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.
Sorry Dr Sher, i don’t think I was clear in my earlier post. My LH is 0.2 after 2 days of 1/2 dose orgalutran. So today is CD2. I start stims on CD4. Three days of stims becomes CD6 which is when I will add 75u Luveris. However, I am really concerned about an LH level of 0.2 after 1/2 dose orgalutran. Are you saying that 0.2 is enough LH to enter my blood? Or is a level of 0.2 so profoundly suppressed? Is this a level you would normally see with your DOR patients on after 2 days of 1/2 dose antagonist. I guess my biggest concern is that by the time i start stims, my LH will be so negligible and trying to revive with luveris will be too late.
It will not present a problem in my opinion…as long as the Luveris is added by day 3 of stimulation.
Geoff Sher
Dear Dr. Sher,
I am 37 and my husband 40. We have done several ivf cycles due to male infertility. 10% motility and 56% sperm dna fragmentation also my husband has PKD so we are also doing PGD testing.
IVF #1 -8 eggs, 4 embryos, 2 normal without PKD. 1 implanted I got pregnant and had a MMC at week 8
Second FET resulted in chemical pregnancy.
IVF 2 I had over 16 follicles but only 4 eggs retrieved. I was stimulated for 15 days and some of my follicles were 30mm. We got 1 embryo that cycle which was PKD affected.
Both those cycles were antagonist without BCP. Then we changed RE and the new one suggested to do TESE due to high sperm dna fragmentation
IVF#3 – microdose lupron with BCP – 10 eggs, 7 mature, 6 fertilized, 1 blastocyst—normal but PGD was undetermined.
IVF#4- Estrogen priming with human growth hormone. 8 eggs, 7 mature, 4 fertilized and 4 made it to day 5. 2 were normal but one had PKD.
We are now left with 1 normal embryo without PKD.
My question is: do you think we have a chance of healthy pregnancy when my husband’s dna fragmentation is so high? Do you normally recommend TESE to your patients in this case?
Also what protocol would you recommend for me at 37, amh 2.1, highest fsh I think around 8.
Thank you so much for taking the time respond.
Maria
Yes! I believe you do still have a chance.
Here is the protocol I advise for women, <40Y who have adequate ovarian reserve.
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.
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
Hi Dr Sher, I am 41 and my husband is 45. Apart from our age, we are both very healthy. If a couple at our age presented to you and the husband had no sperm issues at all, would you recommend ICSI or IVF to fertilise the eggs of a DOR woman? We have read so many articles and can’t seem to make up our mind what to do. We came across articles about hypo-osmotic swelling in sperm which could affect fertilisation. Our country doesn’t test for HOS. We don’t think my husband has it, but do you think it’s best to just stick to ICSI as opposed to IVF given our age? I guess the one advantage of ICSI is that they can see the quality of my eggs before injecting them. But they can’t see anything when they don’t strip the egg and leave the sperm to do all the work with IVF. What is your preferred approach, and what do you routinely use at your clinic, is it ICSI or IVF? We respect your opinion and love to hear if you prefer one over the other and what you tend to do with your older couples re ICSI vs IVF? Thank you so much!
I recommend routine ICSI for all my patients.
Intracytoplasmic Sperm Injection ICSI which began in 1992 as a treatment for severe male factor infertility, involves the direct injection of a single sperm into each egg under direct microscopic vision.
Soon after the turn of the 20th century it was reported that while the diagnosis of a male factor infertility had remained static, the use of ICSI had markedly increased and that indications for ICSI had expanded from solely male infertility (for which it had primarily been developed) to a wide variety of other indications such as “unexplained infertility, unexplained IVF failure, polycystic Ovarian Syndrome (PCOS) and cases where the woman’s eggs had become more resistant to conventional fertilization. ICSI was also being used in cases where sperm was absent (or virtually absent) from the ejaculate due to congenital or traumatic or medically acquired obstruction of the main collecting ducts (vasa deferentia), testicular failure and in cases where for traumatic, neurologic, or psychologi reasons (impotency) no semen/sperm was being ejaculated. In such cases, sperm obtained through Testicular Sperm Extraction (TESE), or aspiration (TESA) was being successfully used for ICSI. Today in the United states more than 70% of all IVF fertilizations are being conducted using ICSI with high fertilization and pregnancy rates being reported, regardless of sperm concentration, motility or morphology.
