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.
Hi!
I just heard about your forum from a friend in a support group. I was hoping you can give me some insight or advice about my situation. I’m 35, husband is 40. I have PCOS and don’t ovulate on my own. No issue with my husband. Did 3 months of clomid with my OBGYN with no success. We did my 4th Clomid cycle with our RE, which turned into an IUI…became pregnant, however, it was ectopic. A few months later we dicided on IVF. Protocol was follistim, menopur, Ganirelix then HCG. My follies were growing, lots of them!! We were expecting lots with a AMH of 9.3. Everything was textbook!!! After the egg retrieval my RE came to tell us they only retrieved 2 eggs, only one was good. Nothing fertilized. We were devastated. Didn’t even dream that could happen with us. Figured we were an easy case! Went to our RE a week ago and he wants us to try a 2nd cycle with different protocol (start on Lupron a week before follistim and menopur). Our RE explained the eggs were probably gone while I was stimmimg. My question…how do we know this won’t be the same outcome if we go to cycle 2? How Can I improve my eggs to have a better outcome?? Thank you so much!
Polycystic ovary syndrome (PCOS) is a common hormonal system disorder among women affecting between 5% and 10% of women of reproductive age worldwide. Women with PCOS may have enlarged ovaries that contain multiple small collections of fluid (subcapsular microcysts) that are arranged like a “string of pearls” immediately below the ovarian surface (capsule).interspersed by an overgrowth of ovarian connective tissue (stroma). The condition is characterized by abnormal ovarian function (irregular or absent periods, abnormal or absent ovulation and infertility, androgenicity (increased body hair or hirsutism, acne) and increased body weight –body mass index or BMI.
Women with PCOS are at increased risk that ovarian stimulation with gonadotropins will result in the, of development of severe ovarian hyperstimulation syndrome (OHSS), a life-endangering condition that is often accompanied by a profound reduction in egg “competency” and on fertilization often yield an inordinately high percentage of “incompetent” embryos which have a reduced potential to propagate viable pregnancies.
Concern and even fear that their PCOS patients will develop of OHSS often leads the treating RE to take measures aimed at reducing the risk of this life-endangering condition. One such measures is to “trigger” egg maturation prematurely in the hope of arresting further follicular growth and the other, is to initiate the “trigger” with a reduced dosage of hCG (i.ed. 5,000U rather than the usual 10,000U of of Pregnyl/Profasi/Novarel, to use or 250mcg rather than 500mcg of Ovidrel or to supplant the hCG “trigger” with a Lupron “trigger” which causes a prompt LH surge from the woman’s pituitary gland to take place. While such measures do indeed reduce the risk of OHSS to the mother, this often comes at the expense of egg quantity and “competency”. Fewer than the anticipated number of eggs are harvested and those that are retrieved are far more likely to be “immature” and chromosomally abnormal (aneuploid”), or “immature” , thereby significantly compromising IVF outcome.
