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,
I am devastated with my bad luck. Each Dr. has failed to catch my LH surges and give Ganirelix after surge occurs. This time I had no priming (almost mini cycle) with stims started with period (Menopur and Follistim). Bloods on CD9 showed LH is 18.6, E2 116 and Progesterone is 1. Dr had not given Ganirelix and when results came CD11, Ganirelix was started on CD11. I have DOR and get only one or two eggs. CD12 they did ultra sound and said lining is 6mm and there are two very small follicles. They say the surge could not have affected the follicles as the follicles are very small 7mm and 5mm. My questions are:
A) Is this a surge on CD9 at 18.6 LH?
B) Since I started Ganirelix two days later than detected high LH on CD11, is the cycle doomed and eggs compromised?
C) In a premature surge does E2 also go up or only LH?
D) Does premature surge affect very small follicles?
E) At what level of LH are eggs compromised?
Sorry for all these questions but I am so upset and have no idea if I should continue or cancel the cycle. At 40 years I am in such a desperate situation.
This forum is a life saver. Thank you
questions are:
1) Is this a surge on CD9 at 18.6 LH?
A: I think it is…but it likely is a manifestation of premature luteinization (see below)
2) In a premature surge does E2 also go up or only LH?
A: The LH and progesterone go up and the E2 drops by >20%
3) Does premature surge affect very small follicles?
A: Yes
4) At what level of LH are eggs compromised?
A: This varies but the LH is usually >4MIU/ml
5)Since I started Ganirelix two days later than detected high LH on CD11, is the cycle doomed and eggs compromised?
A: In my opinion, this is not a good sign…I hope I am wrong.
Normally, following optimal ovarian stimulation, the hCG “trigger shot” is given for the purpose of it triggering meiosis (reproductive division) that is intended to halve the number of chromosomes from 46 to 23 within 32-36 hours. The hCG trigger also enables the egg to signal the “cumulus cells” that bind it firmly to the inner wall of the follicle (through enzymatic activity), to loosen or disperse, so that the egg can detach and readily be captured at egg retrieval (ER).
Ordinarily, normal eggs (and even those with only one or two chromosomal irregularities) will readily detach and be captured with the very first attempt to empty a follicle. Eggs that have several chromosomal numerical abnormalities (i.e., are “complex aneuploid”) are often unable to facilitate this process. This explains why when the egg is complex aneuploid, its follicle will not yield an egg…and why, when it requires repeated flushing of a follicle to harvest an egg, it is highly suggestive of it being aneuploid and thus “incompetent” (i.e., incapable of subsequently propagating a normal embryo).
Older women, women with diminished ovarian reserve, and those with polycystic ovarian syndrome, tend to have more biologically active LH in circulation. LH causes production of male hormone (androgens, predominantly testosterone), by ovarian connective tissue (stroma/theca). A little testosterone is needed for optimal follicle development and for FSH-induced ovogenesis (egg development). Too much LH activity compromises the latter, and eggs so affected are far more likely to be aneuploid following meiosis.
Women with the above conditions have increased LH activity and are thus more likely to produce excessive ovarian testosterone. It follows that sustained, 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.
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
•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?
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 am a 37 year old female who wants to have a child with my 45 year old fiancé. In 2010 I underwent the Essure procedure which left me with an occluded left tube and a patent right tube following 3 HCG tests. I have poor ovarian reserve with my count at .745 and tsh 1.95. My fiancé had poor motility and morphology following sperm analysis tests. My question is do you think it will be a risk to undergo IVF with the Essure in place and other variables? I have a 21 year old son and he a 17 year old. In July 2015 I had a miscarriage at 3.5 weeks anf still have not been able to become pregnant since. Any insight you can give will be helpful.
No I do not believe that the Essure will compromise your ability to conceive with IVF or have a normal pregnancy. But…discuss with your own RE.
Geoff Sher
Dear Dr. Sher,
I recently underwent a cycle of IVF stimulation at your New Jersey office with Dr. Peters, who is fantastic! I had a wonderful experience with him and his staff. The plan was to freeze blastocysts for a later transfer since I am older (39) and wanted to have PGS testing before implantation. Also, I was planning to use a gestational carrier because my natural killer cells are high and this seems to be from an alloimmune implantation dysfunction. I was tested for this because I have had two early miscarriages in the past few years. ( natural pregnancies) I do not want to take intralipids and corticosteroids because my HgA1C is slightly elevated, and I do not want to develop gestational diabetes. My AMH is low 0.2 , so I was not expecting a huge yield of eggs. I underwent one of your protocols that started with BCP suppression with the addition of Lupron and then cetrotide and stimulation with Follistim starting at 675U for the first two days which was then decreased to 450U interspersed with Menopur. On the day of retrieval there were five large follicles with mature eggs. Four of them fertilized and were looking good on day 3. By day 5 they were compacting morulas not blastocysts, and they had not progressed by day 6 so there was nothing to freeze. Naturally, I was disappointed.
I am wondering if it is worth trying again. One other factor is my husband’s sperm. His basic semen analysis was normal for count, motility and morphology, but I was told that on the day of transfer the motility was poor. The fertilization was accomplished by ICSI. He has not had a sperm chromatin structure assay. This may take some time to obtain because he has a very difficult time giving a semen sample. It took us three months to get the specimen for the initial evaluation ( no exaggeration!) and so we used his frozen sperm for the IVF procedure. Also, he is older (59) and takes mirtazipine and allopurinol which I have been told can interfere with DNA in the sperm. He can not be off of the allopurinol. Would it help to use donor sperm? We are amenable to this. Do you think it is worth it for us to continue to pursue IVF? Any of your thoughts would be greatly appreciated. Thank you so much.
I think you should rtry again with husband’s sperm. I agree is not only a great RE, but perhaps even more importantly is a wonderful person. I suggest you discuss with him the adding of Human Growth Hormone to the mix and to consider embryo banking.
Good luck. You are in good hands. Please give Dr Peters my fond regards.
Geoff Sher
Hi sorry to post this question again but your answer did not post I had a day 5 embryo transfer fresh of 2 embryos on March 1st. On March 11th at 15dpo I had 1st beta 62.7, on March 14 at 18dpo 2nd beta 150, on March 16 at 20dpo 3rd beta 273, and on March 18 at 22dpo 4th beta 349. My clinic wants to do a repeat beta and u/s today March 21 I will be 25dpo what exactly would you expect to see on an ultrasound at this point and time? Thanks for taking the time to assist me.
Your betas are rising too slowly. It suggests defective implantation. The question is whether the implantation is occurring in the uterus or in a tube (ectopic). Serial blood haCG tests and ultrasounds will help reach this determination.
Good luck!
Geoff Sher
Kimberly- Hope everything works out for you.
Dr. Sher, my husband and I see Dr. Bundren in Tulsa, OK. We’re currently undergoing Lupron Depot treatment. I have Endo, PCOS and my husband has poor morphology. We were told that if his numbers don’t improve with his next analysis in April that our best option will be IVF. Do you think Micro IVF would be a better option for us or does it make more sense to do IVF? Thank you for your time.
Respectfully, I am not a proponent of long-term Lupron for endometriosis for infertility, unless it is as a prelude to surgery. The endometriosis almost always promptly returns upon stopping the agonist therapy. With endometriosis, unless you are <35Y of age and have normal or above normal ovarian reserve and your husband had normal sperm parameters...IVF is a preferable strategy by far.
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 promptl
•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.
•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?
•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.
•Endometriosis and Infertily
•Treating Ovarian Endometriomas with Sclerotherapy.
•Micro-IVF: Often Preferable to Ovarian Stimulation with or Without IUI
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
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