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 Dr Sher, i had a question about triggers Ovidrel 500mcg v’s Pregnyl 10,000iu. When I have 500mcg Ovidrel as a trigger, I never get sore breasts post trigger, not even during the luteal phase with progesterone support. But when I am given 10,000 pregnyl, I always get sore breasts post trigger and throughout the luteal phase with progesterone support. I know one is rHCG and the other is uHCG, but as they are both HCG, why does one always give me sore breasts when the other does not?? Shouldn’t HCG behave in the same way? My RE had no idea and could not explain it to me.
That is unusual but symptoms are subjective. Ovidrel 500mcg is at least equivalent to 10K of hCG.
Geoff Sher
Hi Dr Sher, how soon after the switch to 1/2 dose ganirelix should stims start? Is 4 days ok or is 3 days better?
Anything up to 7 days should be OK…in my opinion.
Geoff Sher
Hi Dr Sher, do you by any chance know what the shelf life is of refrigerated lupron from the day it is first opened and used?
No! I unfortunately do not. I would go by the expiration date on the product!
Hi Dr Sher,
I got pregnant easily last year but lost the baby at 23 weeks due to a chromosome abnormality. We found out later my husband is the carrier. We turned to ivf with PGD. Our first FET failed. Our 2nd just happened and got a beta of 23. We are thinking this is a chemical. We have done an ERA (receptive), HSS and all other blood work came back normal. What else can we try? We only have 1 embryo left. Thank you.
Before giving up on the last attempt, have you done repeat betas to see whether/how the level goes up? It should double in 2 days.
Geoff Sher
Hi Dr. Sher! Thanks so much for making yourself available in this way. I am 32, husband is 35. We have been trying for 4 cycles. I had an imperforate hymen (removed as a teenager) and I generally have short cycles, 23-24 days, with ovulation around day 11-12. My prenatal labs are supposedly all normal with FSH 7.7, prolactin 11.6, progesterone 0.7 , estradiol 40, taken on day 2 of the same cycle. Husband’s sperm is normal. The 2nd and 3rd cycles we tried, I started having mid-cycle bleeding around day 19 or so, which was completely new in the five years I have been tracking cycles (haven’t been on hormonal birth control since 2012). I saw an RE and was diagnosed with adeno, endo, and a polyp. I do not have significant pain from any of these. I had a hysteroscopy, HSG, and polypectomy all in the same week a few weeks ago, with polypectomy on cycle day 10. My RE also cut into an adhesion in the uterus to “loosen” it. I spotted for about 3 days after the HSG, which was done the day after the polypectomy. The HSG showed right tube open and left tube possibly open, but I have to go back for another HSG and an additional hysteroscopy to see how the adhesions are healing, as well. The ultrasound showed that I would ovulate on the left side. I’m not sure if I ovulated this month or not (it was too stressful to track and do temping/OPKs), but I did have fertile mucus and had intercourse on day 13. Spotting started again, this time on day 18 (a week-ish after the HSG), with some cramping and tenderness. I’m really disturbed by the spotting, as I thought removing the polyp would stop the spotting I’ve been experiencing. The spotting alternates from pink/red/bright red and increasing at this point in my cycle, as if my period is about to come. Obviously this has been a very stressful cycle emotionally, mentally, and physically. Might my uterus/cycle just need some time to normalize or heal, or is the continued spotting caused by something else (an infection, the adeno, the endo?) I understand that LP spotting can indicate poor egg quality, although I have been told I have a good egg quantity, at least. I am doing acupuncture and taking a range of herbs and supplements for uterine, reproductive, and egg health. Does a medicated cycle with Femara or Clomid seem like a good option for me? Should I try a Mirena for a set amount of time to help with the adeno? My RE is unavailable and the PA was not helpful. I know you can’t provide a full answer without clear records and everything else, but appreciate any opinion.
