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.
Hello Dr Sher, I just turned 40 and have DOR. I finished a mini IVF cycle with daily 50mg of clomid and 150ui of follistim every other day, and I had three follicles over 10mm, the two biggest got stock in the same size, 17mm and 16mm for three days after they put me in 1/3 of ganirelix three mornings in a row. The trigger was done while the follicles were the same size and it was two dosis of 20ui of lupron one at 9:30pm and the second at 11:30pm. They just retrieved one egg that fertilized, but did not make it pass the third day. Now they want to do another mini without clomid and more follistim adding hgc during stim as follow: The stimulation will consist of approximately 10 days of Follistim 225iu daily and Microdose HCG 0.1ml every other day. Ganirelix injections will begin on day 5 of stimulation medications. This will suppress ovulation. We will trigger with 10,000 units of Novarel. I am not sure about this protocol, they want to freeze any good 3day embryo to stagger and try to collect more embryos in multiple cycles. I am not sure about the protocol or freezing at day 3. Could you please give me your opinion about these protocols?
Thank you very much for your help,
Andrea
In my opinion, mini-IVF and/or clomiphene or Letrozole, and high dosage Menopur protocols, should best not be used in older women or in women with DOR (see below). Clomiphene causes an increase in LH and with it, an increase in ovarian testosterone as the stimulation begins and this can have a deleterious effect on egg quality/competency…especially in older women and also in women such as yourself who have DOR. You need a modified, robust, long pituitary down-regulation protocol. I would use an agonist/antagonist conversion protocol with human growth hormone (HGH) augmentation and would recommend Staggered IVF with embryo banking of PGS (next generation gene sequencing)-normal blastocysts, to make hay while the sun still shines.
Please visit my new Blog at o to http://goo.gl/4hvjoP , 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.
I also do not agree with the Lupron trigger.
•Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
•Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•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)
•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?
•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 Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
•IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
•Why did my IVF Fail
•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
I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
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
I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
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
I’ve done much research and keep coming across your name. I am just about to turn 42. Besides my age, the only known issue we had was male factor, Had an ivf cycle in June of 2015 with great results, 18 eggs retrieved, 16 mature and fertilized, and ended with 4 pgd/pgs normal embryos. First FET was done in July of 2015, got a postive HCG test 10 days after transfer. It went up but didn’t double for the second test, and then levels started to drop and I miscarried. I did struggle with getting my lining thick enough on oral estrace – vaginal estrace was added in for a few days and then it got to be over 8mm before I started the progesterone. Tried to start another FET cycle in Setember, but again had issues with my lining developing (very slow growth and did not get quite to 7) and things didn’t look right during one ultrasound. My RE suspected I may have had some scar tissue from the previous cycle. The FET was canceled and he performed a hysterocscopy during which he did remove a small amount of scar tissue. Started another FET cycle in November, and this time used del estrogen injections for my lining, which got up to 9.4 before starting progesterone. Had an HCG test done 12 days post transfer and the level was 3. Tested one more time and it dropped to below 2. I was very concerned about 2 failed transfers with pgd embryos so my RE ordered all the standard RPL tests as well as immune testing. All came back normal, except I tested postive for MTHFR – one copy of the C677T mutation and one copy of the A1298C mutation, as well as slightly elevated homocysteine level. My RE doesn’t believe this is causing problems, but suggested I could take 1mg of folate daily if I wished. I was already taking prenatals with 800mcg of folic acid so didn’t bother taking anything more. I did have the immune panel testing by FCLab in Ilinois, which came back normal for everything except for elevated NK cells – CD56+16+ NK at 19.5%. It was decided I would have an intralipid infusion before my 3rd FET, which I just completed. I had the infusion about 12 days before the transfer. I used del estrogen injections again, and struggled a bit with the lining growth, so added in vaginal estrace for the last few days which got the lining up to 9mm before taking progesterone. Just got the result of my HCG test 8 days post transfer and it was negative. I am not sure where to go from here?
The fact that you did not succeed at 42Y of age is not alarming and you should know that chromosomal normality of the embryo, while being the most important determinant of embryo “competency”, is not the only factor. Genetic and metabolic factors that are also age-related factors.
In my opinion, you need a modified, robust, long pituitary down-regulation protocol. I would use an agonist/antagonist conversion protocol with human growth hormone (HGH) augmentation and would recommend Staggered IVF with embryo banking of PGS (next generation gene sequencing)-normal blastocysts, to make hay while the sun still shines.
Please visit my new Blog at o to http://goo.gl/4hvjoP , 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
•Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•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)
•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?
•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 Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
•IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
•Why did my IVF Fail
•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
I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
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
I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
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
Respected Dr Sher – was trying to get to the origin of Sher’s grading of Abruptio placenta and somehow searches lead to you , please excuse me – was it you Sir ?
Yes Nurul…that was me! However, I no longer work in the perinatal arena. I suggest you discuss with your OB.
Geoff Sher
Hello Dr Sher. I really need your help.
I am 40 years old with high fsh and very low amh. I have recently went through a low stimulation cycle(150fsh, 75LH). I had 3 follicles developing. I had egg collection yesterday and i actually got one egg. I have just been informed that it has fertilized and of course i am very happy but really worried to transfer. I have two concerns:
1) during the cycle my LH surged prematurely. On day 6 of stims it jumped to 24. Of course i started ganirelix that day. On day 8 of stims LH came down but e2 dropped drastically as well. Progesterone became a bit higher too. However i did manage to get that one egg. However i am worried that the prmature LH surge may have affected its quality and thus the quality of the developing embryo leading to health defects. Should i transfer this embryo or is it risky?
