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by Dr. Geoffrey Sher on December 1, 2015

You are not alone. Dr. Sher is here to answer your questions and support you.

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Dear Patients,

I created this forum to welcome any questions you have on the topic of infertility, IVF, conception, testing, evaluation, or any related topics. I do my best to answer all questions in less than 24 hours. I know your question is important and, in many cases, I will answer within just a few hours. Thank you for taking the time to trust me with your concern.

– Geoffrey Sher, MD

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  • Olivia - October 20, 2018 reply

    Hi doctor,
    Is a fetal HR of 104 measuring CRL of 2.5 mm at 5 wk 6 days and sac measuring at 16.8 mm sound viable and promising to you?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 20, 2018 reply

    It does not sound encouraging I am afraid. I hope I am wrong. Time will determine.

    Geoff Sher

  • O. Sahin - October 20, 2018 reply

    hi dr sher finally i got FET and 8dpt i couldnt wait and had beta hcg test
    it was 96, 1….
    two days later, dpt10, it was 177,6…
    1 day later dp11 it is 248.75
    6day blast 6a embrio and it is not doubling exactly. should i be worried or can i be complettly relax. another help please
    i had intralipid cd 3 by your advice and 3 day before transfer, by my doctor advice, and again after +pregnancy test . now i know you say it is enough intralipid but my doctor says i should have intralipid every week until 12week pregnancy. is it harmfull for the fetus or is it ok. it has really high calorie but if it helps implantation and doesnt harm my baby i can have intralipid for weeks what do you think? when i have intralipid, that day i have my clexane shot also. is it okey?
    does intralipid have potention of blood plug or something??
    by the way i allways asked what to eat before transfer. now i ask for your recommendation about this early stage of pregnancy.. i am 42 years old 1 ivf 1 fet failed 1 misscarriage of 81/2week spontane pregnancy. i have blood issue i have clexane every day and folic acid and 3*1 estrofem, 3*1 progestanand 2*2 prednisolone and 200ng selenium (for hashimato) 100ng euthyrox thats all. should i have vitamin a e c zinc or should i lower my selenium dosage.. do you recommend carrot juice for amnion likid etc.. i forget all i know what to do or eat

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 20, 2018 reply

    So far, I am optimistic for you. However, given your age and the effect on egg/embryo chromosomal integrity, it is not possible to be confident as yet.

    Additional IL is probably harmless, but it is probably unnecessary.

    Geoff Sher

  • Miranda - October 19, 2018 reply

    Sorry Dr. let me add to that. My transfer was October 1st and it was a 3 day blastocyst. I had light spotting on Thursday October 11. First beta October 12 second October 16 and third October 18.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 20, 2018 reply

    Understood!

    Geoff Sher

  • Miranda - October 19, 2018 reply

    Hello Doctor, wanted to ask what you think of my beta results. First beta 14.7 second 29.7 and third 75.6.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 20, 2018 reply

    On the low side but…Promising…good luck!

    Geoff Sher

  • Allycat - October 19, 2018 reply

    Can terrible gas (IBS episode) adversely affect implantation? My transfer was today

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 20, 2018 reply

    Not at all!

    Geoff Sher

  • Heather Collier - October 19, 2018 reply

    Hey I’m 23 years old, and me and my fiance have been trying to convince for about a year and a half now. And I’m looking for something to help boost my chances of getting pregnant. Are these supplements safe for me to use? And would they have the effects I’m looking for? And what are any side effects I might be looking at?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 19, 2018 reply

    There is no clear evidence that any supplement besides folic acid really helps. However here is my recommendation for patients contemplating IVF and they would not differ for regular fertility.