Against this background, It is my considered opinion that when it comes to performing IVF in women with PCOS, the most important consideration must be the selection and proper implementation of an individualized or customized ovarian stimulation protocol. Thereupon, rather than prematurely initiating the “trigger” to arrest further follicle growth, administering a reduced dosage of hCG or “triggering with a GnRH agonist (e.g. Lupron/Buserelin) that can compromise egg “competency”….. use of one of the following techniques will often markedly reduce the risk of OHSS while at the same time protecting egg quality:
1. PROLONGED COASTING…my preferred approach: My preferred approach is to use a long pituitary down-regulation protocol coming off the BCP which during the last 3 days is overlapped with the agonist, Lupron/Buserelin/Superfact. The BCP is intended to lower LH and thereby reduce stromal activation (hyperthecosis) in the hope of controlling LH-induced ovarian androgen (predominantly, testosterone) production and release. I then stimulate my PCOS patients using a low dosage of recombinant FSH-(FSHr) such as Follistim/Gonal-F/Puregon. On the 3rd day of such stimulation a smidgeon of LH/hCG (Luveris/Menopur) is added. Thereupon, starting on day 7 of ovarian stimulation, I perform serial blood estradiol (E2) and ultrasound follicle assessments, watching for the number and size of the follicles and the blood estradiol concentration [E2]. I keep stimulating (regardless of the [E2] until 50% of all follicles reach 14mm. At this point, provided the [E2] reaches at least >2,500pg/ml, I stop the agonist as well as gonadotropin stimulation and track the blood E2 concentration daily. The [E2] will almost invariably increase for a few days. I closely monitor the [E2] as it rises, plateaus and then begins to decline. As soon as the [E2] drops below 2500pg/ml (and not before then), I administer a “trigger” shot of 10,000U Profasi/ Novarel/Pregnyl or 500mcg Ovidrel/Ovitrel. This is followed by an egg retrieval, performed 36 hours later. Fertilization is accomplished using intracytoplasmic sperm injection (ICSI) because “coasted” eggs usually have little or no cumulus oophoris enveloping them and eggs without a cumulus will not readily fertilize naturally. Moreover, they also tend to have a “hardened” envelopment (zona pellucida), making spontaneous fertilization problematic in many cases. All fertilized eggs are cultured to the blastocyst stage (up to day 5- 6 days) and thereupon are either vitrified and preserved for subsequent transfer in later hormone replacement cycles or (up to 2) blastocysts are transferred to the uterus, transvaginally under transabdominal ultrasound guidance. The success of this approach depends on precise timing of the initiation and conclusion of “prolonged coasting”. If started too early, follicle growth will arrest and the cycle will be lost. If commenced too late, too many follicles will be post-mature/cystic (>22mm) and as such will usually harbor abnormal or dysmature eggs. Use of “Coasting” almost always prevents the development of severe OHSS, optimizes egg/embryo quality and avoids unnecessary cycle cancellation. If correctly implemented, the worst you will encounter is moderate OHSS and this too is relatively uncommon.
2. MULTIPLE FOLLICLE ASPIRATION: In some cases, in spite of best effort, you inadvertently find mean follicle size to exceed 16mm, thereby leaving too little time to implement “coasting”. On other occasions, “coasting” fails to effectively lower the [E2} below 2,500pg/ml within 3 days. In such case the number of developing follicles can effectively and drastically reduced (culled) through selective transvaginal aspiration prior to initiating the “trigger” with 10,000U hCG. This will almost invariably be accompanied by a rapid and significant drop in the plasma estradiol concentration along with a drastic reduction in the risk of OHSS occurring without significantly compromising egg/embryo quality. Upon completing surgical follicular reduction, the surviving follicles can be allowed to continue their full development, at which point the hCG “trigger” can be implemented. The drawback associated with this approach is that it unfortunately interjects an additional surgical intervention into an already complex and stressful situation.
3. EMBRYO FREEZING AND DEFERMENT OF EMBRYO TRANSFEDR (ET): OHSS is always a self-limiting condition. In the absence of continued exposure to hCG, symptoms and signs as well as the risk of severe complications will ultimately abate. Thus, in the absence of pregnancy, all symptoms, signs and risks associated with OHSS will disappear within about 10-14 days of the hCG trigger. Conversely, since early pregnancy is always accompanied by a rapid and progressive rise in hCG , the severity of OHSS will increase until about the 9th or tenth gestational week whereupon a transition from ovarian to placental hormonal dominance occurs, the severity of OHSS rapidly diminishes and the patient will be out of risk. Accordingly, in cases where in spite of best effort to prevent OHSS, the woman develops symptoms and signs of progressive overstimulation prior to planned ET, all the blastocysts should be vitrified and cryostored for FET in a subsequent hormone replacement cycle. In this way women with OHSS can be spared the risk of the condition spiraling out of control.
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.
·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.
