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.
First of all, it is so kind of you to answer questions for so many people. Thank you. I just turned 34 and my husband and I have been diagnosed with unexplained infertility. I have 2 children, ages 9 and 13 from my prior marriage and I had a missed miscarriage at 9 weeks and a chemical pregnancy prior to my 9 year old. My 9 year old was conceived after 1 month of clomid that I was prescribed after my day 21 progesterone was borderline the month before (October 2007). My day 3 labs prior to taking the clomid were FSH 7.3, LH 6.9. My testosterone level was found to be 97.5 at that time as well. Prolactin was normal, Androstenedione was 165, DHEA Sulfate was 280. I was not diagnosed with PCOS at that time. My cycles were 25 days, perfect every month. Weight was 125. 5’2”- age 24.
A few years later (2012), I had gained a significant amount of weight (up to 170 lb) and I went to a weight loss doctor who did an insulin test where they checked my insulin levels before and after drinking a glucose solution. My fasting insulin level was normal, and the post glucose level was elevated. He did not diagnose me with PCOS, however my primary doctor ran labs and found a free insulin level 2.8 and total insulin level 2.8 (fasting), however, he diagnosed me with PCOS based on me reporting that info to him regarding the elevated post glucose insulin. I asked for metformin- (thinking this was the right choice) and received a script for 500 mg BID. He told me to take it only once a day if I wanted, and that’s what I did. April 2016 I got remarried and we began trying to conceive via timed intercourse. (My husband, age 34, type 1 diabetes x 14 years, A1C 6.0 On ketogenic diet, no bio kids, always used contraception). October 2016, I went to my obgyn, who drew labs. AMH 1.2, day 3 estradiol 56, FSH 8.5, LH 6.3, Prolactin 16.8. I received a script for clomid 50mg. I ovulated cycle day 12 (confirmed by u/s) and my day 21 progesterone was 16.7. The next month I took clomid 50mg again and also ovulated cycle day 12, however my day 21 progesterone was only 9.4. The next month I took clomid again with ovidrel. It was unsuccessful, so we were referred to a RE. I increased my metformin to BID hoping to help my possible pcos- although my ovarian ultrasounds all look normal. February 2017, my RE rechecked my AMH- it was 0.54, just 4 months after being 1.2. The only difference was me increasing my metformin. My vitamin D was 20, but has since been corrected to 30 with supplementation. TSH was 3.27, which has been corrected to 1.08 with synthroid 50 mcg. My husbands basic sperm count was normal, 81.3 total motile count, 32.5 motile count, good rapid progression, with the exception of 1% normal morphology. We did an IUI but only had 1 million sperm post wash. Then we had a DNA fragmentation analysis done, which came back at 35%. We were advised for IVF with icsi and told there is only a 2% chance of IUI working with fragmented sperm. I was given a protocol with no BCP, and using testing gel and omnitrope prior to stims. Also I was prescribed Gonal-F and certritide. I got to the point of taking the Gonal F when my insurance approved me for IVF but said that I had to go to a different clinic, so sadly, we had to abandon that cycle before our first follicle scan. I picked up a few months later at a new RE and requested IVF right away. My AMH was rechecked and was 0.64 and my FSH was 7.9. I was given a micro dose flare protocol with BCP for 3 weeks prior. I stimmed for about 14 days and my estrogen was very slow to rise. After 3 days stims it was 37, 5 days- 62, 7 days-111, 10 days-352, 12 days-1085, 14 days- 1358, 15 days- 2198 so we triggered with 10,000 units pregnyl. We retrieved 7 eggs, 5 were mature, but only 1 fertilized with ICSI. The embryo was a 4 cell with 20% fragmentation at day 3. We transferred it and it failed. My RE said that the cycle was unexpectedly a dismal failure and he’s not sure the cause. He encouraged me to try a few IUIs. We have done 2, with clomid, still no success. Notably, my FSH was 10.1 last month (day 4), while my husbands prewash sperm count was 37 million and 8.4 million post wash. This month my day 3 FSH was 7.0 and my husbands prewash sperm count was 34 million and post wash was only 4.7 million. He has been checked for a varicocele, by the way, and there is no palpable varicocele, however I am a nurse and I know this urologist, so I probably went overboard asking for an ultrasound, but we had one and it did show a grade 1 varicocele, and the urologist offered to operate, but then a 2nd urologist which my RE sent us to, said that it’s subclinical and not important. He told my husband that he can drink 2 alcoholic drinks every night but that he believes that my husband’s daily sugar free redbulls are to blame and to stop all fertility treatments until three months after stopping red bull. My RE dismissed that theory. He also does not believe that dna fragmentation affects conceiving, unlike my prior RE who stated it’s very consequential. I don’t know where to go from here. I don’t know if I have pcos, based on my LH to FSH ratios and my normal fasting insulin, regular periods, and ovulation, plus my AMH is low. But then again, I did need clomid to conceive a viable pregnancy at age 25, metformin lengthened my cycles to 28 days and I was confirmed via ultrasound and BBT charting to be ovulating, I don’t know if I was ovulating every month or just some months before the metformin because I’ve been on it so long, but again, I did get pregnant 4 times before it at a weight of 125-130. (I’m 170 now, unfortunately). Then there’s my husband, Type 1 diabetes, dna fragmentation, normal count pre wash, low post wash, 1% morphology, no bio children. I don’t know what to do from here. My insurance will not allow me to switch RE’s and my RE is an awesome doc, I just wonder if the metformin has suppressed my AMH and if I should have also been on a protocol without BCP. I feel like the other doc was onto something with the testim and omnitrope, and maybe even the DNA fragmentation is our diagnosis that we have been searching for, but my current RE says no. I also asked if I should be on luteal phase progesterone supplementation and was told it’s not necessary. Any advice or insight would be so very appreciated. We are willing to do anything and ready to hear tough truths. Thank you.
