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 Doctor
I am 42.3 months. I’m hoping you could give me some insight. Not sure if I should continue with my RE or find another or having a biological child is not in my cards. Please advise
My Day 3 FSH is 14 AMH .277 Estradiol 16.2 before any stims my follicle count was 6. My RE put me on BCP for 12 days before starting a Stims when I stopped my cycle started again a few days later I went back for
My 1st IVF cycle I started with 4 follicles by my second appt I had 1. 3rd appt he saw 2 but 1 was outside my ovary. He retrieved 1 which made it to day 4 but start deteriorating at day 5.
2nd IVF I had 5 with a cyst. Cycle got canceled by my 2nd appt due to early ovulation.
3rd Cycle I started out with 4 on day 3 one was a cyst which went away by my 3rd appointment. By my last appointment I have 6 or 7 measuring 19, 17.5, 16.5, 14.5, 14, 10. My RE only retrieve 1 egg! He said the other follicles were empty. He said next cycle he will do a micro IVF protocol. I’m currently waiting to hear if the embryo made it to blastocyst then I will be doing PGS.
1st IVF I was on on 300 gonal F, 150 iu of menopur which he dropped to 75 & .10 of Lupron which he dropped to .05
2nd IVF 300 Gonal F, 75 IU menopur, .05 Lupron which he dropped to .02 & omnitrop for 4 days which I started on day 3
3rd IVF 300 Gonal F, 75 menopur, 15days prior to my menstruation I took .20 Lupron on day 3 he dropped it to .10 which I took till trigger shot & omnitrop for 4 days starting on my day 3
In my opinion you have severely diminished ovarian reserve (DOR) and especially given your age, you should rather be doing IVF with an egg donor.However, if you insist on trying with own eggs, then using a low-doage protocol or an agonist flare protocol (as in your case) would in my opinion be sub-optimal. 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.
ANNOUNCEMENTS:
1.About my Retirement by mid-2018:
After > 30 years in the field of Assisted Reproduction (AR), the time has finally come for me to plan on retiring from full-time clinical medicine within a year. If you are interested in my medical services prior to my retirement, I urge you to contact my concierge, Julie Dahan ASAP to set up a Skype or an in-person consultation with me. You can also contact Julie by phone or via email at 702-533-2691/ Julied@sherivf.com. You can also apply online at http://www.SherIVF.com.
2.The 4th edition of my newest book ,
“In Vitro Fertilization, the ART of Making Babies” is now available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoffrey Sher MD
Hi Dr sher,
I am supposed to do trigger at midnight. it is 10,000 iu HCG. However, i just noticed that i have 2 different brands of HCG , 5000 iu each(clinic donations). One is called CHORIOMON and the other is PREGNYL. They both say they are human-derived chorionic gonadoptropin
Is it ok for me to mix this 2 brands of HCG together to make 10,000 iu?
Chorionic Gonadotrophin is reported as an ingredient of Choriomon in the following countries: Bulgaria, Georgia, India, Macedonia, Mexico, Oman. It is reportedly identical to Pregnyl/Profasi/Novarel. In my opinion, the ideal dosage needed to trigger egg maturation and ovulation is 10,000U.
Geoff Sher
Dear Dr Sher,
I am reaching out to you after 6 failed ivf cycles due to very low egg quality. I am 33 years old with PCOS and endometriosis. We have tried many types of egg stimulation (gonal f, clomid, erc.) and even double trigger but the eggs are not maturating. I feel so down now because i was informed that my only hope is egg donor although AMH is still acceptable.
Could you please advise if there is any way i can improve my egg quality? It is so hard and it hurts to never being a biological mother for a baby.
Thank you
Leonie
In my opinion, at your young age, the commonest cause of poor egg quality is the protocol used for ovarian stimulation and its implementation. This is especially important in women with PCOS where egg quality is often an issue. So, let me be clear: 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 below is 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.
•Egg Maturation in IVF: How Egg “Immaturity”, “Post-maturity” and “Dysmaturity” Influence IVF Outcome:
•Commonly Asked Question in IVF: “Why Did so Few of my Eggs Fertilize and, so Many Fail to Reach Blastocyst?”
•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?
•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?
•My Retirement in the Year Ahead: A letter of Thanks From me to You!
ANNOUNCEMENTS:
1.About my Retirement by mid-2018:
After > 30 years in the field of Assisted Reproduction (AR), the time is approaching for my retirement. If you are interested in my medical services prior to my retirement, I urge you to contact my concierge, Julie Dahan ASAP to set up a Skype or an in-person consultation with me. You can also contact Julie by phone or via email at 702-533-2691/ Julied@sherivf.com. You can also apply online at http://www.SherIVF.com.
If you are interested in my medical services prior to my retirement, I urge you to contact my concierge, Julie Dahan ASAP to set up a Skype or an in-person consultation with me. You can also contact Julie by phone or via email at 702-533-2691/ Julied@sherivf.com. You can also apply online at http://www.SherIVF.com.
2.The 4th edition of my newest book ,
“In Vitro Fertilization, the ART of Making Babies” is now available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoffrey Sher MD
Fist of all, I’m Emma. I’m from the U.K. I love watching your videos on Facebook and love absorbing the information from them! I have endometriosis and this helps me a lot ! I’m a little sad you will be retiring from this though… but I also I hope you enjoy your freedom to enjoy with family and friends! You’ve done a great job!
Now for the question… I am due for my 2nd IVF consultation in September, however I would like your opinion. My IVF dr mentioned I would have to have my tubes not tied but clamped for the procedure to work effectively (due to toxins released in them due to endo) I was told by this dr that it is reversible. I would like to know if this has really any success in endometriosis patients and will it actually help?
I have also been told that half of the time after having them un-clamped they never recover making it almost impossible for the woman to conceive naturally if they cannot afford more ivf.
Unfortunately/ fortunately I am at a point with my endometriosis that I have to have children now (my endometriosis is aggressive and is growing at a fast rate) I would really like your opinion on this. Thank you very much for being with me through these tough times.
Respectfully in my opinion, unless you have one or both fluid filled tubes (rare in association with endometriosis) tying or removing the Fallopian tubes will have no benefit.
Geoff Sher
Dear Dr.
I had 3 embryos tranfered and my first hcg was 410. second 1100 third 4000. Doctor didnt demand another one but i did it while measuring progesterone levels and was 2600 2 days after and progesterone dropes to 20 from 25. Is there any hope? I also started spoting a little brown the day i had my 4000 result
I doubt there is a problem. I suggest you have an ultrasound done.
Good luck!
Geoff Sher