    It is important to nurture and take care of yourself mentally and physically when preparing and going through your IVF journey. This starts with trying to have a positive attitude about what you are about to go through, creating a stress support system for yourself by using tools such as visualization, acupuncture and meditation, eating the right foods taking a few supplements (see below) and balancing exercise with sufficient rest. . Not only will it help your experience but it may also help to increase your chances for IVF success
    This article will focus on the role of nutritional supplements in preparing for IVF. You’ve probably wondered whether commercially available fertility supplements could help you achieve your goal. The answer is complex.
    Here is my take: Nutrition is indeed a vital prerequisite for optimal reproductive function. However, a well-balanced diet that meets food preferences, coupled with modest vitamin, mineral and antioxidant supplementation (as can be found in many prenatal vitamin preparations) should suffice.
    This having been said, conceiving is a delicate process, and eating the right foods is essential to optimize reproductive potential. Indeed, a balanced diet (i.e. a lot of organic and brightly colored foods) will provide most of the nutrients you need. But the truth is that most people do not have a balanced diet and are unwittingly often deficient in important nutrients.
    A balanced diet is one that is rich in good quality protein, low in sugar, salt, caffeine and industrially created trans-fats (trans-fatty acids or partially hydrogenated oils) and soy, uncontaminated by heavy metals, free of nicotine, alcohol and recreational drugs. This is why routine supplementation with the following nutrients could enhance preconception readiness:
    • Folic acid (400 micrograms daily)
    • Vitamins D-3 1,000U daily; Viamin A (2565 IU daily); B6 (6mg -10 mg daily); B12 (12-20 mcg per day); C- (2,000 mg a day for both men and women); E (both sexes should get 150-200U daily)
    • Co-enzyme Q10 (400-600mg daily )
    • Amino acids such as L-Carnitine (3 grams daily) and L-arginine (1 gram per day )
    • Omega 3 fatty acids (2,000mg per day)
    • Minerals, mainly zinc (15mg per day); selenium (70-100mcg per day); iron (up to 20mg per day ); magnesium (400mg per day )
    There are likely to be significant reproductive health benefits (including enhanced fertility and intrauterine development) associated with the use of nutritional supplements. However there are also certain potential pitfalls associated with their use. Some supplements are not as safe as they would seem. For example, excessive intake of fat-soluble vitamins (A, D, E and K) can even be dangerous to your health and may be associated with fetal malformations.
    Additionally, numerous supplements have been found to contain contaminants such as toxic plant materials, heavy metals and even prescription medications that can compromise fetal development. Prior to the passage of the Dietary Supplement Health and Education Act of 1994, supplements (vitamins, minerals, amino acids, and botanicals) were required to demonstrate safety. However, since passage of “the Act”, they are now presumed to be safe until shown otherwise, thus establishing a rather hazardous situation where a typical prenatal vitamin that will provide sufficient vitamins and minerals for a healthy early pregnancy and potentially dangerous supplements can and are being sold in the same store without product liability.
    What about the use of dehydroepiandrosterone (DHEA)? DHEA is a male hormone supplement that is metabolized to androstenedione and testosterone in the ovaries. While a small amount of ovarian testosterone is needed for optimal follicle and egg development, too much testosterone could be decidedly harmful. DHEA supplements probably won’t do harm if taken by healthy young women who have normal ovarian reserve, but they probably would not derive any benefit either. However, in my opinion, DHEA supplementation could be potentially harmful when taken by women with diminished ovarian reserve (DOR), women who have polycystic ovarian syndrome (PCOS) and older women in their 40’s as such women often already tend to have increased LH-activity, leading to increased ovarian testosterone. Additional ovarian testosterone in such women, could thus potentially compromise follicle development and egg quality/competency.
    In summary: Maximizing reproductive performance and optimizing outcome following fertility treatment requires a combined strategy involving a balanced diet (rich in protein, low in sugars, soy and trans-fats), modest nutritional supplementation, limiting/avoiding foods and contaminants that can compromise reproductive potential, and adopting disciplined lifestyle modification such as not smoking, reducing stress, minimizing alcohol intake, avoiding nicotine and recreational drug consumption, and getting down to a healthy weight through diet and exercise.

    Geoff Sher

  • Hope - October 18, 2018 reply

    The IVF clinics in my area are smaller clinics and need to batch patients using birth control pills. However, I have DOR and was very over-suppressed when on birth control. Is there an alternative to birth control in order to batch patients? I want to try estrogen priming but we need a way to schedule my period precisely, so I’m at a loss. Thanks!

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 19, 2018 reply

    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 PAPs 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 and the follicles will not readily respond to gonadotropins (FSH) , thereby delaying follicle development by up to 7 days and compromising egg quality. 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.

    Geoff Sher

    Hope - October 19, 2018 reply

    Thank you Dr. Sher! Is this similar to the Long Lupron Protocol? Will adding an Agonist to the BCPs also be recommended for someone with DOR?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 19, 2018 reply

    Yes to both questions.

    Geoff Sher

  • Sherry - October 18, 2018 reply

    Hi Dr. Sher,

    On the first day of my FET my doctor told me I should be getting lots of rest for the first 24 hours and not carry heavy things for two weeks to support implantation. The problem is that I have a 20-pound baby to carry around all day. I also slept under warm covers and suddenly realized I was overheating. This happened in the first 24 hours. I read that overheating isn’t good for the embryos. Do you think that these things could have prevented implantation? I just did my tranfer yesterday and I’m very worried. Please let me know.

    Thank you,

    Sherry

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 19, 2018 reply

    No! I do nit believe it would have an adverse effect!

    Geoff Sher

  • Q. - October 18, 2018 reply

    I was told that taking estrogen pills “pauses” your cycle. For example, if I start taking estrogen pills on cycle day 3 (i.e. 3 days after period started), my body will stay at cycle day 3 for any number of days I continue taking the pills. Once I stop the pills, my body gets back to normal. So, according to the calendar I’m now at cycle day 10, but because of the estrogen pills my body thinks it’s still at cycle day 3. I’m using this as preparation for IVF but I’m having a difficult time understanding this concept. Can you help me out? Thanks!

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 19, 2018 reply

    It is true…It can postpone the cycle.

    Geoff Sher

  • Sophia - October 18, 2018 reply

    Hi dr SHER
    Is it possible to still get a period without ovulating? I’m just coming off several months of back to back egg reteievals and giving my body a rest this month before I start BCP again for another egg retrieval. However, my OPK strips have failed to detect an LH surge, and my BBT has failed to rise. I’m currently CD21, whereas I used to always ovulate CD14 prior to all these IVF cycles. This is the first time since January that I haven’t been on either BCP preparing for a cycle or on stim meds. Do you think my cycles are all messed up now? I’m worried I might be going into menopause since I have DOR (was 0.6 in February 2018). I really need my period to start so I can resume BCP for my next IVF- can I start BCP without getting a period?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 18, 2018 reply

    Yes, you can menstruate without functional ovulation. This is not uncommon after several IVF’s. I would not be overly concerned.

