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.
I just completed my second IVF cycle at 41 years old (2.0-3.0 AMH, no known issue other than age plus mild MFI and varicose vein). First cycle was an Antagon protocol with BCP and HCG trigger on day 9/ E2 @3100 – 10 eggs, 6 mature/fertilized, day 6 1 morula and 1 blast, expanding (CB) frozen on day 6 and PGS euploid, failed FET following a mock transfer and biopsy. Second cycle microdose Lupron flare with BCP and daily HGH, day 12 HCG trigger E2 @ 6100, 11 eggs, 10 mature, 7 fertilized, on day six 1 morula, 1 expanding blast (BC) and 1 expanded blast (CC) all discarded by RE per lab cutoff. Heartbroken.
At this point I am questioning whether discarding the grade 2 expanding blast BC was appropriate in light of desire to PGS. Also whether round 3 with my own eggs makes any sense after having been told I have a serious egg quality problem (I took your recommended supplements for 10-12 weeks prior to each cycle, with DHEA the first cycle and without DHEA the second cycle.) I am lost as to what if any next step to take. I feel I have responded well to various protocols but haven’t produced quality blasts. Is it time to stop?
On an aside, Las Vegas has been in my thoughts and my prayers. And, I hope your staff, friends and loved ones are ok.
We need to talk Kristin…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 .
*FYI
The 4th edition of my newest book ,”In Vitro Fertilization, the ART of Making Babies” is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoff Sher
Thank you Dr. Sher for your reply.I had earlier written to you on the 29 th September. I am 42 and was diagnosed with PCOS. But during my ivf cycles I had 18 eggs retrieved in 2014, 13 eggs during ivf in 2015, one egg in 2016 and most recently 10 eggs in August 2017. Would you classify me as a poor rsponder or DOR? My AMH levels in 2016 was 3.95 ngm/mL and has increased to 6.50ngm/mL in 2017. Do you think this indicates my true egg reserve or am I going towards OHS? Would the Agonist/ antagonist conversion protocol be advisable for me if my AHM is increasing due to OHS ?
Also wanted to know if you provide consultations anywhere in the UK?
Many thanks .
Based upon your living in the UK, your AMH is likely expressed in Pmol/L. Thus with an AMH of 6Pmol/L you do have diminished ovarian reserve.
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
If you are interested in seeking my advice or services, 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 .
*FYI
The 4th edition of my newest book ,”In Vitro Fertilization, the ART of Making Babies” is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoffrey Sher MD
Hi, Thank you for the opportunity to ask you my question. I am 39 and had my second retrieval in June. I had 5 embryos, transferred one untested, and sadly had a miscarriage at 12 weeks from what we learned was trisomy 18. My D and C was 5 weeks ago today on 8/28. I just got my cycle back and am wondering how much time (physically, I am ready to move on) I need. My nurse is willing to start me on BCP today for a FET November. I’m wondering if I should wait until Dec. I only have one pgs normal embryo (I thawed and tested). Thank you.
In my opinion it would be wise to allow 2 cycles to pass after the D&C.
Geoff Sher
dear doc
i had a natural cycle (for frozen ET) and had 3 growing follies on day 12 18,18.5 and 15mm and a lining of almost 9mm
but estrogen only 70 and next day it was only 72
LH went from 5 to 7.2 only
the doc said thats unusual and he didnt understand what it is so he went ahead and gave me ovidrel shot and transfered (asked me to start progesterone vaginal pessary crinone gel once a day and duphaston 4 times a day. Also Estrofem 2mg four times a day)
despite all this dosage a begged him to do a hormone test today on the day of FET so it came out the estradiol is still 150 only…
is there something wrong ? what are my chances of a positive? and what tests should i do to find out the problem with my hormones ???
Oh and i must add im 32 with borderline pcos
he gave me letrozole this cycle started on day 3-7
This does not look very promising. I hope I am wrong though!
We really should talk (800-780-7437).
Geoff Sher
Dear Dr. Sher,
I received news of failure of my first IVF cycle a few weeks ago and turned 39 the following week. I previously had 5 unsuccessful medicated IUI’s at a different clinic. My most recent tests showed a Day 3 FSH of 9.75 and LH of 10.72. My latest AMH was 1.91 and my AFC typically ranges from 8-10. I was categorized as unexplained infertility, but my doctor and I went into IVF with high hopes. My first surprise was a very slow response to Follistim 225 & Menopur 150. My estrogen was 40 after 3 days of stims with all unmeasurable follicles. My estrogen had always been on the high side for past cycles, and I always responded well to Clomid & Letrozole. I had been hesitant about the BCP suppression because it took my body several months to have a period when I came off of the pill 2+ years ago. After bumping up to 450 Follistim & 150 Menopur, my follicles started growing with time. I stimmed for 13 days and I had 7 follicles, 6 of which measured 18 – 26 at the last ultrasound. My estrogen was 2100 and lining was 10. I triggered with 10,000 Pregnyl. The next surprise was to only retrieve 4 eggs, and the worst surprise was to find out only 2 were “mature,” and only one fertilized properly. We transferred an 8-cell embryo on Day 3. I am taking off a cycle and then will try a different protocol. I have read your “Repeated IVF failure due to empty follicles” case study as well as other blog entries and I am leery of my new proposed protocol due to the potential detrimental effect of too much LH and androgens. The plan is no BCP (due to over-suppression), Lupron microdose, followed by 500 Follistim & 150 Menopur. I also started 75 mg of DHEA daily per my doctor’s direction, melatonin, and bumped up my CoQ10. We plan to flush the follicles next time and add ICSI and AH. Would you share my concerns on the proposed protocol, and would you recommend me discussing the estrogen priming protocol without BCP with my provider?
Thank you!
sarah
In my opinion, this could likely be the result of the selection and implementation of a suboptimal stimulation protocol.
Here is the protocol I advise for women, <40Y who have adequate ovarian reserve.
My advice is to use a long pituitary down regulation protocol starting on a BCP, and overlapping it with Lupron 10U daily for three (3) days and then stopping the BCP but continuing on Lupron 10u daily (in my opinion 20U daily is too much) and await a period (which should ensue within 5-7 days of stopping the BCP). At that point an US examination is done along with a baseline measurement of blood estradiol to exclude a functional ovarian cyst and simultaneously, the Lupron dosage is reduced to 5U daily to be continued until the hCG (10,000u) trigger. An FSH-dominant gonadotropin such as Follistim, Puregon or Gonal-f daily is started with the period for 2 days and then the gonadotropin dosage is reduced and a small amount of menotropin (Menopur---no more than 75U daily) is added. This is continued until US and blood estradiol levels indicate that the hCG trigger be given, whereupon an ER is done 36h later. I personally would advise against using Lupron in “flare protocol” arrangement (where the Lupron commences with the onset of gonadotropin administration.
I strongly recommend that you visit https://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
• “Triggering” Egg Maturation in IVF: Comparing urine-derived hCG, Recombinant DNA-hCG and GnRH-agonist:
If you are interested in seeking my advice or services, 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 .
*FYI
The 4th edition of my newest book ,”In Vitro Fertilization, the ART of Making Babies” is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoffrey Sher MD