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.
I’m 37 years old and a completely healthy with normal baseline fertility diagnostics (AMH, FSH all within normal and good antral follicle count ~10/ovary). I recently underwent egg retrieval for fertility preservation and was placed on low doses of Gonal-F (200 units nightly) and Menopur (75 units nightly) for 6 days before starting my cetrotide injections (I believe 0.25mg). Things seemed to look promising as there appeared to be as many as 18 growing follicles on ultrasound. By day 9, they saw that there were 12 follicles in my left ovary and 6 follicles in my right. There were 4 follicles in my right ovary that had reached 18-20mm, however many of the follicles in my left ovary were still mid-sized, some as small as 10-13 mm. The decision was made at this point for me to self-administer 5mg of lupron in the evening for retrieval 36 hours later despite my concern that there were still so many smaller follicles. On the day of retrieval, they were able to obtain 13 eggs, however only 7 of those were actually mature and frozen.
As someone who is completely healthy with normal fertility labs/tests and a promising follicle count (18 upon stimulation), I was completely surprised by the low yield of frozen eggs at the end. How normal is this? What could have been done to optimize my cycle of controlled ovarian hyperstimulation? Specifically, would it have helped to delay the lupron trigger for another day to allow those smaller follicles to develop further? Should a higher dose of lupron have been used? I’m trying to better understand which variables in my cycle could have been further optimized to achieve a better outcome.
Thank you.
In my opinion, the protocol used for ovarian stimulation should be carefully reviewed and revised accordingly. One consideration is how and when the trigger shot was given.
Concern and even fear of severe ovarian hyperstimulation 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/or chromosomally abnormal (aneuploid”).
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.
Geoff Sher
Hi Dr. Sher,
I had PGS performed on 11 5 day blasts – 6 were euploidy and 5 were aneuploidy:
– Abnormal: +1, Female
– Abnormal: +4q, +5 Female
– Abnormal: -14, Male
– Abnormal: +3, +15, +19, Male
– Abnormal: XO (Turner)
Of the Abnormal female embryos are these designations associated with mosaicism ?
Possibly the +1 female!
Geoff Sher
Dear Dr.Sher,
Can you please provide your views on whether the below summary from MRI-Pelvis could be a cause for concern for a patient with recurrent implantation failure.
Tiny hypointense lesion with tiny cyst in the left posterior lateral fundus region indenting the endometrium – s/o adenomyoma.
We are quite concerned since the location is the fundus region and that is where the embryo implants.
If you feel this could be a possible reason for RIF, do you think it would be a good idea to have leuprolide or lupron depot before the next cycle or do you think we should any further investigation.
Regards
Dhivya
I would do a hysteroscopy to confirm because if it represents a surface lesion protruding into the uterine cavity it needs to be excised and this could possibly be done at the time. In my opinion, depot Lupron will not help.
Geoff Sher
Hi Dr Sher – we have just had our first failed round of IVF here in New Zealand with only one fresh transfer that didn’t stick and none to freeze. Absolutely devastated. We are MFI – my husbands count is 4 million and we did IVF with ICSI . I am 29 – with an AMH of 12, and I have had two pregnancies previously (terminations) when I was 17 and 21. We retrieved 8 eggs after a short protocol of 225 puregon which was increased to 300 after there wasn’t a lot of action on Day 8 at the first scan. I also stinmed for two extra days. 6 of the eggs fertilised, and we had four blastocyst on Day 5 but 3 of them arrested/stopped developing/weren’t suitable to freeze. For our next cycle it is suggested that I do a short protocol again with the puregon but with 300 from the get go and with the major difference being using IMSI as we think that the sperm may have had some DNA fragmentation damage hence the arresting of the blastocysts. I will also do an endo scratch and the Colorado protocol this time to assist with implantation. Any thoughts on this second cycle protocol and if it will result in any more blastocysts? We so hope that it does.
I do not think an endometrial scratch procedure has merit and don’t advocate its use. The issues are the protocol used for ovarian stimulation needing review and revision (I also do not advocate the use of “flare”(short) protocols and whether your husband has irreversible or reversible oligozoospermia (he needs his FSH/LH/testosterone to be measured).
My thought would be 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
Geoff Sher
Hi Dr Sher, why do you put your poor responding patients on BCP before starting an agonist in the conversion protocol? Don’t poor responders get over suppressed? Could you just start lupron and do away with BCP?
One often hears the expressed opinion that the BCP suppresses response to ovarian stimulation. This is not the case, provided that the BCP is overlapped with administration of an agonist (e.g. Lupron, Buserelin, Superfact) for several days leading up to the start of menstruation and the initiation of ovarian stimulation cycle with gonadotropin drugs. If the latter precaution is not taken, and the cycle of stimulation is initiated coming directly off the BCP the response will often be blunted and subsequent egg quality could be adversely affected. The explanation for this is that in natural (unstimulated) as well as in cycles stimulated with fertility drugs, the ability of follicles to properly respond to FSH stimulation is dependent on their having developed FSH-responsive receptors . Pre-antral follicles (PAF) do not have such primed FSH receptors and thus cannot respond properly to FSH stimulation with gonadotropins. The acquisition of FSH receptor responsivity requires that the pre-antral follicles be exposed to FSH, for a number of days (5-7) during which time they attain “FSH-responsivity” and are now known as antral follicles (AF). These AF’s are now able to respond properly to stimulation with administered FSH-gonadotropins. In regular menstrual cycles, the rising FSH output from the pituitary gland insures that PAFs convert tor AF’s. The BCP (as well as prolonged administration of estrogen/progesterone) suppresses FSH. This suppression needs to be countered by artificially causing blood FSH levels to rise in order to cause PAF to AF conversion prior to COS commencing, otherwise pre-antral-to –antral follicle conversion will not take place in an orderly fashion, the duration of ovarian stimulation will be prolonged and both follicle and egg development may be compromised. GnRH agonists (e.g. Lupron, Buserelin, Superfact) , cause an immediate surge in release of FSH by the pituitary gland thus causing conversion from PAF to SAF. This is why, women who take a BCP to launch a cycle of COS need to have an overlap of the BCP with an agonist. By overlapping the BCP with an agonist for a few days prior to menstruation the early recruited follicles are able to complete their developmental drive to the AF stage and as such, be ready to respond appropriately to optimal ovarian stimulation. Using this approach, the timing of the initiation of the IVF treatment cycle can readily and safely be regulated and controlled by varying the length of time that the woman is on the BCP.
Since optimizing follicular response to COS requires that prior to stimulation with gonadotropins, FSH-induced conversion from PAF to AF’s first be completed and the BCP suppresses FSH, it follows when it comes to women launching COS coming off a BCP something needs to be done to cause a rise in FSH for 5-7 days prior to menstruation heralding the cycle of CO S.This is where overlapping the BCP with an agonist (e.g. Lupron/Superfact/Buserelin) comes in. The agonist causes FSH to be released by the pituitary gland and if overlapped with the BCP for several days and this will (within 2-5 days) facilitate PAF to AF conversion…. in time to start COS with the onset of menstruation. Initiating ovarian stimulation in women taking a BCP, without doing this is suboptimal
I believe it to be essential regardless of the protocol of COS protocol being contemplated, for women who launching ovarian stimulation coming off a BCP to overlap with an agonist for several days in advance of initiating ovarian stimulation with the onset of menstruation,
Hope that helps!
Geoff Sher
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