    Geoff Sher

  • Padme Amidala - October 18, 2018 reply

    Dear Dr Sher
    I’m a 33 year old female physician with no medical co-morbidities a 42 year old husband with hypercholestrolemia, obstructive sleep apnea with a BMI of 31. We have a diagnosis of unexplained infertility after 2 years of trying to conceive. We just had a first failed IVF cycle. He did take Finasteride 1.25mg for 15 years in his 20’s and 30’s for male pattern hair loss- but has stopped now for > 3 years.
    I have a normal HSG, normal pelvic usg, AFC: 5 and 9. My ovarian reserve is normal. My cycles are 36 day cycles- although long, they are fairly regular, with biochemical evidence of ovulation around d20. My husband’s basic sperm analysis is normal aside from being slightly reduced.
    For this IVF protocol: Baseline Day 2 bloods were: estrogen 134, progesterone 1, LH 2, and FSH 8. The protocol used was Gonal-F 200 IU starting on D3 with the addition of Orgulatran from D6 250mcg at 5PM daily. Bloods on D 8 were estrogen 2630, progesteron 1, LH: low. Bloods on D9 were estrogen 2909, progesterone 1, LH 20mm: 1 follicle. I was asked to trigger with Ovidrel 250mcg at 1130PM on D9. Drug free on D10, Egg collection on D11 at 1130AM.
    Egg collection revealed 10 eggs. 2 successful normal fertilizations, 3 immature eggs, 4 abnormal fertilization, and 1 egg with no signs of maturation. None of which reached a successful d5 blastocyst, as they arrested at D3.
    I have read through your blogs and notice that the protocol used is quite different from the ones you prescribe. ( for example: you recommend Ovidrel 500mcg for triggering)
    I would like to have your thoughts on :
    -if the prolonged use of Finasteride can affect sperm DNA. Is there any way to test this?
    – our absence of successful blastocyst
    – our causes of ‘ abnormal fertilisation’
    – usage of anti-oxidants: Po melatonin 3mg, co-enzyme q 10, fish oil and vitamin e
    Thank you very much for your kind assistance.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 18, 2018 reply

    Thank you doctor! I do not believe the prior use of Finasteride is a factor. Your age and normal ovarian response/reserve are both in your favor. i do NOT agree with the dosage of Ovidrel at 250mcg. That is like receiving 5,000-6000U hCHu and that is about half of what is required. You need 10,000U hCG or 500mcg Ovidrel for the trigger in my opinion. And while a late antagonist suppression protocol is OKL, i think it can be improved upon.

    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 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.
    • 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 my advice or medical services, I urge you to contact my patient concierge, ASAP to set up a Skype or an in-person consultation with me. You can also set this up by emailing concierge@sherivf.com or by calling 702-533-2691 and/or 800-780-743. You can also enroll for a consultation with me, 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 .

    Geoffrey Sher MD

  • Nelly - October 18, 2018 reply

    I am preparing for my last embryo transfer. I had a D&E in August (16 week loss) and a MRI to confirm Adenomyosis in the beginning of September. At my baseline ultrasound last Wednesday the tech noted a possible 9x5mm fibroid with blood flow near the endometrium. Yesterdays ultrasound she noted it is now 16mm but not near the endometrium. With my MRI in September they didn’t note any fibroids. Is it possible for a fibroid to grow that quick? Should I cancel my last transfer because of it? The nurse at my clinic said it isn’t likely to be a fibroid since I just had a MRI. I wanted a second opinion before I transfer my last embryo. Thank you so much for your help.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 18, 2018 reply

    It would be most surprising for a fibroid to emerge that rapidly.

    Adenomyosis is a condition where endometrial glands develop outside the uterine lining (endometrium), within the muscular wall of the uterus (myometrium). Definitive diagnosis of adenomyosis is difficult to make. The condition should be suspected when a premenopausal woman (usually>25 years of age) presents with pelvic pain, heavy painful periods, pain with deep penetration during intercourse, “unexplained infertility” or repeated miscarriages and thereupon, when on digital pelvic examination she is found to have an often smoothly enlarged (bulky) soft tender uterus. Previously, a definitive diagnosis was only possible after a woman had her uterus removed (hysterectomy) and it this was inspected under a microscope. However the use of uterine magnetic resonance imaging (MRI) now permits reliable diagnosis. Ultrasound examination of the uterus on the other hand , while not permitting definitive diagnosis, is a very helpful tool in raising a suspicion of the existence of adenomyosis.

    Criteria used to make a diagnosis of adenomyosis on transvaginal ultrasound:

    • Smooth generalized enlargement of the uterus.
    • Asymmetrical thickening of one side of the (myometrium) as compared to another side.
    • Thickening (>12mm) of the junctional zone between the endometrium and myometrium with increased blood flow.
    • Absence of a clear line of demarcation between the endometrium and the myometrium
    • Cysts in the myometrium
    • One or more non discrete (not encapsulated) tumors (adenomyomas) in the myometrium.

