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.
Dear Dr Sher
In light of the news from the FDA about breast implants causing ALCL. Do you think breast implants could be the reason behind female fertility immune issues? Such as high natural killer cells and high cytokines?
Thank you for your time
No Stacey, I do not!
Geoff Sher
Dr.Sher
I had my first failed IVF. My FSH:LH is 1:3,5 (pcos). I was on short protocol with 7 days of Puregon 150mg, 2days of Ovitrelle and I hot a stop trigger on the 9 day 250 units. Result: 1 cell immature. Now for the second IVF they prescribed the same protocol with higher dosage 200units of Puregon and stop trigger to be puted later. I read in your posts that women with LH need a long protocol with Bcp, is higer dosage of Puregon a ok solution for me? I am afraid the result would be the same, many folicles but all with immature cells?
I am 31 years old, no children.
Thank you in advance
It is important to be strategic and selective when it comes to ovarian stimulation in women with PCOS. It is not simply a matter of a single adjustment, the entire approach needs to be reviewed.
Let me start by saying that there is no doubt that PCOS exacts a toll on egg quality. This having been said, the egg quality can in large part protected through the judicious implementation of an individualized protocol for ovarian stimulation.
Women with PCOS are hypersensitive to gonadotropin stimulation and are often at risk of developing serious complications associated with severe ovarian hyperstimulation syndrome (OHSS). Concern for this occurring often leads the treating physician to take precautionary measures aimed at slowing down or stopping hyperstimulation. Such measures include:
1.Cutting the stimulation short to prevent the E2 from rising too high. Unfortunately this often results in the eggs being underdeveloped at the time of the “trigger” and thus, far more likely to end up being “immature”., “dysmature” and “incompetent”.
2.Administering a lower “trigger dosage” of hCG , supplanting it (partially or completely) with an Agonist trigger (e.g. Lupron/Buserelin/aminopeptidyl/Superfact). While such measures can certainly reduce the risk/severity of OHSS, it often comes at the expense of egg competency (see below).
In my opinion, another error of commission during ovarian stimulation of women with PCOS is the indiscriminate use of drugs that either elicit an exaggerated ovarian LH-induced testosterone response (e.g. clomiphene or Letrozole), or provide too much LH (e.g. Menopur/Menogon). Too much ovarian testosterone is harmful to egg development and thus prejudicial to embryo quality/competency.
In my opinion the best way to approach ovarian stimulation for IVF in women with PCOS, is through the use of a low dosage, FSH-dominant Long ovarian down-regulation protocol, done in readiness for “prolonged coasting” (see below) and “triggering” egg maturation with a full 10,00U dosage of hCG or (no less than) 500mcg of recombinant hCG (Ovidrel)….see belowis If this is implemented appropriately, with proper timing, egg/embryo quality can be optimized.
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
•Should IVF Treatment Cycles be provided uninterrupted or be Conducted in 7-12 Pre-scheduled “Batches” per Year
•A personalized, stepwise approach to IVF
•Taking A Fresh Look at Ovarian Hyperstimulation Syndrome (OHSS), its Presentation, Prevention and Management
•Preventing Severe Ovarian Hyperstimulation Syndrome (OHSS) with “Prolonged Coasting”
•Understanding Polycystic Ovarian Syndrome (PCOS) and the Need to Customize Ovarian Stimulation Protocols.
•“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?
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.
Hello Dr. Sher,
I am 27 days after FET (early blastocyst 1BB). So I guess it is counted as 6 weeks and 3 days but there was no heart beat yet on the ultrasound.
The clinic, where I did transfer, is using really high doses of medications. Below are my current results:
Estradiol 3422
Progesterone 24.5
BHCG 4951
My current doctor (different clinic) is concerned with Estradiol level and told me to decrease the estradiol medication significantly (from 3x6mg vaginally + 3x2mg orally to 3x2mg vaginally + 3x2mg orally).
I am very worried and would love to hear your opinion:
1. What is the correct/normal estradiol level after medicated FET (does it matter if vaginal or oral medication is used?)
2. I understand that I need to decrease the medication but I am worried that doing it right away could be like a shock. Shouldn’t I rather do it gradually. (What is a typical dosage?)
3. Can this high level affect development of the baby? (could this be the reason for low BHCG level?)
Thank you so much,
Zuza
1. What is the correct/normal estradiol level after medicated FET (does it matter if vaginal or oral medication is used?)
A: I aim for and [E2] of 500-100pg/ml.
2. I understand that I need to decrease the medication but I am worried that doing it right away could be like a shock. Shouldn’t I rather do it gradually. (What is a typical dosage?)
A: That very much depends on the protocol being used. Perhaps we should discuss this.
3. Can this high level affect development of the baby? (could this be the reason for low BHCG level?)
A: Not likely.
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.
•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.
•IVF: Selecting the Best Quality Embryos to Transfer
•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
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.
I have a little over 2 year old girl from IVF thanks to the Sher fertility in Peoria IL. We have to do IVF due to PCOS and low motility. All other levels, including AMH, are great. For my daughter we did 1 retrieval (6 day 5 blastocysts but I did get ohss), 1 fresh transfer and 2 FETs.
At the beginning of 2016, my daughter was 1 at the time, we began trying for #2. We did a retrieval (7 day 5 blastocysts, and again ohss), 1 fresh, and 3 frozen transfers. Out of those one ended in a miscarriage at 6 weeks (1 day after the ultrasound)and the rest failed. After the miscarriage we did auto and allo immune testing, which we found I do have an elevated level of natural killer cells, but even with adding in intralipids the next two transfers failed.
In march of this year we did another fresh cycle. We decreased my meds and got 4 day 5 blastocysts and no ohss. We sent all 4 for PGS testing and all came back abnormal. Both the current doctor and the previous doctor (who was at Sher when I conceived my daughter and I have stayed in contact with) say that clinically this makes no sense. Great hormone levels and reserve. Great quality, mature eggs, embryos that the lab graded at a 2 and made it to day 5. We did keryotype testing and all came back normal.
At this point we have done so many tests and as you know, a lot of money. Financially, emotionally, and physically we can’t keep taking these hits. It’s even more frustrating that we have a healthy daughter from ivf and now we can’t figure out what is causing our issue.
Do you have any thoughts or suggestions?
Also, I am 26 and my husband is 29. All hormone levels are good. And if it wasn’t for PGS testing, the lab would have figured they were very good quality embryos.
Dr. Sher,
Is it normal for an embryologist to freeze embryos on day 5 if they are still in the early blast stage? I just obtained my records and found out that 1 of the 2 chromosomally normal embryos we got from our IVF cycle was frozen as an early blast on day 5. Do you think it has a chance of being viable?
Its probably OK!
Geoff Sher
I am 26, my husband is 29. I have PCOS and he has low motility. I have a 2 year old daughter from IVF. Last year we did another retrieval to try for baby #2. We made 7 embryos and did 4 transfers, none of which were successful. We did another retrieval this March. We made 4 embryos (decreased meds due to previous 2 retrievals I got OHSS). We sent them off for PGS testing and all came back abnormal. Its not our age, my reserve and hormone levels and all testing comes back normal. The embryos we create all make it to day 5 and are graded highly in the lab. We keep hearing that clinically it makes no sense. But we don’t know what we can do. After 2 retrievals and 11 embryos with no success, we don’t know if we should keep going. Especially after the last batch all coming back abnormal from PGS testing. Since they don’t even make it through PGS testing, we know my lining and implantation isn’t the issue. So I’m not for sure what could be causing our issue.