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,
At age 46, I had a mini IVF cycle with clomid, gonal-F and centrotide on standard timetable. Lost (likely ovulated) dominant follicle a few days before trigger. Triggered 12 days after start of clomid. Retrieved 7 eggs and 2 made themselves to day 5 blasts. Unfortunately, none attached in a subsequent FET.
We have gone through your blogs: the question I have is whether the stim timing, the early ovulation, or any part of the protocol played a bigger role in compromising the IVF outcome in my case (apart from my age factor), so we know what could be improved in subsequent cycle?
Thank you!
Sincerely,
Angela
Hi Angela,
While as you no doubt are aware, while I for reasons repeatedly stated and not a proponent of mini-IVF , natural IVF or the use of clomiphene in IVF, under virtually any circumstances as success rates are very low. I am especially opposed to such approaches in older women where the chance of success is in my opinion, dismal. But at 46Y of age, the only rational advice I can give you is to go directly to egg donation. If however, in spite of the chance of your succeeding with IVF using own eggs in spite of your chance of a baby per cycle being under 5% per attempt, you still feel compelled to try…..then in my opinion you need to carefully consider the following:
The older a woman becomes, the more likely it is that her eggs will be chromosomally/genetically “incompetent” (not have the potential upon being fertilized and transferred, to result in a viable pregnancy). That is why, the likelihood of failure to conceive, miscarrying and of giving birth to a chromosomally defective child (e.g. with Down Syndrome) increases with the woman’s advancing age. In addition, as women age beyond 35Y there is commonly a progressive diminution in the number of eggs left in the ovaries, i.e. diminished ovarian reserve (DOR). So it is that older women as well as those who (regardless of age) have DOR have a reduced potential for IVF success. Much of this is due to the fact that such women tend to have increased production of LH biological activity which can result in excessive LH-induced ovarian male hormone (predominantly testosterone) production which in turn can have a deleterious effect on egg/embryo “competency”.
While it is presently not possible by any means, to reverse the age-related effect on the woman’s “biological clock, certain ovarian stimulation regimes, by promoting excessive LH production (e.g. short agonist/Lupron- “flare” protocols, clomiphene and Letrozole), can make matters worse. Similarly, the amount/dosage of certain fertility drugs that contain LH/hCG (e.g. Menopur) can have a negative effect on the development of the eggs of older women and those who have DOR and should be limited.
I try to avoid using such protocols/regimes (especially) in older women and those with DOR, favoring instead the use of the agonist/antagonist conversion protocol (A/ACP), a modified, long pituitary down-regulation regime, augmented by adding supplementary human growth hormone (HGH). I further recommend that such women be offered access to embryo banking of PGS (next generation gene sequencing/NGS)-selected normal blastocysts, the subsequent selective transfer of which by allowing them to to capitalize on whatever residual ovarian reserve and egg quality might still exist and thereby “make hay while the sun still shines” could significantly enhance the opportunity to achieve a viable pregnancy
Please visit my new Blog on this very site, http://www.DrGeoffreySherIVF.com, find the “search bar” and 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 Approach
•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
•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
•Frozen Embryo Transfer (FET) versus “Fresh” ET: How to Make the Decision
•Frozen Embryo Transfer (FET): A Rational Approach to Hormonal Preparation and How new Methodology is Impacting 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.
•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
•Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
•Traveling for IVF from Out of State/Country–
•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
•Premature Luteinization (“the premature LH surge): Why it happens and how it can be prevented.
•IVF Egg Donation: A Comprehensive Overview
I invite you to arrange to have a Skype or an in-person consultation with me to discuss your case in detail. If you are interested, please contact Julie Dahan, at:
Email: Julied@sherivf.com
OR
Phone: 702-533-2691
800-780-7437
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,
I recently started IVF and had an estradiol level drawn today. I am 29 years old. I’m doing ivf for both difficulty conceiving and recurrent pregnancy loss. I started the lupron injection last wednesday or thursday. My estradiol level was 5 which seems low to me. I was trying to read on how the injection works on estradiol but was getting a little confused. Is this a low value or anything I need to worry about? Thanks in advance.
Also, I had one more question. This is my first time with IVF. My losses occurred both with IUI at 8 and 10 weeks and without any medications 3 occurred at 5 weeks. I’d really like to transfer 2 embroyos pending our pgs which I’m not sure how often they all come back abnormal at age 29 which is a big fear. Anyways, the policy at my clinic is generally 1. Im not sure how to discuss this with them in regards to transferring 2. Any recommendation?
I do not think it is anything to worry about!
Geoff Sher
I have 3 chromosomally normal embryos and am 32. Prior to my IVF cycle, I had low AMH and high FSH. I have no known uterine issues. I am deciding how many embryos to transfer for an FET and have looked at the ASRM guidelines for numbers of blastocysts to transfer, by age and favorable/unfavorable prognosis. Is diminished ovarian reserve considered an unfavorable prognosis for an FET, even if there are euploid embryos to transfer? I had two egg retrievals get my three embryos, but this will be my first embryo transfer.
I would seriously consider transferring up to 2.
Geoff Sher
What timing do you recommend for IVIG before a FET transfer?
10 days or so…before the FET.
Geoff Sher
I am 6 weeks and 4 days pregnant my hcg came back at 2120 is that bad?
Only an ultrasound can tell!
Geoff Sher