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,
I started bleeding at 5wks 2 days pregnant, it has been ongoing for 7 days with lots of small clots but no pain. An ultrasound the following day (5wks 3 days) confirmed gestational sac but nothing else. HCG was 4400 at 5wks 6 days and 5400 at 6wks 2 days (4 days apart). Is this cause for concern? Should I be concerned of an eptopic pregnancy?
Thank you
I would give it until 7 weeks and repeat the US to reevaluate!
This is becoming somewhat concerning!
Good luck!
Geoff Sher
Dr. Sher, Your wealth of knowledge is incredible! I’d love your advice. I’m 40 yrs old, healthy and my baseline tests all came back good (FSH 7.19, AMH 3.23, E2 44.99). My doc was initially very positive and thought we’d do extremely well with IVF. Due to my age, our goal was to freeze-all and bank around 4-6 PGS-tested embryos with the goal of having 2 children. Our doc thought we could accomplish this in 2 rounds of IVF. We just finished our 2nd round and the results are not what I expected as we only have 1 frozen embryo. At this rate we’re going to need to do a dozen rounds! We start our 3rd round soon and I’ve asked my doc what he would change about my protocol and he said ‘nothing, it’s going fine’. Here are the details of my 2 cycles:
#1: No BCP. Day 3 started 375 Gonal-F & 75 Menopur. Day 9 started 0.25 Cetrotide. Day 12 Leuprolide trigger (E2 was 1978). Result: 7 follicles, 6 mature, 5 fertilized, 2 tested, 1 normal.
#2: same protocol. (E2 at trigger was 1067). Result: 3 follicles, 3 mature, 3 fertilized, 1 tested, 0 normal.
Here are my questions…
1. Based on my blood tests, age and results, do you think I have DOR?
2. Are you pleased with the result of my first 2 cycles or do you think I can produce more eggs?
3. Do you think my protocol contributed to low result or is that just my age and what I should expect?
4. Would you recommend the A/ACP protocol for me?
5. My doc didn’t want to put me on BCP because he thought it would suppress me too much. I read your posts that suggest starting Lupron during the last few days on BCP, but my doc didn’t seem to want to do that. He prefers to just have me start naturally. Do you see much benefit in the BCP/Lupron start versus natural start?
Thank you SO much!!
Jessica
Your response does suggest DOR.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
Hello. I will be doing IVF in December, and am still currently breastfeeding (gave birth June 28 to my first.) If I stop breastfeeding within the next 10 days (by Nov 19,) would it be ok to cycle in December? The doctor will put me on birth control to start my menstrual cycle. Thank you! It’s incredible that you take time to answer all of us. Truly, thank you.
It should be OK!
Good luck!
Geoff Sher
PS: Thank you for your kind sentiments. I enjoy doing this. “What goes around, comes around”.
Hi Dr. Sher, I am 29 healthy young female and my husband and I just got results for a second failed IVF cycle. Failed meaning, no embryos. First cycle I was on 450 Follistim, 25 Mini HCG, with Ganirelix as an antagonist. I was a slow responder so we did not trigger until day 14, retrieval day 16: 10 Eggs, 8 Mature, 6 Fertilized via ICSI, 1 made it to blast and it had trisomy 18 so we did not transfer. Cycle 2, exact timeframe, medication was the same except mini HCG was 50 per day. I triggered day 14 but estradiol was almost 5000 so trigger was halved. 11 Eggs retrieved, 7 Mature only 2 fertilized, 0 made to blast (1 had some hope but stopped dividing at day 6). Both cycles my eggs ranged from 18-22mm the day of trigger.
My husband has less than 1% morphology but good motility and forward progression. I have FSH is 10.2 and AMH 1.34, no immediate concern with reserve but not quite matching my age. We both have no balance translocations. We had one natural conception a year and a half ago that was a missed miscarriage, ended via D&C @ Wk12.
Is there a more effective protocol I should be on? Am i being over suppressed with the birth control protocol before starting? Should there be concerns with egg quality or do you think it makes sense to utilize the same protocol and do a sperm donor for our third cycle to see if we get different results? First cycle his sample post wash was 77 million concentration, motility 90% speed and forward progression 4, total motile 10.4 million volume 0.15 ml. Second post wash 33 million concentration, motility 90%, speed and forward progression 4, total motile 2.97 million, volume 0.1 ML. Is there still a chance that there is a sperm DNA fragmentation that could be the issue or is that not a possibility of there is no translocation?
Any insight is appreciated
I should have added that my estradiol was 13 and 10 at the suppression checks.
Thanks, Dr Sher. One final question is to do with LH. You say LH is bad for women with DOR. My levels are normal and my AMH is 1, although LH is consistently low at 4 and sometimes below 3. Are you saying that even with consistent blood levels showing low LH that a woman with DOR will still be susceptible to increased release of pituitary LH even with low day 3 LH levels?? What is the point of taking the measurement of LH when it doesn’t reflect what’s really going on??
No! What I am suggesting that regardless of blood levels, the biological activity of LH in older women and those with DOR is likely significantly increased.
Geoff Sher