·Egg Maturation in IVF: How Egg “Immaturity”, “Post-maturity” and “Dysmaturity” Influence IVF Outcome:
·Commonly Asked Question in IVF: “Why Did so Few of my Eggs Fertilize and, so Many Fail to Reach Blastocyst?”
·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?
·Taking A Fresh Look at Ovarian Hyperstimulation Syndrome (OHSS), its Presentation, Prevention and Management
·Preventing Severe Ovarian Hyperstimulation Syndrome (OHSS) with “Prolonged Coasting”
·Understanding Polycystic Ovarian Syndrome (PCOS) and the Need to Customize Ovarian Stimulation Protocols.
·“Triggering” Egg Maturation in IVF: Comparing urine-derived hCG, Recombinant DNA-hCG and GnRH-agonist:
·The “Lupron Trigger” to Prevent Severe OHSS: What are the Pro’s and Con’s?
•.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.
•Implications of “Empty Follicle Syndrome and “Premature Luteinization”
•Premature Luteinization (“the premature LH surge): Why it happens and how it can be prevented.
•Preventing Severe Ovarian Hyperstimulation Syndrome (OHSS) with “Prolonged Coasting”
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
Greetings from Down Under! I’ve had three failed transfers (1st fresh x chemical, 2nd PGS tested natural FET x negative, third fresh x negative). I’ve just had a second implant of Zoladex for undiagnosed endo (no symptoms MRI has come back all clear but this is a jiztbin case protocol) had the scratch and have begun my first ever medicated FET, I am responding well to the estrogen, my lining messured 9mm this morning with transfer scheduled next Thursday. I am doing intralipids as well. My question when should I be having the intralipids and if this fails, would you recommend a lap to check for endo? I’m not convinced I have endo, but I do feel it’s something auto immune, I did test positive for ANA 1/80 speckled but my FS does not believe in Clexane or Steroid treatment. I feel like I’m throwing away my last two perfect 5AA embryos, what can I do to get the care and support required for a successful pregnancy? I’m becoming a bit synical thinking every failure = more money for them. Any advice on recent studies that I can share to sway them? Many thanks for your time and I do hope you find the time to enjoy your pending retirement- a well deserved break from a very successful career.
Sorry for the typos! It’s late here! 🙂
Hello a little update on me had first ivf in march got 13 follicles got 2 eggs out 8 and 6cell did three day transfer negative results… Second ivf only 5 follicles and no eggs produced question is there any way to help better your chances of producing eggs?!! I’m 38 years old dh is 36 do I have any hope ??
Doctor advised me 125 mg ACP once a day, can I take 75 mg ACP TWICE
A DAY?
This should be discussed with your RE.
Geoff Sher
Dr Sher, if you use OCP in your conversion protocols and ur banking, after you finish a cycle do you have to go back on the pill for the next cycle? How would that work if you’re out of state? Would I have to stay the whole time or just leave when I have to take the pill and return on day 7? Just trying to figure out logistics.
For more than three decades, about 70% of the patients that I have performed IVF on, have journeyed to see me from out state or out of country. Over the years, I have been repeatedly asked how, given the distance separates us from our patients, we are able to provide optimal, efficient, and congenial services. This blog represents an attempt to describe how we accomplish this. It will outline the processes involved, and explain how the system we have put in place allows us to fully prepare and triage our patients at a distance, receive them in Las Vegas, monitor and treat them here, discharge them back to their home environments and then follow up with them through the diagnosis of pregnancy and post-IVF treatment (often with the welcomed and invited participation of their local primary physicians). It will also spell out how we are able to provide full and ready access to me and my team constantly, and finally, it will emphasize that the core of our success is routed in a commitment to being as accessible and affable as possible, at all times. In truth treating patients from afar is really not more complicated than is treating local patients. I am quite confident that if you were to ask those that have gone through the process, most, if not all, would tell you that we are well organized, seasoned in what we do and that the entire process is comfortable, easy and seamless.
