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.
Hello Dr. Sher,
I am a healthy 41 yr old and have gone through 4 failed ivf’s. I respond will to meds and produce about 10 eggs each time with over 80% mature and fertilising. Husband is good.
Do you think there is an ideal protocol for someone with poor egg quality? to date, all cycles have consisted of 7 or 8 days of stim on 150 of Gonal and 150 Menopur with orgulatran, some with birth control and some without. Also did a short lupron protocol which was a total bust. Been taking ubiquinol for past 4-5 months and little improvement on last round.
Any suggestions on supplements or changes in protocol?
Hi Michelle,
Hi Michelle,
In my opinion, “microdose” (“flare”) Lupron and late antagonist protocols, are less than optimal in older women and hose with with DOR (see below). The former surges LH and the latter fails to suppress body’s own LH from the get-go of the stimulation process, often resulting in a rise in ovarian testosterone as the stimulation begins. Excessive ovarian testosterone can have a deleterious effect on egg quality/competency…especially in older women and also in women s who have DOR. In my opinion 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.
I strongly recommend that you visit my NEW personal website at http://www.DrGeoffreySherIVF.com and when you reach the home page, go to my new Blog 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
•Ovarian Stimulation for IVF: Comparing “conventional” use of GnRH antagonists to the Agonist/Antagonist Conversion Protocol (A/ACP)
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•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)
•Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
•Frozen Embryo Transfer (FET): What Does it Involve?
•Hereditary Clotting Defects (Thrombophilia)
•Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
•PGS-Biopsy for the Assessment of Embryo Numerical Chromosomal integrity (Ploidy): Should it be done on Day 3 or on Day 5-6 post fertilization?
•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
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
•The Role of Nutritional Supplements in Preparing for IVF
I invite you to call 702-699-7437 or 800-780-7437 and set up an 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
Please visit my new Blog on this very site, 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)?
•The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
•Frozen Embryo Transfer (FET): What Does it Involve?
•Hereditary Clotting Defects (Thrombophilia)
•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.
•PGS in IVF: Are Some Chromosomally abnormal Embryos Capable of Resulting in Normal Babies and Being Wrongly Discarded?
•IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to 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
Dr Sher,
Is there erally a difference between patient responses to Follistim versus Gonal-F? My insurance will pay for the follistim, but not Gonal-F. I just had an aweful cycle with Follistim. Can switching to Gonal-F really make a difference?
Dear Dr. Sher,
I am hoping you can provide insight on what went wrong and give your honest opinion how we could have had better results from IVF.
Our history – I’m 34, husband is 41, trying to conceive our first child. We were told based on poor sperm morphology and sub par progression that our chance of conceiving without IVF was less than 5%. So after 2 years and three failed clomid/femara IUIs we moved on to IVF. I have never been pregnant and my husband has never impregnated anyone, but neither of us tried prior to us trying now. We have a known issue with the sperm , but after a very disappointing IVF cycle I am wondering whether my eggs have a quality issue and that is contributing to the problem, or the failure lies more with the IVF protocol we used.
My lab stats for the pre IVF workup were all good numbers. RE says I don’t have PCOS because no hormone imbalance, but do have PCO due to high AMH and antral follicle count. My periods are very regular and I have “strong” ovulations.
Day 3 labs:
FSH: 5.1
LH: 7.1
Estradiol: 45
AMH: 8.06
Testosterone: 51 (slightly elevated?)
Free testosterone: 2.6 pg/mL
DHEAS: 249 mch/dL
DHEA: 339 ng/DL
TSH: 2.28
IVF meds protocol: BCP for three weeks (Desogen)
E2 check at baseline was 4 and over 30 AFC.
Day 5 of cycle, start stims, 150 IU follistim.
E2 level after 3 days of follistim: 687. Responding too quickly, instructed to lower dose to 100IU follistim.
E2 day 5 stims: 1667. Level “good”, add in 75 IU Menopur and ganirelex to 100IU follistim.
E2 day 7 stims: 3600.
E2 day 8 stims: 5142. Instructed to trigger that night with 4mg Lupron and 600IU HCG.
Was told HCG is superior for triggering, but I would end up very sick so going with a safer protocol. My fear was that the trigger would not finish the job and that I stimmed too quickly knowing slow and steady statistically has better outcomes.
Retrieval day: RE is expecting 30 mature eggs based on E2 level morning of trigger and ultrasound. 32 eggs were retrieved, yet only 13 (initially) mature eggs. Was told by the embryologist that another 12 could maybe be mature and they would update us in a few hours. Final count of mature eggs was 18 for attempted fertilization with ICSI. 10 fertilize with ICSI but still waiting on embryo grading status. Of the 18 mature eggs, 3 were graded good (highest rating at our clinic) and 15 graded as fair. Are fair eggs good enough?