Hi Carrie,
The time has come for you to consider IVF seriously. However, before doing so you need to undergo a very thorough preparatory evaluation into the factors that affect IVF success.
For about 10% of all infertile couples, the cause of the infertility cannot be readily determined using conventional diagnostic methods. Such cases are often referred to as “unexplained infertility.” The truth however is that in most such cases, the diagnosis of “unexplained infertility is in fact “presumptive because a more in-depth evaluation would have revealed a cause. This having been said, people diagnosed with so called “unexplained infertility” fall into two broad groups: a)those couples who don’t have any biological problems interfering with pregnancy and, b) those who do but the reason cannot be found due to insufficient medical information or technology. It is in this latter group that improved testing techniques have made infertility easier to diagnose and treat.
In order to make even a presumptive diagnosis of “unexplained infertility” the answers to the following questions must be in the affirmative.
?Is the woman ovulating normally?
?Is the couple having intercourse regularly in the periovulatory phase of the cycle?
?Are the fallopian tubes normal and open?
?Can endometriosis be excluded?
?Does the male partner have normal semen parameters (most specifically with regard to sperm count and motility?
?Is the post coital (Huhner) test (periovulatory examination of cervical mucous, done 6-18 hours after intercourse) normal?
The definitive diagnosis of “unexplained infertility” has a lot to do with the thoroughness of the health care provider in excluding all possible causes. The fewer tests performed, the more likely a presumptive diagnosis
For Example:
?Abnormalities of the fallopian tubes (adhesions or developmental defects) of the finger-like “petals” at their outer ends of the tubes that help sweep eggs inside (i.e. fimbriae). can prevent eggs from being collected and transported to the awaiting sperm
?Chromosomal abnormalities of eggs or embryos: Eggs must be euploid (contain the right number of chromosomes) to be successfully fertilized and embryos must also be euploid in order to implant successfully in the uterine lining. Until recently there was no reliable method for determining whether eggs and embryos were euploid. The recent introduction of genetic tests such as comparative genomic hybridization (CGH) now allows for identification of all chromosomes in the egg and embryo. As such CGH represents an important addition to the “infertility” diagnostic armamentarium.
?Luteinized Unruptured Follicle (LUF)Syndrome: Here, the eggs can become trapped in the follicle and not be released (trapped ovulation) In such cases routine tests done to detect ovulation ((temperature charting, Urine LH testing, Blood progesterone levels) may be normal resulting in false interpretation that ovulation is actually occurring.
?Ovulation (hormonal) Dysfunction: Abnormalities in ovarian hormone production in the preovulatory phase of the cycle (follicular phase defect) and/or in the postovulatory phase (luteal phase defect) can negatively affect preparation of the uterine lining (endometrium), thus thwarting normal implantation.
?Immunologic implantation dysfunction (IID): Sometimes, the woman’s or the man’s own immune system can attack sperm cells, killing them or causing them to become immobilized. Also, immunologic dysfunction involving the uterine lining can cause the implanting embryo to be rejected so early that the woman does not even recognize that she in fact had conceived.
?Cervical infection ; Ureaplasma urealyticum infection of the cervical glands can prevent sperm from migrating through the cervix and uterus to reach the egg(s) in the fallopian tube(s). Such infection will usually not be detectable through routine examination and/or cervical culturing methods.
?Mild or Moderate Endometriosis: Endometriosis is in 100% of cases associated with the production of “pelvic toxins” that reduce the fertilization potential of otherwise normal eggs by a factor of 3-5. In addition, about 1/3 of woman with endometriosis (regardless of its severity) have immunologic implantation dysfunction (IID). Furthermore mild and often even moderately severe endometriosis can only be accurately diagnosed by direct visualization of the lesions through laparoscopy or laparotomy and, the detection of IID requires highly sophisticated tests that can only be adequately performed by a handful of Reproductive Immunology Reference Laboratories in the United States. Finally, a condition called nonpigmented endometriosis, in which the endometrium may be growing inside the pelvic cavity with many of the same deleterious effects as overt endometriosis, cannot be detected even by direct vision (at laparoscopy/laparotomy). The fertility of these patients may be every bit as compromised as if they had detectable endometriosis.
