a few days. I watch the E2 rise (regardless of how high a blood concentration it reaches) and then track it coming down again. As soon as the [E2] drops below 2500pg/ml (and not before then), I administer a “trigger” shot of 10,000U hCGu (Profasi/ Novarel/Pregnyl) or hCGr (Ovidrel/Ovitrel-500mcg) and perform an egg retrieval 36 hours later. ICSI is a MUST because “coasted” eggs usually have no cumulus oophoris envelopment and eggs without a cumulus will not readily fertilize naturally. Moreover, they also tend to have a “hardened” envelopment (zona pellucida), making spontaneous fertilization problematic in many cases. All fertilized eggs are cultured to blastocyst (up to 6 days) and are then either vitrified and preserved for subsequent transfer in later hormone replacement cycles or up to two (2) fresh blastocysts are transferred transvaginal 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 “Coasting” 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. The obvious remedy for these adverse effects on egg and endometrial development is to employ stimulation protocols that limit ovarian over-exposure to LH and allowing the time necessary for the follicles/eggs to develop optimally, prior to administering hCG through the judicious implementation of “Prolonged coasting” (PC).
2.MULTIPLE FOLLICLE ASPIRATION: In some cases, where because of mean follicle size exceeding 16mm or when “coasting” fails to effectively lower the [E2} below 2,500pg/ml within 3 days, the number of developing follicles can effectively and drastically reduced through target transvaginal aspiration, 1-3 PRIOR to planned the hCG trigger. This will almost invariably be accompanied by a rapid and significant drop in the plasma [E2] and in the process will drastically reduce reduce the risk of OHSS occurring without significantly compromising egg/embryo quality. The drawback of this effective approach is the fact that it interjects an additional surgical intervention into an already complex and stressful situation. i
3.TRIGGERING WITH LOW DOISAGE hCG; Because of the fact that hCG augments the development of OHSS (unless preceded by “coasting”), may RE’s prefer to use a lower dosage of hCG for the “trigger. This is either done by administering 5,000U (half the traditional dosage) or by administering, a 250mcg (rather than 500mcg) of DNA recombinant form of hCGr (Ovidrel/Ovitrel. Some clinicians, when faced with a risk of OHSS developing will deliberately elect to reduce the “trigger” dosage of hCG administered (from 10,000U to 5,000U or 250mcg of recombinant hCG-Ovidrel) in the hope that by doing so the risk of critical OHSS developing will be lowered. While this might indeed be true, it is my opinion, that such a reduced dosage is usually insufficient to optimize the efficiency of egg meiosis, e3specially when there are so many follicles present. While the use of a reduced “trigger” dosage of hCG does indeed reduce the risk and occurrence of OHSS-related life-endangering complications, the price to be paid is reduced egg quality/”competency”.
4.“TRIGGERING” WITH A GnRH AGONIST (E.G. “LUPRON/BUSERELIN): More recently, an increasing number of RE’s prefer to trigger meiosis by way of an agonist (Lupron/Buserelin/Superfact () “trigger” rather than through the use of hCG. The idea is to mimic what happens in natural cycles to promote egg maturation (meiosis) and ovulation, namely to have the agonist cause a “surge” in the release of body’s own pituitary LH to trigger egg meiosis (maturation) .But the amount of LH released in by the pituitary gland is often insufficient to optimize meiotic egg maturation and thus, while this approach also lowers the risk of OHSS it again comes at the expense of egg quality/competency.
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
•Use of GnRH Antagonists (Ganirelix/Cetrotide/Orgalutron) in IVF-Ovarian Stimulation Protocols.
•Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
•Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
•A personalized, stepwise approach to IVF
•Preventing Severe Ovarian Hyperstimulation Syndrome (OHSS) with “Prolonged Coasting.
•“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?
•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, is there a link between rheumatoid arthritis and repeat chemical pregnancies? If so, how does RA cause chemical pregnancies and what, if any, is the treatment?
In a significant percentage of RA cases there will be a immunologic implantation dysfunction linked to NK cell activation and this indeed can cause chemical pregnancies.
•The Role of Immunologic Implantation Dysfunction (IID) & Infertility (IID):PART 1-Background
•Immunologic Implantation Dysfunction (IID) & Infertility (IID):PART 2- Making a Diagnosis
•Immunologic Dysfunction (IID) & Infertility (IID):PART 3-Treatment
•Thyroid autoantibodies and Immunologic Implantation Dysfunction (IID)
•Immunologic Implantation Dysfunction: Importance of Meticulous Evaluation and Strategic Management:(Case Report
•Intralipid and IVIG therapy: Understanding the Basis for its use in the Treatment of Immunologic Implantation Dysfunction (IID)
•Intralipid (IL) Administration in IVF: It’s Composition; How it Works; Administration; Side-effects; Reactions and Precautions
•Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
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, for a frozen embryo transfer cycle, what is the optimal blood estrogen level before progesterone initiation in a FET? What range do you want to see of estrogen in blood test before you start progesterone at the mid cycle ultrasound?
Using estradiol valerate (Delestrogen) by injection twice weekly, I like the E2 to reach 500-1000pg/ml.
Geoff Sher