2) my other concern is that i have MTHFR homozygous(C677T). I wasn’t told to take anything preconception. I am now reading and panicking that i should have been on L-methylfolate a long time ago. I have also read that i should have started lovenox injections same day as egg collection.
I was advised non of the above. Should i transfer this embryo now or will it suffer from health defects as i was not proactive on taking prenatals or L-methylfolate?
3) what do you suggest for MTHFR homozygous? Which prenatals(have no idea what to take!!!)? When do i start them? Can i start them after transfer or is this too late? What about lovenox?
I am thinking that maybe we did not do a good job here and maybe it is better to freeze this embie and try to get new ones if i am lucky as i have severely diminished ovarian reserve. Or to transfer it later on when i get my body ready with prenatals and supplements.
Thanks a lot. I am very much looking forward to your advice!
First: Sadly, if (as it sounds) you have had premature luteinization, then I am afraid that the embryo you have might not be “:competent”, whether you transfer it now or freeze it. Premature elevations in LH or premature luteinization (often referred to as a “premature LH surge”) will prejudice egg development. Such compromised eggs are much more likely to end up being complex aneuploid following the administration of the hCG trigger, leading to fruitless attempts at retrieval and the so called “empty follicle syndrome.”
The developing eggs of women who have increased LH activity (older women, women with diminished ovarian reserve, and those with PCOS) are inordinately vulnerable to the effects of protracted exposure to LH-induced ovarian testosterone. Because of this, the administration of medications that provoke further pituitary LH release (e.g., clomiphene and Letrozole), drugs that contain LH or hCG (e.g., Menopur), or protocols of ovarian stimulation that provoke increased exposure to the woman’s own pituitary LH (e.g., “flare-agonist protocols”) and the use of “late pituitary blockade” (antagonist) protocols can be prejudicial.
The importance of individualizing COS protocol selection, precision with regard to the dosage and type of hCG trigger used, and the timing of its administration in such cases cannot be overstated. The ideal dosage of urinary-derived hCG (hCG-u) such as Novarel, Pregnyl and Profasi is 10,000U. When recombinant DNA-derived hCG (hCG-r) such as Ovidrel is used, the optimal dosage is 500mcg. A lower dosage of hCG can, by compromising meiosis, increase the risk of egg aneuploidy, and thus of IVF outcome.
Second: The homozygous MTHFR mutation, probably is best treated with Lovenox/Clexane throughout pregnancy.
Third, I am not supportive of low stimulations in women (like you) who have DOR. In my opinion, you need a modified, robust, long pituitary down-regulation protocol. I would use an agonist/antagonist conversion protocol with human growth hormone (HGH) augmentation and would recommend Staggered IVF with embryo banking of PGS (next generation gene sequencing)-normal blastocysts, to make hay while the sun still shines.
Please visit my new Blog at o to http://goo.gl/4hvjoP , 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
•Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•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)
•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?
•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 Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
•IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
•Why did my IVF Fail
•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
I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
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.
I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
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 Dr Sher, We just finished our first fresh, ICSI IVF cycle (on 2/19/16), which produced a chemical pregnancy. I have been second guessing our protocol and am wondering if you can offer some recommendations for our next cycle? Our last protocol was “Micro-dose Lupron” due to my AMH level being a 0.4. I was on BCPs for 20 days and did not start Lupron until 5 days after my last BCP. 2 days of 40u Lupron then added 300iu Gonal-F and 150iu Menopur for 8 days, then trigger shot. On day of retrieval I had 6 follicles – 3 were not very mature but they retrieved 6 eggs. 3 did not fertilize. We did a 3 day transfer of all 3 embryos (ICSI and assisted hatching) – Grade 1 – 7 cell, Grade 1 – 6 cell and Grade 2 – 3 cell. My retrieval was on 2/16 and my estradiol levels leading up were 942.1 on 2/12, 1342 on 2/13 and 1499 on 2/14. To prepare for the cycle, I cut out caffeine, gluten, dairy and soy for 3 months prior. I also took DHEA 75mg, Prenatal Multivitamin, Ubiquinol 300mg, Omega-3 2,000mg (DHA 600mg, EPA 800mg), Vitamin C 1,000mg and Vitamin D 6,000iu for 3 months prior. I also did acupuncture for 3 months and did not drink alcohol for 1 month prior. My AMH of 0.4 was tested in 9/2015 and my 3-Day FSH of 7.7 was tested in 12/2014 (over 1 year prior). Vitamin D of 27.9 was tested in 9/2015. We have a male factor, which is why we went straight to IVF for treatment. I turned 38 in Dec 2015 and am in good health. I eat very healthy (no meat only fish) and cut out anything that could be inflammatory from my diet. No sodas, artificial sweetners or added sugar. I can’t think of any other lifestyle changes I could make so I am reaching out to you for advice with a different protocol and possibly changing my supplements. Thank you so much for your time and consideration, I am so grateful there is someone like you who takes the time to help those struggling with infertility. –Katie
In my opinion, “microdose” (“flare”) Lupron protocols, the use of clomiphene or Letrozole, and high dosage Menopur protocols, should best not be used in women with DOR (see below). It surges LH and with it ovarian testosterone as the stimulation begins and this can have a deleterious effect on egg quality/competency…especially in older women and also in women such as yourself who have DOR. You need a modified, robust, long pituitary down-regulation protocol. I would use an agonist/antagonist conversion protocol with human growth hormone (HGH) augmentation and would recommend Staggered IVF with embryo banking of PGS (next generation gene sequencing)-normal blastocysts, to make hay while the sun still shines.
Please visit my new Blog at o to http://goo.gl/4hvjoP , 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
•Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•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)
•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?
•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 Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
•IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
•Why did my IVF Fail
•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
I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
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
I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
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