    Since there is no proven independent relationship between adenomyosis and egg/embryo quality any associated reproductive dysfunction (infertility/miscarriages) might be attributable to an implantation dysfunction. It is tempting to postulate that this is brought about by adenomyosis-related anatomical pathology at the endometrial-myometrial junction. However, many women with adenomyosis, do go on to have children without difficulty. Given that 30%-70% of women who have adenomyosis also have endometriosis…. a known cause of infertility, it is my opinion that infertility caused by adenomyosis is likely linked to endometriosis where infertility is at least in part due to a toxic pelvic environment that compromises egg fertilization potential and/or due to an immunologic implantation dysfunction (IID) linked to activation of uterine natural killer cells (NKa). Thus, in my opinion all women who are suspected of having adenomyosis-related reproductive dysfunction (infertility/miscarriages) should be investigated for endometriosis and for IID. The latter, if confirmed would make them candidates for selective immunotherapy (using intralipid/steroid/heparin) in combination with IVF.

    Surgery: Conservative surgery to address adenomyosis-related infertility involves excision of portions of the uterus with focal or nodular adenomyosis and/or excision of uterine adenomyomas. It is very challenging and difficult to perform because adenomyosis does not have distinct borders that distinguish normal uterine tissue from the lesions. In addition, surgical treatment for adenomyosis-related reproductive dysfunction is of questionable value and of course is not an option for diffuse adenomyosis.

    Medical treatment: There are three approaches.
    • GnRH agonists (Buserelin/Lupron) which is thought to work by lowering estrogen levels.
    • Aromatase inhibitors such as Letrozole have also been tried with limited success
    • Inhibitors of angiogenesis: The junctional zone in women with adenomyosis may grow blood vessels more readily that other women (i.e. angiogenesis). A hormone known as VEGF can drive this process. It is against this background that it has been postulated that use of drugs that reduce the action of VEGF and thereby counter blood vessel proliferation in the uterus could have a therapeutic benefit. While worth trying in some cases, thus far such treatment has been rather disappointing
    • Immunotherapy to counter IID: The use of therapies such as Intralipid (or IVIG)/steroids/heparin in combination with IVF might well hold promise in those women with adenomyosis who have NKa.

    Fortunately, not all women with adenomyosis are infertile. For those who are, treatment presents a real problem. Even when IVF is used and the woman conceives, there is still a significant risk of miscarriage. Since the condition does not compromise egg/embryo quality, women with adenomyosis-related intractable reproductive dysfunction who fail to benefit from all options referred to above…(including IVF) might as a last resort consider Gestational surro resort consider Gestational surrogacy.

    Geoff Sher

  • Hope - October 18, 2018 reply

    I am worried. I did frozen embryo transfer of 5 days embryos at 27/9 then first beta at 5/10 was 157

    second beta at 7/10 was 473 so doubling time around 32 hr but third beta at 10/10 was 976 so doubling time increase to 69 hr I am afraid help me. Update and today 18/10 is 6190 is it good

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 18, 2018 reply

    I suggest an ultrasound ASAP! I am optimistic.

    Good luck!

    Geoff Sher

  • Carla - October 18, 2018 reply

    Hi Dr Sher,

    I will be 23 weeks pregnant with twins and will be traveling by plane for 7 hours. Is that ok you think?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 18, 2018 reply

    Yes! I think that would be fine.

    Geoff Sher

  • Justin - October 18, 2018 reply

    Hi Dr
    I have had 2 pregnancies so far. First resulted in a late term miscarriage in week 17 and the second was a early onset severe iugr where the baby was born in week 28 with 340 grams, passed away after 4,5 months in hospital. My placenta was sent away and analyzed and found to have CHIV and the drs have said that if we decide to go through another pregnancy then i need to take 10mg predisolone, heparin, intralipid, aspirin. Do you think this is ok? We are worried that we will be faced with the same issue again especially with a severe IUGR baby.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 18, 2018 reply

    I concur with that advice!

    Good luck!

    Geoff Sher

  • Sherry - October 18, 2018 reply

    Hi dr SHER
    I researched your success rates as published on CDC website and it seems to be significantly below the national averages. I had wanted to make an appointment but was concerned about these low pregnancy success rates. Is this because you deal with difficult cases?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 18, 2018 reply

    You are correct, my practice is heavily biased towards very difficult cases (e.g. older women, those who have severely diminished ovarian reserve (DOR), women who have repeatedly failed IVF elsewhere and older women using their own eggs)….cases that many other IVF centers prefer not treat. In fact, most of my patients travel from out of state and from abroad for services with me.
    Separately, in spite of having been a founding member of SART, originally (prior to a name change), perhaps more aptly was known as, “The IVF Special Interest Group”, I felt compelled to resign my membership >12 years ago.
    My resignation came after repeated vocal complaints regarding the manner in which SART was reporting clinic-specific IVF outcome statistics on the SART website were completely ignored. SART knowingly continued to publish non-audited, non-validated annual IVF outcome statistics and having taken a strong stand on principle, I was left with no other choice than to resign.
    It has been a while since I have thoroughly reassessed the SART/CDC reporting system, however, to the best of my knowledge little has changed over the last 20y, in this regard. SART still reports, unaudited (with very few onsite reviews), self-generated, non-validated annual IVF outcome statistics on its website. While most physicians/clinics provide their data as honestly as they can, this lack of oversight on the part of SART in my opinion, leaves the door open to abuse which in turn prompts similar behavior by others in an effort to remain competitive.
    Furthermore, SART reports categorize cases on the basis of the woman’s age and the type of ART procedure performed. This fails to adequately differentiate between “easy” and “more difficult” cases, thereby rendering any comparison of success rates a matter of comparing “apples with oranges”. To make matters worse, such results are published 2 years after the fact.
    It is also common knowledge that in an effort to report the highest possible success rates so as to be competitive arena, many IVF programs in an effort to boost their statistics, deliberately either decline treating very difficult cases, or endeavor get around the problem by not reporting such cases through categorizing these under the heading of “research”.
    Accordingly, in my opinion, both IVF practitioners, and consumers have little reason to feel confident about the validity and reliability of SART published ART outcome statistics.
    Geoff Sher