Arranging for a Skype Consultation with me: Patients largely hear of Sher-IVF through word of mouth coming from the many thousands of women I have assisted in having babies over the years. Others reach Sher-IVF through Physician referrals, access to books and articles I have written on IVF and related topics, media and internet exposure or through personal online research by way of search engines. They then contact my wonderful “patient concierge”, Julie Dahan to set up a Skype consultation, either directly by calling 702-533-2691 or by email at julied@sherivf.com. Others access us by going to the Sher-IVF website at http://www.sherivf.com and making an online appointment for a Skype consultation with me that way. Regardless of how we are contacted, be assured that Julie (or her designee) will respond promptly to any such requests.
The Initial Consultation and the Report: During the initial consultation we discuss the medical and reproductive history in detail and I recommend additional testing necessary to identify the exact cause of the infertility and define an optimal approach to solving the problem. I thereupon promptly dispatch a comprehensive report by email along with a list of recommended reading of relevant articles to be found on my blog (to be found on http://www.sherivf.com).
Follow-up Administrative consultation: One or two working days later, patients receive a call from us to set up a date for a 1 hour phone consultation with our Practice Administrator, Sharon Jochman on the relevant logistical and financial considerations relating to IVF treatment with me. Thereupon, she will forward email information on such issues to patients for their review. At this point, no financial commitment to undergo treatment with me is requested or required. However, Sharon will place the patient (s) name on a tentative list for treatment in an upcoming IVF cycle batch (see below) and as that cycle draws near, she will contact the patient/couple to determine whether they wish to proceed with treatment, defer or cancel. This process protects the patient/couple from losing a chosen spot in the upcoming IVF cycle.This is because, unless in spite of best effort to contact them they are unreachable, or they expressly indicate a change of heart and wish to defer to a later cycle batch or opt out of the program, they will not lose their spot in their selected cycle of treatment. Then, subject to an expressed interest to proceed, the patient/couple would, for the 1st time, be required to make a financial commitment.
Consultation with a Nurse Coordinator: The nurse coordinator prepares patients for a cycle of treatment with me. She will discuss all the recommended testing and medical visits necessary.
Follow-up Consultation with me: Once the initial Clinical Coordinator consultation is completed and the requested tests and preparatory investigations have been done, the patient/couple has a wrap-up Skype or telephone consultation with me patients to discuss results advise and to finalize the protocol necessary for ovarian stimulation and fine tune the complete strategy for treatment.
The Nurse Coordinator Develops a Color-coded Calendar for the Upcoming IVF Cycle: At this point, the Nurse Coordinator generates an individualized and detailed color-coded electronic calendar that lays out the precise protocol that will be implemented. It starts with the use of a birth control pill, to be overlapped (for a few days) with a GnRH agonist (Lupron/Buserelin/Superfact), followed by all necessary medications involved in the process of preparation. She will go over the entire process and answer questions. A standard consent form will be forwarded to the patient/couple for their review and they will be invited to ask any questions on issues that are unclear. Thereupon consent form must be signed before we can proceed to treatment.
Access to us Throughout the Process: I provide all my patients with my cell phone number and encourage them to contact me with any medical issues at any time. They are informed that if they call and I am not immediately available, to leave their name and phone number on my voice mail and I will respond. Patients are also provided with Julie’s cell phone number and are invited to call her on any non-medical issue. Julie does an outstanding job of assisting patients with scheduling appointments with our staff and for testing, both locally and afar. She will also gladly assist and advise on travel/accommodation/and transportation to and from our office. I am told that rapidly Julie creeps into the hearts of my patients who rapidly bond with her and feel comfortable reaching out to her for advice and comforting.