You clearly have diminished ovarian reserve and your husband has reduced sperm morphology and motility. To me this does not sound like PCOS. You have regular menses, seem to be ovulating on your own and you have DOR. That is not the usual presentation of PCOS. In my view, IUI is the wrong approach. You need IVF/ICSI BUT, it is essential that the protocol used for ovarian stimulation be carefully constructed. In my opinion, the approach you described is not 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”.
Women 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 effect of DOR, certain ovarian stimulation regimes, by promoting excessive LH production (e.g. short agonist/Lupron- “flare” protocols, clomiphene and Letrozole), can in my opinion, 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 women 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 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, https://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
I personally again would state that this could simply be a stimulation protocol issue!
Geoff Sher
What is the bmi cutoff for a surrogate? My bmi is 36 and has been forever and higher. I have 4 kids with easy pregnancy and deliveries. I’m healthy. My obgyn thinks I’ll be a great candidate even with my bmi.
You could be fine but in my opinion a BMI of>36 would be associated with greater pregnancy risk!
Geoff Sher
Dear Dr. Sher,
I am an almost 42 year old, single woman hoping to get pregnant with sperm donor. My AMH is 0.4480 ng/ml or 3.2 pmol/l, my AFC done on day 14 of my cycle is 3 on my left ovary and 5 on my right and my day 3 FSH is 6 IU/L (admittedly I didn’t do an estradiol test). I also have an intramural submucous fibroid on the top of my uterus which I need to have removed. All in all not good.
I’ve never had fertility treatment before and would very much like to use my own eggs. I would like to roll the dice with an IUI in November, but I’m afraid my fibroid may hurt any potential baby. A fertility clinic in London has suggested I go for Modified Natural Cycle IVF or Mild Stimulation IVF as they advocate egg quality over quantity. I’ve read that these types of IVF are good for older women with extremely low amh or greatly DOR, but the success rate puts me off. Do you agree with my clinic’s assessment or would you advise different treatment, i.e. conventional IVF if you were my doctor?
I read that you have a special Controlled Ovarian Stimulation for Older women and Women who have DOR. Do you happen to know any doctors or fertility clinics in London, UK who follow your protocols please? I’m so lost – I have no idea what the right thing to do is.
Even if you can’t answer my question I want to say how kind it is of you to find the time to answer people’s questions – we’re all very grateful. Thank you so much.
P.S. Also, I’d like to add something that may help women who are younger than me and who want children. In April 2016 my AMH was 1.372 ng/ml, my AFC higher and I had no fibroid growing into my uterus. 1.5 years later it is a very different story – that’s how quickly fertility declines after 40. Please don’t delay fertility treatment like me – I deeply regret it.
Your age and diminished ovarian reserve pose problems. Your fibroid, if it is encroaching on the uterine cavity needs to be removed. I would however respectfully submit that mini-IVF is not the right way for you to go.
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.
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 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
34 year old with unexplained infertility. AMH 1.89, AFC 32. Cycle 1 IVF antagonist protocol, 9 day stimulation of 300 gonal-f + 75 menopur, peak estradiol 2600. 42 eggs retrieved, 17 fertilized (sample split between ICSI and conventional), severe fragmentation by day 3 with subsequent embryo arrest of all embryos. No transfer. 3 months coq10 supplementation followed by ivf cycle 2 – long lupron agonist protocol with 10 days stimulation starting with 225 gonal-f for 2 days followed by 8 days of 150 gonal-f + 150 menopur, peak estradiol 3800. 22 eggs retrieved, 18 fertilized (1/2 conventional, 1/2 icsi) – 80% fertilization with icsi, less than 50% conventional for total 12 fertilized. Different lab/institution for cycle 2 with repeated >40% fragmentation of all embryos at day 3 and subsequent arrest after day 3. Day 3 transfer of the “least” fragmented 2 embryos, pregnancy test negative. Of large quantity of embryos obtained in 2 cycles, none ever make it to blast, are looking poor quality on day 3. No symptoms of OHSS.
The egg/embryo quality deficit could in my opinion have to do with the protocol used for ovarian stimulation and its implementation:
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