Our question now, as it hadn’t even been discussed until the disappointing retrieval and fertilization, is are we dealing with an inherent quality issue with my eggs? Or rather was our IVF protocol not ideal and caused mainly immature eggs with a poor fertilization rate?
While still in recovery it was discussed a change of protocol (if next time is needed) and whether or not I should be treated more as a PCOS patient with egg quality issues and not as a woman without any known fertility issues seeking IVF to overcome MFI. Until now the diagnosis was MFI and that we would have excellent IVF success.
Any insight or speculation as to where we went wrong is very much appreciated.
I do not think you have inherently defective eggs, nor in my opinion, is this a sperm issue.
Based upon your inverted FSH:LH ratio, your high AMH and the large number of follicles you produce, Ido think you have PCOS. This condition is typically associated with ovarian hyper-response and a higher % of poorer quality eggs. The problem is often that in an attempt to avoid severe ovarian hyperstimulation, the doctor often will trigger before follicles have reached optimal development and then use either a lower than ideal dosage of hCG or use Lupron for the trigger. In my opinion there is a better way to stimulate PCOS women…i.e. “prolonged coasting”.
Down-regulation + “prolonged Coasting: My approach is consistently to use a long pituitary DR protocol with an agonist, coming off 1-2 months on the BCP. The latter is intended to lower LH and thereby reduce stromal activation (hyperthecosis) in the hope of controlling ovarian androgen release. I then stimulate with low dosage FSHr to which I add a smidgeon of LH/hCG (Luveris/Menopur) from the 3rd day and watch for the # of follicles and [E2] starting on the 7th day of COS. If there are > 25 follicles, I keep stimulating (regardless of the [E2] until 50% of all follicles reach 14mm. Then, provided the [E2] is >2500pg/ml, I stop the agonist and the gonadotropin stimulation and follow the E2 (only) daily, without doing further US examinations. The [E2] will almost invariably climb and I watch it go up (regardless of how high the concentration of E2reaches) and track it coming down again. As soon as the [E2] drops below 2500pg/ml (and not before then ever), I administer 10,000U hCGu or hCGf (Ovidrel/Ovitrel-500mcg) as the “trigger” and perform an egg retrieval 36h later. ICSI is a MUST because “coasted” eggs usually have no cumulus oophoris and eggs without a cumulus will not readily fertilize on their own. All fertilized eggs are cultured to blastocyst (up to 6 days). And up to two (2) are transferred transvaginally under US guidance.
The success of this approach depends on precise timing of the initiation and conclusion of “prolonged coasting”. If you start too early, follicle growth will stop and the cycle will be lost. If you start too late, you will encounter too many post-mature/cystic follicles (>22mm) that usually harbor abnormally developed eggs.
Use of the above approach avoids unnecessary cycle cancellation, severe OHSS, and optimizes egg/embryo quality. The worst you will encounter is mild to moderate OHSS and this too is uncommon.
I do not use antagonists in high responders (e.g., PCOS) because it interferes with the assay of E2 (often causing the value to be understated), a valuable index in assessing risk for the development of severe/critical OHSS. I also do not believe in the agonist trigger to prevent OHSS. The reason is that the magnitude of the induced LH surge varies and if too little LH is released, meiosis can be compromised, thereby increasing the oocyte aneuploidy index.
Please visit my new Blog on this very site, 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
•nti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF)
•Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
•Frozen Embryo Transfer (FET): What Does it Involve?
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF
•The Role of Nutritional Supplements in Preparing for IVF
•Understanding Polycystic Ovarian Syndrome (PCOS) and the Need to Customize Ovarian Stimulation Protocols.
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
Dr. Sher, I am cycling for 7th time after a miscarriage break. My stim is same under estrogen prime with ganirelix. However, my day 7 estrogen is only 200 instead of the usual 500 or 600. My protocol is 300 foll/75 menopur. Was wondering if I should speak to dr about increasing med at day 9, is it too late? Will it make a difference? If yes, is menopur is better or follistim? Your insight is much appreciated. I’m not sure if I should speak to doctor again on adjusting dose. My FSH is 8 and LH 2, amh 2 which I think is normal so no high LH concern, correct? Hope to hear from you soon. Many thanks. Sue
Hi Sue,
I fear that it might be too late to really optimize response this cycle. I think the protocol used for ovarian stimulation needs to be reviewed and perhaps changed….see below.
Please visit my new Blog on this very site, 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)
•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.
•Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
•Frozen Embryo Transfer (FET): What Does it Involve?
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to 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
Hello Dr Sher,
I want to make sure the clinic here is doing this properly since they’re new at it. For autoimmune implantation dysfunction is the right protocol 100ml of 20% IL emulsion dissolved in 500ml saline, infused over 3-4h, administered once 7-14 days prior to ET and then once again upon confirmation of pregnancy? Thanks so much
Looks fine!. But preferably 10-14 days prior to transfer.
Geoff Sher