How long will Patients Need to Spend in Las Vegas for Treatment? For fresh IVF cycles with embryo transfer the female partner needs to plan on being in las Vegas for up to 2 weeks here. While male partners are encouraged to spend as much time with their partners in Las Vegas as possible, they are really only required to be here on the day of egg retrieval (and we can provide them with a 3-4-day advance notification of that day). Actually, if the man is perfectly fertile, he does not even need to come to Las Vegas at all. Instead we could arrange for a specimen of his frozen sperm to be delivered to the clinic. This will not prejudice IVF results in any way. In cases where we do frozen embryo transfers (FET), it is not imperative that the male be present at all. However, we do encourage the male partner to be here with his partner to provide emotional support wherever possible. In cases of embryo recipient cycles (egg donation/embryo adoption/gestational surrogacy and FET the woman is needed to be present in Las Vegas for about 7-9 days. Those times can be calendared a few months in advance. In cases involving FET, the male partner is really not needed onsite at all, although his presence is encouraged for the purpose of providing his partner with the support she needs. In cases of Staggered IVF which involves preimplantation genetic sampling (PGS) of embryos for chromosomal selection, the embryo transfer is deferred to a later cycle to allow for genetic testing to be completed. This means that the woman is only required to be present onsite with us for about 7 days. The day following the ET, both she and her partner can return home. We stay in touch with them regarding embryo development and planning for the future.
Follow-up at home: The day after embryo transfer (or following egg retrieval in cases where all eggs or embryos are frozen and no ET is contemplated in the same cycle), the woman and her partner (as applicable) can return home to be followed at a distance by us and/or locally by their own primary care physician who (under our oversite) will conduct pregnancy testing and subsequent gynecologic services and when applicable, prenatal care.
IVF Cycle Batches and how use of the Birth Control Pill Facilitates this: At Sher-IVF, we perform IVF cycles in 9-10 two, week “batches per year. This means that a number of patients arrive together at a predetermined date for treatment. These batches are prescheduled to start on set dates that are calendared for an entire year in advance. This enables patients to make travel and accommodation arrangements well in advance. In order to effect this, patients who are to be treated in a particular batch need to start their cycles (onset of menstruation) on or around the same date. To synchronize their cycles, we place each woman on a birth control pill (BCP) to lead into the cycle of stimulation. By shortening or lengthening the time on the BCP, we can ensure that menstrual bleeding starts at the required time to coincide with the start of a given cycle batch. Contrary to the erroneous belief that the BCP suppresses response to gonadotropin therapy, provided that in the last few days of using the BCP, it is overlapped with a GnRH agonist (e.g. Lupron, Superfact, Buserelin), this approach actually improves response to ovarian stimulation.
Following the launching an ovarian stimulation cycle on a BCP and the subsequent addition of a GnRH-agonist the woman will have a bleed. At this point she will be required to have a baseline ultrasound assessment and have blood drawn for measurement of estradiol (E2). If she is from out of town, this will have to be done by her primary OB/GYN. Provide that the ultrasound does not detect an ovarian cyst and her estradiol level is <70pg/ml), she will be eligible to start taking gonadotropins for ovarian stimulation under our oversight. . We will by this time have schooled her and partner in administering the shots…so this should not present a problem. Thereupon she will need to arrange to arrive in Las Vegas for me to begin monitoring her response, 7-8 days after commencing ovarian stimulation. It is unusual (and even inadvisable) for a woman undergoing controlled ovarian stimulation (COS) for IVF to be ready for triggering with hCG prior to the 8th day of stimulation so her arrival should be timely and not be too late..
The process of treating patients who journey to Sher-IVF in Las Vegas from afar, might at first glance seem somewhat complex, but it really is not. I have, over the last 3 decades, developed a system that is very easy, convenient, safe, seamless, uncomplicated and highly effective. The vast majority of the seventy percent (70%) of my IVF patients who journey from out of state and from abroad for treatment with us in Las Vegas would attest to this. In fact, many of my patients who underwent IVF in their own environments before coming to Las Vegas have commented on our availability and accessibility, in spite of the distance separating us.
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.