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 think I might have PCOS.
I’m 43 years old with a BMI of 25. I have recently seen excess facial hair, but it is very fine hair, not coarse. I have never been regular, however 8 years ago I conceived quickly without a problem.
I recently skipped one period and instead spotted for 15 days, on the 16th day I had contractions. It was an extraordinarily stressful time.
This month I spotted during ovulation – new for me.
During my pelvic lap in November, a very small amount of endometriosis was removed. My periods are still very painful.
My LH is 9.4, my FSH is 6.8. My AMH is 4.16. I thought that was excellent, but am now worried it is inflated due to PCOS. If I do have PCOS, how would that affect IVF? My gynecologist said it wouldn’t because drugs induce ovulation. I’m feeling very lost and confused.
Respectfully, I disagree with your gynecologist. If indeed you do have PCOS, this can and often does affect egg (and thus also embryo) quality. However, given your age, and the progressive and profound effect that advancing years has on the incidence of chromosomal numerical irregularities (aneuploidy) you absolutely need IVF .
In my opinion, the protocol used for ovarian stimulation, against the backdrop of age is an important driver of egg quality and egg quality is the most important factor affecting embryo “competency”. Older women a tend to produce 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 , 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:
•Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
•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”
•PCOS
. Severe Ovarian hyperstimulation syndrome (OHSS)
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
Hi,
I wonder if you could tell me if it is better to be on the birth control pill for 1 month or 3 months before a cycle?
It does not really matter as long as you overlap with a BCP ….see below.
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 PAFs 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, the duration of ovarian stimulation will be prolonged and both follicle and egg development may be compromised. 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.
Since optimizing follicular response to COS requires that prior to stimulation with gonadotropins, FSH-induced conversion from PAF to AF’s first be completed and the BCP suppresses FSH, it follows when it comes to women launching COS coming off a BCP something needs to be done to cause a rise in FSH for 5-7 days prior to menstruation heralding the cycle of CO S.This is where overlapping the BCP with an agonist (e.g. Lupron/Superfact/Buserelin) comes in. The agonist causes FSH to be released by the pituitary gland and if overlapped with the BCP for several days and this will (within 2-5 days) facilitate PAF to AF conversion…. in time to start COS with the onset of menstruation. Initiating ovarian stimulation in women taking a BCP, without doing this is suboptimal
I believe it to be essential regardless of the protocol of COS protocol being contemplated, for women who launching ovarian stimulation coming off a BCP to overlap with an agonist for several days in advance of initiating ovarian stimulation with the onset of menstruation,
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.
•Human Growth Hormone Administration in IVF: Does it Enhances Egg/Embryo Quality and Outcome?
•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.
Dr. Sher – Our surrogate had two cycles cancelled due to thin lining and thus we tried, per your recommendation, adding 4 sildenafil per day. Her lining got up to a 6.9 on CD9 (her highest ever!) but we just got news today that the lining went down to 6.4 on CD12. We are shocked. We are doing baby asprin, acupunture (using Dr. Yu’s protocol for acupunture + sildenafil), and vaginal and injectible estrogen (2 mg vaginal daily and 4 mg of injectible every 3 days). We are at a loss for what to do. Do you have any advice for how to proceed? Thank you so, so much!
Warmly,
Inna
There are circumstances where Viagra will not help….Perhaps we should talk!
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, thank you so much for answering my questions in the past. Because of your help, I have been able to convince my RE here in South Africa to try out your A/ACP protocol, YAY! My RE has prescibed lucrin 3.75mg to be taken on the 21st day of my cycle. Your AACP protocol however says to take 10 units everyday starting from 5 days before stopping BCP. This has confused me a bit.
1. Is it better to take it as a single shot on day 21, or to use 10 units ED for about 10 days before period comes?
2. Is it better to do the 3.75mg single shot with BCP or not?
3. Last try in Jan, i was taking 150iu of Menopur in addition to 450 iu of gonal. Given that my LH rose to 10 miu/L after 4 days of stims (even though it was below 4 before starting stims), is it advisable to still add Menopur (or any other LH injects) to my protocol? Or is it better to only add LH after day 5 of stims?
Thank you so much for being such an angel Dr Sher…
1. Is it better to take it as a single shot on day 21, or to use 10 units ED for about 10 days before period comes?
2. Is it better to do the 3.75mg single shot with BCP or not?
A: Use BCP with a 3 day 10U Lupron overlap as outlined in the protocol.
A: In my opinion it is far better to take daily dosages and avoid the lon-acting product.
3. Last try in Jan, i was taking 150iu of Menopur in addition to 450 iu of gonal. Given that my LH rose to 10 miu/L after 4 days of stims (even though it was below 4 before starting stims), is it advisable to still add Menopur (or any other LH injects) to my protocol? Or is it better to only add LH after day 5 of stims?
A: This is not likely to happen on the A/ACP. Up to 75U Menopur daily is OK, in my opinion.
Good luck!
Geoff Sher
Hi Dr. Sher,
I had a day 5 embryo transfer five days ago. Last night (day 4) I had bad diarrhea accompanied by some stomach cramps, probably due to the progesterone supplements. I was constipated early yesterday and then had an unsettled stomach. Could the cramping from the diarrhea affect implantation at all? I’m a little worried. Thanks for your insight.
Highly unlikely!
Just hang in there!
Good luck!
Geoff Sher