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 am a 33 y/o female with a longstanding history of anovulation and amenorrhea. My former ob/gyn informed me it was due to pcos because of my high lh:fsh ratio and amh taken many years ago. I have a 1 year old baby that was conceived through timed intercourse with Letrozole and Ovidrel. After giving birth I stopped breastfeeding after two months (i had to have a lumpectomy) but I continued lactating for another 3-4 months. After a trip to an endocrinologist I was told I had very high prolactin levels and a prolactinoma was ruled out via MRI. Since I didn’t have a day 3, bc I am not menstruating, he did a RANDOM blood hormone panel and my fsh was 5, lh was 4, estradiol was less than 60 and my TSH was 1.66. It has now been slightly over a year since my daughter was borm and I still have not had a period. I had 3 episodes of extrememy light (pink) spotting that lasted anywhere from a few hours to a few days. That is it. I am terrified I am experiencing POF/POI or ROS. My questions are: should I get a repeat random blood hormone panel (will this give an accurate diagnosis of pof since I am not menstruating and wont have a day 3) OR should I take provera with the hopes of bringing on a period and measure the levels on day 3? Are the values above considered normal (again bearing in mind it was not measured on a day 3)? What is the likelyhood it is POF/POI. or ROS in your opinion? Also if my fsh was 5, does this mean that if i do take the provera and if i get a day 3, this amount will soar to 10 or 12 (in otherwords, is 5 high since it is taken randomly and outside of the standard day 3 time)? I know anythimg over 10 is suggestive of a problem. I have also stopped lactating so I don’t think prolactin levels are the cause of this. As you can tell I am panicking!
Your FSH/LH/E2 levels are neither suggestive of POF or of PCOS. This looks more like a hypothalamic amenorrhea. Given the length of amenorrhea, it is in my opinion highly unlikely that you will respond to Letrozole or clomiphene. You will probably require gonadotropin stimulation but it should only be done by someone who is very experienced because you could be at serious risk of developing ovarian hyperstimulation and this requires careful strategic selection of a protocol as well as its careful implementation. Might I also suggest that you have an AMH blood test which more reliably will determine your ovarian reserve.
Good luck!
Geoff Sher
It will not likewly respond
Dear Dr Sher,
I am considering doing my first IVF cycle at the age of 43. Am I a fool to think I can do it with my own eggs? Will concurrent accupuncture and/or DHEA supplementation increase my chances? Should I do mini-IVF rather than normal IVF? Would you advise CGH method for pre-implantation genetic screening?
my Background info:
-started trying for a child late in life at age 38 in January 2012
– miscarriage 25.12.12 at 5 weeks
– pregnancy Feb 2013, with live baby boy in October 2013 via caesarean
– tried to conceive for 8 months, then ectopic pregnancy and salpingectomy January 2014
– Clomiphene cycles x2 with exaggerated response (5 follicles over 24mm, 3 under 10mm on 50mg dose, Oestradiol 6600) in April/May 2015
– natural pregnancy in June 2016 – terminated at 13 weeks due to trisomy 18
Recent Hormone results 27.02.17:
day 4 of cycle:
FSH 4.8 IU/L, LH 3.1 IU/L, Progesterone <1.0 nmol/L, Oestradiol 272 pmol/L
AMH 1.1 pmol/L or 0.154ng/ml
– regular periods 25-28 days, usually heavy periods
– am on Thyroxine 50mcg daily for hypothyroidism (prev. hemithyroidectomy)
– normal BMI
– husband had normal spermiogram, but prev. diagnosis of hard to treat non-specific urethritis
Thank you very much for your time and greetings all the way from New Zealand.
Sarah
I would advise against DHEA . At 43Y you need very strategic ovarian stimulation.
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
Dr. Sher, my 1st beta was Monday at 14dp3dt- it was 208. A few hours after, I began to spot, then the spotting increased the next day. Last night spotting stopped before today’s 2nd beta. The result today was only 236 today, clearly failing to double. Spotting has now resumed lightly today so decided to be on bedrest today and tomorrow. Is it likely this pregnancy will fail? Thank you for your honest feedback.
If .1 embryo was transferred, it is possible that you started with a multiple and the failure of the hCG level to double is due to a spontaneous reduction taking place. Repeat the beta hCG in 2 days. If it drops further , that is gad news but if it now starts to double, you could be OK!
Good Luck!
Geoff Sher
Dear Dr Sher,
I am approaching 41 and ttc with my partner for a year. Last year we conceived naturally following laparoscopy for endometriosis and uterine polyp removal. Unfortunately it ended in missed miscarriage at 6 weeks. I’m considering IVF, my clinic advises long protocol is better for endometriosis in terms of womb lining. However, I’ve read that the drug dosages can make endo worse and impact lining for egg transfer. I was hoping mild IVF or natural cycle IVF might be better, as I’m also concerned about how long it takes for natural cycle to return if IVF fails on long protocol and due to my age in time taken for normal cycles to return after a long protocol. My AMH is 16, clinic advised this was fine for long protocol. No male fertility issues as high sperm count but some antibodies. Can you advise if mild or natural cycle is better for endometriosis in terms of a more receptive uterus environment working with the natural cycle? My last laparoscopy some endo was untreated on the left side of ovaries due to difficulty but surgeon advised it was not blocking the ovary. I know being over 40 is reason enough to embark on IVF however we did conceive naturally, I also wonder if it is worth ttc naturally a little longer. If you could advise particularly regarding type of protocol for endometriosis due to research about drugs that cause it to flare up further. Many thanks.
I would NOT use a low-stimulation protocol.
Yes! I agree that a long down-regulation protocol is best. Also you need to understand that endometriosis is associated with immunololoc implantation dysfunction which in your case needs to be investigate.
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?
•The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
•Blastocyst Embryo Transfers Should be the Standard of Care in IVF
•Hereditary Clotting Defects (Thrombophilia)
•Blastocyst Embryo Transfers done 5-6 Days Following Fertilization are Fast Replacing Earlier day 2-3 Transfers of Cleaved Embryos.
•Embryo Transfer: The “Holy Grail in IVF.
•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!
•Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas
•Should IVF Treatment Cycles be provided uninterrupted or be Conducted in 7-12 Pre-scheduled “Batches” per Year
•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
•Endometriosis and Infertily
•Endometriosis and Immunologic Implantation Dysfunction (IID) and IVF
•Endometriosis and Infertility: Why IVF Rather than IUI or Surgery Should be the Treatment of Choice.
•Endometriosis and Infertility: The Influence of Age and Severity on Treatment Options
•Treating Ovarian Endometriomas with Sclerotherapy.
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, our doctor has advised to do a blood Karyotype test since we are going to do PGS. My partner already has a daughter who is 20 years old. Is it necessary for him to do a Karyotype test since he has already successfully had a daughter? Thanks so much in advance!
Clearly your doctor wants to exclude a balanced translocation, but I personally do not see the rationale for karyotyping him, since PGS should reveal any unbalanced embryo translocation.
Geoff Sher