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 there,
I am interested to know the below in the case that the husband is HSV2+ and the wife is HSV2-:
1. can a child be conceived via IVF without infecting the mother and child)?
2. also does an HSV2+ father genetically impact the child in any way?
Has there been any scientifc study regarding the above questions to confirm one way or the other? Thank you.
Best regards,
Jason
It is possible but highly unlikely the conceptus would be infected through vertical transmission with intercourse or through IVF. However, direct contact with the baby at delivery can cause serious neonatal infection and this if there is an active, open lesion in birth canal or a very recent lesion, delivery should be by Cesarean section.
Geoff Sher
Hello Dr. Sher,
I was wondering, during an egg retrieval (specially for a 40 yr. with low ovarian reserve), do Doctors. typically just go in and only remove the eggs from the “bigger” sized follicles and not the others?
I just recently had an egg retrieval, I am 40 yrs. old and my Dx is Low Ovarian Reserve and was told I was a poor responder. This was my 1st IVF cycle (prior I tried 2 stimulated natural cycles and 1 IUI cycle). For the IVF cycle, with aggressive stimulation I developed only 4 follicles. on day 9 they measured on my left side one at 1.1mm and one was undetected at the time, on the right they saw 2 which measured at 0.9. On day 12 I returned and the left side had 1 @ 1.7 and 1 @ 1.2 and they were unable to see the 2 follicles on the right side (most likely due to a cyst that I have, which they said they were monitoring in case it got larger which they never mentioned anything about because previous cycles, they had no problems seeing the right side, and on day 9 the Dr. did see 2 follicles at 0.9). I went back in day 14 and again she measured the left side at 1.9 and the other at 1.5 and again unable to view the 2 on the right side (they needed them to be at least a 1.7 to be considered mature, I am in Canada, I am not sure if the measurements are the same).
I don’t understand why they couldn’t see the ones on the right side, when on day 9 another Doctor was able to see them. So when I asked that, they told me that their ultra sound for the retrieval is more advanced so they will be able to see them better, So I triggered that night and went for the retrieval 2 days later.
After the retrieval she said she only got 1, and I asked about the other 3 she kind of brushed me off, and said they were too small. I asked my husband how long did the procedure take? (he was in there with us), he said under 5 mnts. she went in and was done. I asked him if she maneuver my abdomen to try to look at the right side, he said she didn’t touch your abdomen at all. So unfortunately the 1 egg she retrieved did not multiply after icsi. So when the Embryologist called to deliver my bad news, i asked her what happened with the other 3 follicles, were they empty? She hesitated a bit and said you had 4? She said I was under the impression it was 1 follicle. She said hold let me look at your chart, then she came back and said, well the Dr. noted that 1 was too small on the left and unable to see right side, so she only retrieved the largest one.
I was very upset because She knows the odds were against us (I am fully aware that the other 3 may not have been viable or contain any eggs at all, but It would have been nice to know. I feel like she did not even try, and this is a very emotional and expensive process and I have no idea in terms of the rules of her retrieving mature and non mature.
Now the one that was at 1.1 on day 9 grew to 1.9 3 days prior to retrieval, which means if the others on the right side grew at the same rate, that would have put them at 1.7 which was the minimal they required for maturity. What are your thoughts on that? I need a professional opinion to ease my mind, cause I am very frustrated right now.
1. About Diminished Ovarian Reserve:
You clearly have diminished ovarian reserve.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”.
About Empty Follicles:
Frequently, when following vigorous and often repeated flushing of follicles at egg retrieval they fail to yield eggs, it is ascribed to “Empty Follicle Syndrome.” This is a gross misnomer, because all follicles contain eggs. So why were no eggs retrieved from the follicles? Most likely it was because they would/could not yield the eggs they harbored.
This situation is most commonly seen in older women, women who have severely diminished ovarian reserve, and in women with polycystic ovarian syndrome (PCOS). In my opinion it is often preventable when an optimal, individualized and strategic protocol for controlled ovarian stimulation (COS) is employed and the correct timing and dosage is applied to the “hCG trigger shot.”
Normally, following optimal ovarian stimulation, the hCG “trigger shot” is given for the purpose of it triggering meiosis (reproductive division) that is intended to halve the number of chromosomes from 46 to 23 within 32-36 hours. The hCG trigger also enables the egg to signal the “cumulus cells” that bind it firmly to the inner wall of the follicle (through enzymatic activity), to loosen or disperse, so that the egg can detach and readily be captured at egg retrieval (ER).
Ordinarily, normal eggs (and even those with only one or two chromosomal irregularities) will readily detach and be captured with the very first attempt to empty a follicle. Eggs that have several chromosomal numerical abnormalities (i.e., are “complex aneuploid”) are often unable to facilitate this process. This explains why when the egg is complex aneuploid, its follicle will not yield an egg…and why, when it requires repeated flushing of a follicle to harvest an egg, it is highly suggestive of it being aneuploid and thus “incompetent” (i.e., incapable of subsequently propagating a normal embryo).