    Geoff Sher

  • Whitney Sweet - October 18, 2018 reply

    Hi Doc,
    My husband and I are just starting our second IVF cycle. Our first one resulted in 6 embryos, but 5 were low mosaic and 1 abnormal. The clinic I go to discourages the implantation of even low mosaic, so we’re on to our second cycle with no implantation done on the first. For this cycle, they would like to add Human Growth Hormone to my medications. Is that something you recommend or have seen commonly used before? My doctor has also requested that I start taking CQ10 supplements to aid in increasing the quality of embryos we receive. Are you familiar with that?
    Thanks in advance for your expert opinion!

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 18, 2018 reply

    Older women and those who have diminished ovarian reserve (DOR) have greater difficulty in conceiving naturally or through assisted reproductive technology (ART). This is largely due to an inevitable increase in egg aneuploidy (numerical chromosome irregularity). However, although less significant than the rising increase in egg aneuploidy, advancing age and DOR are both also associated with non-chromosomal egg deterioration involving a decline in mitochondrial activity as well as a progressive reduction in the ability of the granulosa cells that line the inside of the follicle to respond to FSH stimulation.
    Getting older women and those with DOR to respond optimally to ovarian stimulation often represents a serious challenge. Many will fail to respond adequately to standard ovarian stimulation regimens, requiring any individualized and strategic approach to ovarian stimulation…. one that regulates and limits exposure of ovarian follicles and eggs to LH-induced local male hormones (predominantly testosterone). This, in my opinion is best addressed by using a modified long pituitary down regulation protocol with an agonist (e.g. Lupron/Buserelin/Superfact) coming off a birth control pill. Thereupon, as soon as the period starts, the agonist is supplanted by an antagonist (e.g. Cetrotide/Orgalutron/Ganirelix) and stimulation with recombinant FSH (Follistim/Gonal-F/Puregon) along with a small amount of menotropin (e.g. Menopur) until t optimal follicle development prompts initiation of the hCG trigger. More than 15 years ago, I reported on the observation that in some women with severe DOR, the addition of intramuscular administration of estradiol valerate (i.e. Delestrogen) prior to and during gonadotropin stimulation (i.e. “estrogen priming”) is capable of further enhancing follicle growth .
    More recently, researchers have shown that the administration of human growth hormone (HGH), as an adjunct to ovarian stimulation, can enhance follicle response in older women and those with DOR. Two basic mechanisms have been proposed: a) enhanced response to FSH by up-regulating the FSH receptors on follicular granulosa cells and, b) through a direct effect of HGH on the egg itself whereby mitochondrial activity is enhanced. Human eggs do have receptors to HGH but eggs retrieved from older women show decreased expression of such receptors (as well as a reduced amount of functional mitochondria. It was recently observed that some such women treated with HGH, show a marked increase in egg functional mitochondria along with improved egg quality.

    Geoff sher

  • Kris - October 17, 2018 reply

    Hi Dr. Sher,
    What drugs are best to use in older women with very low reserve? I have always tried menopur and have been reading that this probably isn’t helpful because of excessive LH. Are there other drugs I could try?