?Psychological Factors: The entire reproductive process is governed by the brain. Thus it should come as no surprise that stress and negativity can interfere with hormonal balance and decrease the ability to conceive. .
Management:
Successful management of “Unexplained Infertility” requires that a very individualized approach be taken. Wherever possible the underlying cause should first be identified. Problems that involve ovulation dysfunction (hormonal imbalance) require ovulation induction with oral or injectible fertility drugs. Cervical mucous hostility due to infection with ureaplasma (which is transferred back and forth sexually to both partners) requires specific and concurrent antibiotic therapy. In other cases involving younger women (under 39 years) where there is a problem with sperm migration via the cervix and uterus to the fallopian tube(s) intrauterine insemination (IUI) with or without ovulation induction, is indicated. When these treatments fail, in cases, women over the age of 39 years, in women with IID, in men or women who harbor antisperm antibodies in significant concentrations and in cases associated with tubal abnormalities, in vitro fertilization (IVF) is needed. All cases of intractable, moderate or severe male infertility call for injecting sperm directly into the egg to achieve forced fertilization (intracytoplasmic sperm injection-ICSI).
It is an indisputable fact that most causes of infertility can be diagnosed and it is a great pity that the diagnosis of “unexplained infertility” is often used as an excuse for not having performed a full and detailed evaluation of the problem. Couples should not simply accept a diagnosis of “unexplained infertility” at face value since treatment is most likely to be successful when the specific cause of the problem can be fully identified
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.
•Hereditary Clotting Defects (Thrombophilia)
•Blastocyst Embryo Transfers done 5-6 Days Following Fertilization are Fast Replacing Earlier day 2-3 Transfers of Cleaved Embryos.
•Embryo Transfer: The “Holy Grail in IVF.
•Frozen Embryo Transfer (FET): A Rational Approach to Hormonal Preparation and How new Methodology is Impacting IVF.
•Staggered IVF
•IVF Failure and Implantation Dysfunction:
•The Role of Immunologic Implantation Dysfunction (IID) & Infertility (IID):PART 1-Background
•Immunologic Implantation Dysfunction (IID) & Infertility (IID):PART 2- Making a Diagnosis
•Immunologic Dysfunction (IID) & Infertility (IID):PART 3-Treatment
•Thyroid autoantibodies and Immunologic Implantation Dysfunction (IID)
•Immunologic Implantation Dysfunction: Importance of Meticulous Evaluation and Strategic Management:(Case Report
•Intralipid and IVIG therapy: Understanding the Basis for its use in the Treatment of Immunologic Implantation Dysfunction (IID)
•Intralipid (IL) Administration in IVF: It’s Composition; How it Works; Administration; Side-effects; Reactions and Precautions
•Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
•Endometrial Thickness, Uterine Pathology and Immunologic Factors
•Vaginally Administered Viagra is Often a Highly Effective Treatment to Help Thicken a Thin Uterine Lining
•A Thin Uterine Lining: Vaginal Viagra is Often the Answer (update)
•Cervical Ureaplasma Urealyticum Infection: How can it Affect IUI/IVF Outcome?
•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
•How Many Embryos should be transferred: A Critical Decision in IVF.
•Avoiding High Order Multiple Pregnancies (Triplets or Greater) with IVF
•The Role of Nutritional Supplements in Preparing for IVF
•Male Factor Infertility
•Routine Fertilization by Intracytoplasmic Sperm Injection (ICSI): An Argument in Favor
•Endometriosis and Infertily
•Deciding Between Intrauterine Insemination (IUI) and In Vitro Fertilization (IVF).
If you are interested in my advice or medical 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.
Also, my 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