Older women, women with diminished ovarian reserve, and those with polycystic ovarian syndrome, tend to have more biologically active LH in circulation. LH causes production of male hormone (androgens, predominantly testosterone), by ovarian connective tissue (stroma/theca). A little testosterone is needed for optimal follicle development and for FSH-induced ovogenesis (egg development). Too much LH activity compromises the latter, and eggs so affected are far more likely to be aneuploid following meiosis.
Women with the above conditions have increased LH activity and are thus more likely to produce excessive ovarian testosterone. It follows that sustained, premature elevations in LH or premature luteinization (often referred to as a “premature LH surge”) will prejudice egg development. Such compromised eggs are much more likely to end up being complex aneuploid following the administration of the hCG trigger, leading to fruitless attempts at retrieval and the so called “empty follicle syndrome.”
The developing eggs of women who have increased LH activity (older women, women with diminished ovarian reserve, and those with PCOS) are inordinately vulnerable to the effects of protracted exposure to LH-induced ovarian testosterone. Because of this, the administration of medications that provoke further pituitary LH release (e.g., clomiphene and Letrozole), drugs that contain LH or hCG (e.g., Menopur), or protocols of ovarian stimulation that provoke increased exposure to the woman’s own pituitary LH (e.g., “flare-agonist protocols”) and the use of “late pituitary blockade” (antagonist) protocols can be prejudicial.
The importance of individualizing COS protocol selection, precision with regard to the dosage and type of hCG trigger used, and the timing of its administration in such cases cannot be overstated. The ideal dosage of urinary-derived hCG (hCG-u) such as Novarel, Pregnyl and Profasi is 10,000U. When recombinant DNA-derived hCG (hCG-r) such as Ovidrel is used, the optimal dosage is 500mcg. A lower dosage of hCG can, by compromising meiosis, increase the risk of egg aneuploidy, and thus of IVF outcome.
There is in my opinion no such condition as “Empty Follicle Syndrome.” All follicles contain eggs. Failure to access those eggs at ER can often be a result of the protocol used for controlled ovarian stimulation.
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 had a 5 day FET blast transfer on 11/10/17. According to the Ferring wheel app, I would have been 7w4d during my US on 12/15/17. The doctor was not able to detect a heartbeat or fetal pole at that time. He suspects a blighted ovum, but has told me I need a second scan to confirm. He has suggested I stop my progesterone in oil at that point. My HCG and progesterone levels have been WNL so far. On one hand, I have not had any nausea, breast tenderness, etc at all. Conversely, I have not had any cramping or heavy spotting, just very scant light brown spotting, similar to what I had days after my FET.
I had already made my first prenatal appointment with my general OBGYN for next week, 7 days after my first scan. Is there any hope? If not do you recommend D&C or letting the miscarriage occur naturally? I am 36 and have a history of stage 1 endometriosis that I had removed earlier this year.
Sadly this does not sound very promising, I am afraid.
I hope I am wrong!
Good luck and G-d bless!
Geoff Sher
What is an ideal blood progesterone level during the two week wait in your opinion?
My last progesterone read was 127, so my RE took me to a half dose of PIO (1ml to 0.5mL). Tested yesterday and it was 56. He was happy with that and said continue on the half dose of PIO. Would you agree? Is there an ideal number?
Background FET – two 5 day blastocysts.
Thanks!
I should add – I am also using one crinone vaginal applicator daily as well.
Better than 20 is fine!
Geoff Sher
Hello Dr. Sher,
I came across your website online. I have read thru a lot of it. My husband and I would like to consult with you. Our situation is the I lack both fallopian tubes but still have both of my ovaries. I would like to try a natural ivf, and would like to know more about the process. I am leary on the costs of ivf and also mostly the process of all the meds. My husband’s concern is my health and safety with this procedure.
A Skype consultation is doable for us as we both work heavy schedules.
We would appreciate a response.
Candace and James Grof
It would be a pleasure to interact with you Candace.
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.
•Optimizing Response to Ovarian Stimulation in Women with Compromised Ovarian Response to Ovarian Stimulation: A Personal Approach.
•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
•Multiple Pregnancies Carry Serious Risks: How Many Embryos Should we Transfer at One Time?
•Frozen Embryo Transfer (FET): A Rational Approach to Hormonal Preparation and How new Methodology is Impacting IVF.
•Staggered IVF
•IVF: Selecting the Best Quality Embryos to Transfer
•Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene
•IVF Failure and Implantation Dysfunction:
•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
•Avoiding High Order Multiple Pregnancies (Triplets or Greater) with IVF
•The Role of Nutritional Supplements in Preparing for IVF
•The Role of IVF in the Management of Infertility Caused by Pelvic Inflammatory Disease (PID).
•Micro-IVF: Often Preferable to Ovarian Stimulation with or Without IUI
•Tubal infertility.
I invite 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.