    Thank you.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 17, 2018 reply

    The older a woman becomes, the more likely it is that her eggs will be chromosomally/genetically “incompetent” (not have the potential upon being fertilized and transferred, to result in a viable pregnancy). That is why, the likelihood of failure to conceive, miscarrying and of giving birth to a chromosomally defective child (e.g. with Down Syndrome) increases with the woman’s advancing age. In addition, as women age beyond 35Y there is commonly a progressive diminution in the number of eggs left in the ovaries, i.e. diminished ovarian reserve (DOR). So it is that older women as well as those who (regardless of age) have DOR have a reduced potential for IVF success. Much of this is due to the fact that such women tend to have increased production, and/or biological activity, of LH. This can result in excessive ovarian male hormone (predominantly testosterone) production. This in turn can have a deleterious effect on egg/embryo “competency”.
    While it is presently not possible by any means, to reverse the age-related effect on the woman’s “biological clock, certain ovarian stimulation regimes, by promoting excessive LH production (e.g. short agonist/Lupron- “flare” protocols, clomiphene and Letrozole), can make matters worse. Similarly, the amount/dosage of certain fertility drugs that contain LH/hCG (e.g. Menopur) can have a negative effect on the development of the eggs of older women and those who have DOR and should be limited.
    I try to avoid using such protocols/regimes (especially) in older women and those with DOR, favoring instead the use of the agonist/antagonist conversion protocol (A/ACP), a modified, long pituitary down-regulation regime, augmented by adding supplementary human growth hormone (HGH). I further recommend that such women be offered access to embryo banking of PGS (next generation gene sequencing/NGS)-selected normal blastocysts, the subsequent selective transfer of which by allowing them to to capitalize on whatever residual ovarian reserve and egg quality might still exist and thereby “make hay while the sun still shines” could significantly enhance the opportunity to achieve a viable pregnancy
    Please visit my new Blog on this very site, http://www.DrGeoffreySherIVF.com, find the “search bar” and 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 Approach
    • 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.
    • A Rational Basis for selecting Controlled Ovarian Stimulation (COS) protocols in women with Diminished Ovarian Reserve (DOR)
    • 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?
    • Blastocyst Embryo Transfers Should be the Standard of Care in IVF
    • Frozen Embryo Transfer (FET) versus “Fresh” ET: How to Make the Decision
    • Frozen Embryo Transfer (FET): A Rational Approach to Hormonal Preparation and How new Methodology is Impacting IVF.
    • 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
    • Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF
    • How Many Embryos should be transferred: A Critical Decision in IVF.
    • The Role of Nutritional Supplements in Preparing for IVF
    • Premature Luteinization (“the premature LH surge): Why it happens and how it can be prevented.
    • IVF Egg Donation: A Comprehensive Overview

    If you are interested in my advice or medical services, I urge you to contact my patient concierge, ASAP to set up a Skype or an in-person consultation with me. You can also set this up by emailing concierge@sherivf.com or by calling 702-533-2691 and/or 800-780-743. You can also enroll for a consultation with me, 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 .

    Geoffrey Sher MD

  • Ashley childress - October 17, 2018 reply

    Dr. Sher,

    My husband and I started IVF in February of this year. He is 50 and has severe male factor infertility. 0 sperm count to be exact. He was told he would never have children due to congenital testicular torsion with orichiectomy and a coloureteral fistula repair due to what he calls “wolfian duct” syndrome. He had 9 infantile surgeries and had an iliostomy until the age of 4. He has seen a renown male reproductive specialist(dr Larry lipshultz at Baylor in Houston) And performed a TESE. I’m 29 and and retrieved 24 eggs with 23 being mature. We had 4 PGS normal embryos out of 13 blasts sent and All of them were day 6 and 7. My first transfer miscarried at 5w3, followed that with an ERA and moved transfer back 24 hours. I still had a chemical on my 2nd transfer. I’ve had an HSG and hysteroscopy that we’re normal and have labs sent for thrombophillia testing. Next cycle doc says that he is going to do the EMMA test by igenomix and immunology testing.

    I’ve asked my doctor if he thinks the embryos that are 4AB are failing even though they are PGS tested. He doesn’t think it can be the embryos. I’m at a loss and terrified I’ll never have a family. I have interstitial cystitis in the mild form and wonder if I could have endometriosis, but the doc seems to think it wouldn’t affect anything. I have regular cycles and they aren’t particularly painful, but can be a little bit heavy. Other than that, I’m healthy as can be and at a healthy weight.

    Is there anything that we may be missing or do you think it could really be the embryos?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 17, 2018 reply

    Clearly, the TESE has successfully addressed the azoospermia and the fact that you have had several chromosomally normal blastocysts, suggests that this is now no longer an egg/sperm issue.ore than likely there is an implantation dysfunction that needs to be considered carefully.