Clearly ICSI is increasingly replacing conventional insemination due to its many benefits and lack of definable drawbacks. In fact, pregnancy rates achieved by this method of fertilization are at least as high as those of conventional IVF performed in cases of non-male-factor infertility. Indeed, ICSI is associated with high fertilization and pregnancy rates regardless of sperm concentration, motility or morphology.
Notwithstanding, the above, the proposition that ICSI be preferentially used as the routine method for fertilizing eggs in IVF continues to meet with resistance. Die hards argue that about 1-3% of pregnancies resulting from ICS are associated with congenital developmental and genetic defects that affect the offspring. They cite conditions such as *Beckwith-Wiedemann syndrome, *Angelman syndrome, *hypospadias, sex chromosome abnormalities, a slightly increased miscarriage rate and the fact that male offspring resulting fom ICSI pregnancies are themselves at risk of subsequently developing male infertility in later life.
What you do not often hear from nay-sayers is that those studies that site the above mentioned risks do not distinguish between cases where ICSI is/was mandated for male infertility )and cases where ICSI is/was done for other (non-male infertility) reasons. If this was done, what in my opinion would emerge is that the above mentioned birth defects and developmental conditions are largely confined to the underlying male factor for which ICSI was indicated and are not due to the ICSI process itself. In fact a relatively recent study performed in Sweden demostrated this well. Here 542 children who were conceived naturally were compared with 941 children conceived through IVF (440 by conventional IVF & 541via ICSI) The babies/children were assessed at birth and during the first 5 years of life: The findings revealed that while the incidence of birth and developmental defects was indeed higher in ICSI babies, this only applied to cases where ICSI had been done for male infertility. It did not apply to cases where ICSI was done in the absence of male factor infertility.
Another very important consideration that supports the routine fertilization of eggs by ICSI is the fact that good quality IVF relies heavily on an ability to adequately assess egg maturation immediately following egg retrieval. To do this requires removal of layers of cumulus oophoris (CO) cells that cover the egg envelopment (zona pellucida). Only after the CO is stripped can the 1st polar body (PB-1) which is located immediately under the zona pellucida be identified and it is the presence of PB-1 signifies that indicates that the egg has gone through meiosis (reproductive division) and is thus mature (M2) and overwhelmingly, successful fertilzation and viable embryo development requires that the fertilized egg was mature (M2). This assessment for the presence of PB-1 cannot be reliably done without first removing the cumulus oophoris cells attached to the outer surface of the zona pellucida. The problem is that stripping the cumulus oophoris cells away, markedly reduces natural fertilization potential, leaving ICSI as the only alternative by which to subsequently achieve viable embryo propagation. The only way by which to avoid fertilization by ICSI would be to bypass the important step of assessing egg maturation and this in my opinion would compromize IVF outcome significantly. Thus optimization of the entire IVF process virtually mandates routine ICSI in IVF.
For the above reasons, I proudly count myself among a growing majority of IVF practitioners who support the routine use of ICSI for all IVF patients
*Angelman syndrome is a complex genetic disorder characterized by delayed development, intellectual disability, speech impairment, and problems with movement and balance (ataxia). Most cases are not inherited, particularly those caused by a deletion in the maternal chromosome 15 or by paternal uniparental disomy. These genetic changes are random events that take place during the formation of reproductive cells (eggs and sperm) or in early embryonic development.
Geoff Sher
Hi Dr Sher, is it ok to start vaginal viagra suppositories 4 days before trigger? My lining is around 5.9mm and i have about 4 days to go before trigger. Your article says it takes around 72 hours to see an improvement in lining with viagra suppositories, but i see that you start you patients on them when stimulation starts.. is it too late to start now or is late better than not at all?
No it is not too late.
Geoff Sher
Hi Dr Sher, I have noticed that my blood LH levels on 1/2 dose orgalutran is really low. It’s amazing how even 1/2 dose can really bring down LH levels. My LH level was 0.2, on day 2, 2 hours after taking the 1/2 dose. I’m wondering, is that LH level, 0.2, enough of my own LH to enter my blood to promote and optimise follicular growth? I find that when I use gonal-f, that LH tends to plummet even further. I know you have previously said the LH level in ovarian blood is 6-8 times higher than the LH in peripheral blood, so I can only assume an LH level of 0.2 on day 2 of 1/2 dose orgalutran is nothing to worry about? Would adding luveris 75u on day 6 when between days 1-5 LH was less than 0.2 a bit late?
The addition of LH/hCG (in small doses) in the form of Menopur or Luveris from day 3 is adequate to provide enough of a stimulus.
Geoff Sher