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 have been suffering repeated ivy failure with no apparent reasons. My embryos are perfect, my linning is perfect. Its just the implantation that fails. what should I do, Kindly suggest please. Should I give up the hope of ever having a kid?
Hi Dr Sher, what is your view of splitting Gonal f doses so if you are given 300 IU, instead of taking it in the evening, you split it and take 150iu in the morning and 150iu in the evening 12 hours apart? Would this create more even growth?
There would in my opinion be no difference.
Geoff Sher
Hello Dr. Sher,
I just turned 40 years old a week ago. I conceived my two beautiful daughters naturally when I was 31 and 34 years old. This year I also conceived naturally after we tried 6 months, but this pregnancy ended in a miscarriage (Tuner Syndrome) We were devastated and because of my age, we decided to do IVF with PGS. My day three testing result is: AMH 1.31, FSH 8.01, E2 63, LH 2.21 and AFC 7. My baseline E2 was 17 and AFC was 7 after 16 days of birth control pills. I started stimulation with 300iu Follistim and 150iu Menopur from the fourth day after my last BCP. Doctor only found 1 measurable follicle and E2 was 90 on day 4 monitoring. He said it was still too early to tell but he increased the Menopur to 225iu. Today is the day 6 monitoring, still only one measurable follicle 10mm*8mm and E2 is 149. My Menopur dosage is increased again to 300iu and Ganirelix is also added. This Sunday I will do one more monitoring. If there is still nothing going on, this cycle will be cancelled. I will talk with my doctor and nurse about the incoming plan if this cycle is cancelled. They didn’t expected I would have such low response to the medication. What would be your concern and recommendation based on the information I provided? For the next round, what would be your recommendation for the course of action?
Thank you and Have a wonderful weekend!
Mimi
You now have diminishing ovarian reserve (DOR) and this requires a very strategic approach to ovarian stimulation.
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
Thank you dr Sher and in response to Stella, here is also some more information about my cycle and eggs.
all 3 of my embryos were Monosomy. One was day 5ab and 2 were day 6 4cc.
1 was a partial, 1 had two missing chromosomes and third had three missing chromosomes.
My first beta 13 days post 5 day transfer was 260 and by 15 days it was over 900.
From those numbers and the sonogram it was pretty clear that all theee implanted!!!
However only two sacks were growing with viable size and heartbeats.
So yes mosony’s can implant. And none of these were mosaic.
Just an FYI – Before my cycle I did a 90 day cleanse of high organic lean protein, no sugar, caffeine, alcohol,minimal amounts of carbs and only whole grains. I did coq10, dhea and royal jelly. Lots of greens, fish, eggs and avocados, nuts and coconut/ fish oils.
Part of me was determined to implant the embryos simply because I refused to believe such a painful diet would leave me wit nothing. Why not try?
I wanted to see if maybe the bad cells were pushed to the other layer or I was one of the small percentage of errors.
My question to you dr Sher is have any of your patients who reached a heartbeat with an abnormal embryo then gone on to miscarry?
Thank you so much.
No! but then I have not had that many cases to be able to quote meaningful statistics.
Geoff Sher
Dear Anne, I would love to stay in contact with you if you would like to email me. I will see if my lab still has my embryo although I suspect they may have discarded it. My email is fairyfloss7676 at gmail dot com.
Dr Sher, why does the literature out there say monosomy embryos die before implantation? That’s what my clini said!!!!
Anne – first of all congrats! What exciting news. I don’t know if you ever post on inspire.com (it is a web board that offers a bit more privacy) but if you wanted to connect with others who are in a similar position it’s a good place for that. There are several women who have transferred abnormal pgs embryos that share info there. I follow their journeys as I also have monosomy embryos that I would like to try. If I can find an RE in my area willing to do it.
Hi Anne – if you are open to sharing what clinic you are with that was open to exploring the transfer of a monosomy, I would be most grateful. Best wishes for continued success on your pregnancy. My email is ann dot tahini at gmail dot com
Hi I am doing fet I am on day 12 of my medicated fet cycle and my oestradiol level are 391/poml I start the sending stage in 2 day and have transfer on day 19 my level seem to low
I should also add my lining of womb was 11mm so good
It is on the low side!
Good luck and G-d bless!
Geoff Sher