    Whenever a patient fails to achieve a viable pregnancy following embryo transfer (ET), the first question asked is why! Was it simply due to, bad luck?, How likely is the failure to recur in future attempts and what can be done differently, to avoid it happening next time?.
    It is an indisputable fact that any IVF procedure is at least as likely to fail as it is to succeed. Thus when it comes to outcome, luck is an undeniable factor. Notwithstanding, it is incumbent upon the treating physician to carefully consider and address the causes of IVF failure before proceeding to another attempt:
    1. Age: The chance of a woman under 35Y of age having a baby per embryo transfer is about 35-40%. From there it declines progressively to under 5% by the time she reaches her mid-forties. This is largely due to declining chromosomal integrity of the eggs with advancing age…”a wear and tear effect” on eggs that are in the ovaries from birth.
    2. Embryo Quality/”competency (capable of propagating a viable pregnancy)”. As stated, the woman’s age plays a big role in determining egg/embryo quality/”competency”. This having been said, aside from age the protocol used for controlled ovarian stimulation (COS) is the next most important factor. It is especially important when it comes to older women, and women with diminished ovarian reserve (DOR) where it becomes essential to be aggressive, and to customize and individualize the ovarian stimulation protocol.
    We used to believe that the uterine environment is more beneficial to embryo development than is the incubator/petri dish and that accordingly, the earlier on in development that embryos are transferred to the uterus, the better. To achieve this goal, we used to select embryos for transfer based upon their day two or microscopic appearance (“grade”). But we have since learned that the further an embryo has advanced in its development, the more likely it is to be “competent” and that embryos failing to reach the expanded blastocyst stage within 5-6 days of being fertilized are almost invariably “incompetent” and are unworthy of being transferred. Moreover, the introduction into clinical practice about a decade ago, (by Levent Keskintepe PhD and myself) of Preimplantation Genetic Sampling (PGS), which assesses for the presence of all the embryos chromosomes (complete chromosomal karyotyping), provides another tool by which to select the most “competent” embryos for transfer. This methodology has selective benefit when it comes to older women, women with DOR, cases of unexplained repeated IVF failure and women who experience recurrent pregnancy loss (RPL).
    3. The number of the embryos transferred: Most patients believe that the more embryos transferred the greater the chance of success. To some extent this might be true, but if the problem lies with the use of a suboptimal COS protocol, transferring more embryos at a time won’t improve the chance of success. Nor will the transfer of a greater number of embryos solve an underlying embryo implantation dysfunction (anatomical molecular or immunologic).Moreover, the transfer of multiple embryos, should they implant, can and all too often does result in triplets or greater (high order multiples) which increases the incidence of maternal pregnancy-induced complications and of premature delivery with its serious risks to the newborn. It is for this reason that I rarely recommend the transfer of more than 2 embryos at a time and am moving in the direction of advising single embryo transfers …especially when it comes to transferring embryos derived through the fertilization of eggs from young women.
    4. Implantation Dysfunction (ID): Implantation dysfunction is a very common (often overlooked) cause of “unexplained” IVF failure. This is especially the case in young ovulating women who have normal ovarian reserve and have fertile partners. Failure to identify, typify, and address such issues is, in my opinion, an unfortunate and relatively common cause of repeated IVF failure in such women. Common sense dictates that if ultrasound guided embryo transfer is performed competently and yet repeated IVF attempts fail to propagate a viable pregnancy, implantation dysfunction must be seriously considered. Yet ID is probably the most overlooked factor. The most common causes of implantation dysfunction are:
    a. A“ thin uterine lining”
    b. A uterus with surface lesions in the cavity (polyps, fibroids, scar tissue)
    c. Immunologic implantation dysfunction (IID)
    d. Endocrine/molecular endometrial receptivity issues
    Certain causes of infertility are repetitive and thus cannot readily be reversed. Examples include advanced age of the woman; severe male infertility; immunologic infertility associated with alloimmune implantation dysfunction (especially if it is a “complete DQ alpha genetic match between partners plus uterine natural killer cell activation (NKa).
    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.
    • Ovarian Stimulation in Women Who have Diminished Ovarian Reserve (DOR): Introducing the Agonist/Antagonist Conversion protocol
    • Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
    • 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
    • IVF: How Many Attempts should be considered before Stopping?
    • “Unexplained” Infertility: Often a matter of the Diagnosis Being Overlooked!
    • 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
    • Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
    • A personalized, stepwise approach to IVF
    • How Many Embryos should be transferred: A Critical Decision in IVF?
    • The Role of Nutritional Supplements in Preparing for IVF

    If you are interested in my advice or medical services, I urge you to contact my patient concierge, ASAP to set up a Skype or an in-person consultation with me. You can also set this up by emailing concierge@sherivf.com or by calling 702-533-2691 and/or 800-780-743. You can also enroll for a consultation with me, 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 .

    Geoffrey Sher MD

  • Amanda - October 17, 2018 reply

    Hi Dr Sher, I have had 2 fail IUI’s. So I just completed a course of Decapeptyl 100 and Menopur 300 to do ICSI. 2 days ago I did the double trigger of Pregnyl 5000 and today was egg retrieval resulting in 7 empty follicles. I am mentally exhausted and don’t know if I should try again. Any feedback would greatly be appreciated.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 17, 2018 reply

    Hi Amanda,

    You need to wait for the outcome before you plan for the future.

    Good luck!

    Geoff Sher

  • Amanda Frohreich - October 17, 2018 reply

    I have had 2 fail IUI’s. So I just completed a course of Decapeptyl 100 and Menopur 300 to do ICSI. 2 days ago I did the double trigger of Pregnyl 5000 and today was egg retrieval resulting in 7 empty follicles. I am mentally exhausted and don’t know if I should try again. Any feedback would greatly be appreciated.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 17, 2018 reply

    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.

    Call 800-780-7437 for a Skype consultation with me if you wish.

    Geoff Sher

    Amanda - October 17, 2018 reply

    Hi Dr Sher,
    I am 43 so do you think I should give it another try and do I need to use different medications.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 17, 2018 reply

