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,
Like many ladies my LH gets surges if I am not primed with estrogen prior to starting stims. However I can prime only about 3 days as my ovaries easily get suppressed leading to lengthy stims. I am 43 with DOR. My question is, can I take birth control pills for about 3 days prior to my period and commencement of stims and have the same effect as estrogen patches to lower FSH and keep LH under control?
No Fiona,
That is not nearly long enough. Ideally you need at least 10 days before launching into an overlap with an agonist (Lupron or equivalent), then wait for a period and then the stim process begins.
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
Dear Dr Sher,
My bloods show LH is 44 on 15th day of stimulation. Is there any research anywhere in the world that suggests that the IVF cycle can go on as planned and result in success if triggered two days from now that is when I was scheduled to trigger?
Thanks,
Gloria
Very respectfully, I do not believe so.
Geoff Sher
Dr. Sher,
I am about to turn 37 years old and I got my first ever FSH measured with a level of 15. I am not sure if I should be devastated or if I can still hope to have my own children. Is there any point in looking at egg freezing or IUI? I presently don’t have a suitable partner and will be looking to be a single mom by choice.
Thank you for the time you take to write this blog.
You need to get an AMH measured (any time in the cycle.
It is inevitable reality that all women will at some point or another, experience a progressive decline in their reproductive potential. This occurs as their ovarian egg population falls below a theoretical threshold. Ultimately once it is all but depleted, a total cessation of ovulation and menstruation (the menopause) ensues making the chance of having a baby with own eggs virtually impossible. This decline in so called “ovarian reserve” usually starts when the women reaches her mid-thirties, accelerates she approaches and enters her 40’s, ending with the onset of menopause. In a small but significant percentage of women, the process of diminishing ovarian reserve (DOR) commences much earlier, often leading to premature menopause occurring, before the age of 40 years.
Ultimately however, it is not only ovarian reserve that affects the woman’s reproductive potential, but also the “competency” of her eggs (i.e. their potential, upon fertilization to propagate embryos that have the potential to develop into normal offspring) The term “biological clock” refers to the impact of both these factors on the woman’s reproductive potential.
1. “Ovarian Reserve”: The number of eggs available in a woman’s ovaries at any given time is referred to as the woman’s “ovarian reserve”. All women are born with all the eggs that will be available to them through their lifetime. The majority of these eggs are lost between birth and puberty. The remainder will be used up progressively. Once they ‘run out” the woman menopause has been reached. The number of eggs available from the onset of menses (menarche) to menopause differs from woman to woman and is genetically determined. Once the total number of eggs falls below a certain threshold (which varies), ovarian reserve starts diminishing (DOR) that is characterized by an increase in the release by the pituitary gland of both FSH and LH ,in a fruitless effort to prompt the ovaries to produce more eggs. Concomitantly blood Anti-Mullerian Hormone (AMH) levels begin to decline.
2. “Egg competency”: It is primarily the egg, rather than the sperm that determines the ultimate ability of an embryo to propagate a viable baby. To be “competent”, an embryo must have all 46 chromosomes intact (i.e. it must be euploid). Only a mature (M2) egg that has its full contingency of 23 chromosomes (i.e. is “competent”) has the potential, (upon being successfully fertilized) to propagate a “competent” embryo. Two factors affect egg competency: a) Age and, b) Ovarian hormonal environment during egg development.
a.Age: Up to age 30Y, roughly one in two M2 eggs are likely to be chromosomally normal; 1 in 6 by age 40; 1 in 10 by age 43Y and about 1 in 20 by age 45. “Embryo competency” follows the same age-related decline. This serves to explain the decreasing fertility, rising miscarriage rates and increasing chromosomal birth defects that occur with advancing maternal age.
b.Ovarian hormonal environment: As a woman get older and/or as her ovarian reserve declines, her pituitary gland starts producing luteinizing hormone (LH) in increasing amounts and/or biopotency. This chronic increase in LH activity can cause her ovaries to over-produce male hormones (predominantly testosterone). While these hormones are essential for follicle production of estrogen and for egg development, excessive testosterone compromises egg development and increases the likelihood of chromosomal numerical irregularities (aneuploidy) and aneuploid eggs cannot propagate “competent embryos”. It is my considered opinion, especially when comes to older women and women with DOR that, the dosage of drugs (e.g. Menopur) or ovarian stimulation protocols that deliver too much LH (or hCG) or stimulate over-production of LH by the pituitary gland (agonist/Lupron “flare” protocols) , should best be limited in women undergoing IVF because excessive LH/hCG activity induces excessive ovarian testosterone production which can and does compromise egg competency. This is particularly advised in older women and those who have DOR where too much LH-induced testosterone activity often already exists. There are also certain medications that provoke overproduction of pituitary LH (e.g. clomiphene citrate, and Letrozole/Femara). Accordingly, for the same reason, these too are best limited in women undergoing IVF …most particularly in older women and women who have DOR. Instead, long protocols that down-regulate LH and include delivery of predominantly purified FSH, should in my opinion be used preferentially.
The role of embryo banking: The introduction of embryo karyotyping (using PGS) has opened the door to older women as well as those with DOR accumulating numerous competent (PGS-normal) embryos over multiple IVF cycles of stimulation. Since such euploid embryos (regardless of their often having been derived from older women), usually display comparable viability to those derived from younger counterparts. The process, referred to as Embryo Banking offers such women whose “biological clocks” are fast running out of time, the only realistic option of still having a baby with their own eggs. For those who have very severe DOR , Egg Donation-IVF represents the best recourse
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
Dear Dr. Sher,
Does menopause mean no follicles develop?
Alas…yes it does!
Geoff Sher
Dear Dr, Sher,
Is it bad for the body is stimming is done for over 15 days and suddenly stopped due to no growing follicle?
Alley
Not really!
Geoff Sher