    The older a woman becomes, the more likely it is that her eggs will be chromosomally/genetically “incompetent” (not have the potential upon being fertilized and transferred, to result in a viable pregnancy). That is why, the likelihood of failure to conceive, miscarrying and of giving birth to a chromosomally defective child (e.g. with Down Syndrome) increases with the woman’s advancing age. In addition, as women age beyond 35Y there is commonly a progressive diminution in the number of eggs left in the ovaries, i.e. diminished ovarian reserve (DOR). So it is that older women as well as those who (regardless of age) have DOR have a reduced potential for IVF success. Much of this is due to the fact that such women tend to have increased production, and/or biological activity, of LH. This can result in excessive ovarian male hormone (predominantly testosterone) production. This in turn can have a deleterious effect on egg/embryo “competency”.
    While it is presently not possible by any means, to reverse the age-related effect on the woman’s “biological clock, certain ovarian stimulation regimes, by promoting excessive LH production (e.g. short agonist/Lupron- “flare” protocols, clomiphene and Letrozole), can make matters worse. Similarly, the amount/dosage of certain fertility drugs that contain LH/hCG (e.g. Menopur) can have a negative effect on the development of the eggs of older women and those who have DOR and should be limited.
    I try to avoid using such protocols/regimes (especially) in older women and those with DOR, favoring instead the use of the agonist/antagonist conversion protocol (A/ACP), a modified, long pituitary down-regulation regime, augmented by adding supplementary human growth hormone (HGH). I further recommend that such women be offered access to embryo banking of PGS (next generation gene sequencing/NGS)-selected normal blastocysts, the subsequent selective transfer of which by allowing them to to capitalize on whatever residual ovarian reserve and egg quality might still exist and thereby “make hay while the sun still shines” could significantly enhance the opportunity to achieve a viable pregnancy
    Please visit my new Blog on this very site, http://www.DrGeoffreySherIVF.com, find the “search bar” and 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 Approach
    • 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.
    • A Rational Basis for selecting Controlled Ovarian Stimulation (COS) protocols in women with Diminished Ovarian Reserve (DOR)
    • 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?
    • Blastocyst Embryo Transfers Should be the Standard of Care in IVF
    • Frozen Embryo Transfer (FET) versus “Fresh” ET: How to Make the Decision
    • Frozen Embryo Transfer (FET): A Rational Approach to Hormonal Preparation and How new Methodology is Impacting IVF.
    • 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
    • Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF
    • How Many Embryos should be transferred: A Critical Decision in IVF.
    • The Role of Nutritional Supplements in Preparing for IVF
    • Premature Luteinization (“the premature LH surge): Why it happens and how it can be prevented.
    • IVF Egg Donation: A Comprehensive Overview

    If you are interested in my advice or medical services, I urge you to contact my patient concierge, ASAP to set up a Skype or an in-person consultation with me. You can also set this up by emailing concierge@sherivf.com or by calling 702-533-2691 and/or 800-780-743. You can also enroll for a consultation with me, 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 .

    Geoffrey Sher MD

  • Sara - October 17, 2018 reply

    Hi Dr. Sher

    I would like to conceive and have waited 4 years for a baby and still trying. My RE told me to take 500mg metformin every night for my pcos. I just want to ask is metformin safe for me to take in long term run without having diabetes? Is it safe for my health and if I stop will there be any adverse side effects?

    Also do you think high cholesterol might be the cause of infertility? Appreciate your advice. Thanks

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 17, 2018 reply

    I believe that if taken for a valid indication Metformin will do no harm…nor should an elevated cholesterol affect fertility.

    Geoff Sher

    Sara - October 17, 2018 reply

    Thanks for your prompt reply!

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 17, 2018 reply

    You are welcome!

    Geoff Sher

  • Jyoti - October 17, 2018 reply

    Dear Dr. Sher,

    Thank you for your blog, it has lots of information for the newbies to IVF like me.

    My husband and I are 35 and just completed our first round of IVF with PGS. We found out today that one is a normal 4AA (morphokinetic=A+) day 6 hatching blastocyst and another 4BB (morphokinetic=B+) day 6 hatching blastocyst with mosaic loss (30ML) in chromosome 20. Would you recommend transferring the mosaic embryo with the normal one? If yes, would it affect the chances of the normal one? Would you recommend transferring the mosaic alone, would it stand a good chance of normal live birth?

    Sincerely appreciate your advice.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 17, 2018 reply

    Yes I would, and in my opinion, this would not prejudice the chance of the euploid one taking.

    Good luck!

    Geoff Sher

    Jyoti - October 18, 2018 reply

    Thank you Dr. Sher for your prompt reply. Would you be able to please shed some lights on the risks associated with this kind of mosaicism please? Sorry very new to this and would really want to make an informed decision. Would you recommend transferring both of them together or better to do it in two shots?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 18, 2018 reply

    We would need to talk!

    Geoff Sher
    PH: 800-780-7437

  • O. sahin - October 17, 2018 reply

    Hi Dr sher
    Which pair do you prefer to transfer
    4aa and 3bb 5dayblast embryo or 6a and 2bc 6dayblaat embryos

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 17, 2018 reply

    All 4 are worthy of transfer but I would give preference to the day-5 blasts!

    Geoff Sher

  • O. sahin - October 17, 2018 reply

    Hi Dr sher cd20 i had two frozen 6day blast embryo transfer.
    7days past transfer (that is excactly the time of my 28day ciclus) ı had White Brown spot like epitelium issue or blood plug Day 8 it is black issue one or two in a Day.. İ dont use jel vaginally but Just vaginall tablet of progestronand i put it gently and not through deep
    Could it be implantation bleeding this kate. Or is my period try to start and and these issues are the leak of blood

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 17, 2018 reply

    Not likely…but I would not be overly concerned!

    Geoff Sher

  • Cas - October 17, 2018 reply

    Hi doc. Our 28yr old surrogate just had a 5day FET. The embryo had been PGS tested normal. She’s 4weeks 3days & her 1st HCG came back at 52. Is this reason to worry? We’re a tad bummed. Thx for insights.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - October 17, 2018 reply

    Repeat in 2 days. It should be >100. If so, things are likely to turn out fine!

    Good luck!

    Geoff Sher

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