Congratulations!!

I wish I could predict. Unfortunately you will need to wait for the US result!

Good luck!

Geoff Sher

I would need much more information to provide an authoritative opinion. Feel free to contact my assistant, Patti (concierge@sherivf.com to set up an online consultation with me. to discuss.

Geoffrey Sher MD

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ADDITIONAL INFORMATION:

Herewith are  online links to 2  E-books recently  co-authored with  my partner at SFS-NY  (Drew Tortoriello MD)……. for your reading pleasure:

1. From In Vitro Fertilization to Family: A Journey with Sher Fertility Solutions (SFS) ; https://sherfertilitysolutions.com/sher-fertility-solutions-ebook.pdf

1. Recurrent Pregnancy Loss and Unexplained IVF Failure: The Immunologic Link ;https://drive.google.com/file/d/1iYKz-EkAjMqwMa1ZcufIloRdxnAfDH8L/view

Thank you for reaching out. I will do my best to help:

1. Given your diminished ovarian reserve; IUI is definitely not for you. The success rate is far too low and you do not have the time to spare. You do need IVF but unless an individualized protocol for ovarian stimulation that wont likely work either. Please read the article I wrote below and then consider calling Patti (702-533-2691) or emailing her at concierge@sherivf.com to set up an online consultation with me.

Geoffrey Sher MD

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• ADDRESSING DIMINISHING OVARIAN RESERVE (DOR) IN IVF

Understanding the impact of ovarian reserve on the success of in vitro fertilization (IVF) is crucial when it comes to reproductive health. This article aims to simplify and clarify these concepts, emphasizing their significance in the selection of ovarian stimulation protocols for IVF. By providing you with this information, we hope to shed light on the importance of considering these factors and making informed decisions regarding fertility treatments.

1. The Role of Eggs in Chromosomal Integrity: In the process of creating a healthy embryo, it is primarily the egg that determines the chromosomal integrity, which is crucial for the embryo’s competency. A competent egg possesses a normal karyotype, increasing the chances of developing into a healthy baby. It’s important to note that not all eggs are competent, and the incidence of irregular chromosome numbers (aneuploidy) increases with age.
2. Meiosis and Fertilization: Following the initiation of the LH surge or the hCG trigger shot, the egg undergoes a process called meiosis, halving its chromosomes to 23. During this process, a structure called the polar body is expelled from the egg, while the remaining chromosomes are retained. The mature sperm, also undergoing meiosis, contributes 23 chromosomes. Fertilization occurs when these chromosomes combine, resulting in a euploid embryo with 46 chromosomes. Only euploid embryos are competent and capable of developing into healthy babies.
3. The Significance of Embryo Ploidy: Embryo ploidy, referring to the numerical chromosomal integrity, is a critical factor in determining embryo competency. Aneuploid embryos, which have an irregular number of chromosomes, are often incompetent and unable to propagate healthy pregnancies. Failed nidation, miscarriages, and chromosomal birth defects can be linked to embryo ploidy issues. Both egg and sperm aneuploidy can contribute, but egg aneuploidy is usually the primary cause.
4. Embryo Development and Competency: Embryos that develop too slowly or too quickly, have abnormal cell counts, contain debris or fragments, or fail to reach the blastocyst stage are often aneuploid and incompetent. Monitoring these developmental aspects can provide valuable insights into embryo competency.
5. Diminished Ovarian Reserve (DOR): As women advance in their reproductive age, the number of remaining eggs in the ovaries decreases. Diminished ovarian reserve (DOR) occurs when the egg count falls below a certain threshold, making it more challenging to respond to fertility drugs effectively. This condition is often indicated by specific hormone levels, such as elevated FSH and decreased AMH. DOR can affect women over 40, but it can also occur in younger

Why IVF should be regarded as treatment of choice for women who have diminished ovarian reserve ( DOR):

Understanding the following factors will go a long way in helping you to make an informed decision and thereby improve the chances of a successful IVF outcome.

1. Ovarian Reserve: While chronological age plays a vital role in determining the quality of eggs and embryos [there is an increased risk of egg aneuploidy (irregular chromosome number) in eggs,  leading to reduced embryo competency. Additionally, women with declining ovarian reserve (DOR), regardless of their age, are more likely to have aneuploid eggs/embryos. Therefore, it is crucial to address age-related factors and ovarian reserve to enhance IVF success.
2. Excessive Luteinizing Hormone (LH) and Testosterone Effects: In women with DOR, their ovaries and developing eggs are susceptible to the adverse effects of excessive LH, which stimulates the overproduction of male hormones like testosterone. While some testosterone promotes healthy follicle growth and egg development, an excess of testosterone has a negative impact. Therefore, in both older women or those who (regardless of their age) have DOR, ovarian stimulation protocols that down-regulate LH activity before starting gonadotropins are necessary to improve egg/embryo quality and IVF outcomes.
3. It is possible to regulate the  decline in egg/embryo competency by tailoring ovarian stimulation protocols. Here are my preferred protocols for women with relatively normal ovarian reserve:

1. Conventional Long Pituitary Down Regulation Protocol:

• Begin birth control pills (BCP) early in the cycle for at least 10 days.
• Three days before stopping BCP, overlap with an agonist like Lupron for three days.
• Continue daily Lupron until menstruation begins.
• Conduct ultrasound and blood estradiol measurements to assess ovarian status.
• Administer FSH-dominant gonadotropin along with Menopur for stimulation.
• Monitor follicle development through ultrasound and blood estradiol measurements.
• Trigger egg maturation using hCG injection, followed by egg retrieval.

1. Agonist/Antagonist Conversion Protocol (A/ACP):

• Similar to the conventional long down regulation protocol but replace the agonist with a GnRH antagonist from the onset of post-BCP menstruation until the trigger day.
• Consider adding supplementary human growth hormone (HGH) for women with DOR.
• Consider using “priming” with estrogen prior to gonadotropin administration

1. Protocols to Avoid in Women with DOR: Certain ovarian stimulation protocols may not be suitable for women with declining ovarian reserve:

• Microdose agonist “flare” protocols
• High dosages of LH-containing fertility drugs such as Menopur
• Testosterone-based supplementation
• DHEA supplementation
• Clomiphene citrate or Letrozole
• Low-dosage hCG triggering or agonist triggering for women with DOR

Preimplantation Genetic Screening/Testing for aneuploidy (PGS/PGTA): PGS/PGTA is a valuable tool for identifying chromosomal abnormalities in eggs and embryos. By selecting the most competent (euploid) embryos, PGS/PGTA significantly improves the success of IVF, in women with DOR.

Understanding the impact of declining ovarian reserve on IVF outcomes is essential when making decisions about fertility treatments. Diminished ovarian reserve (DOR) can affect egg quality and increase the likelihood of aneuploid embryos with resultant IVF failure. By considering this factor, you can make informed choices and work closely with fertility specialists to optimize your chances of success. Remember, knowledge is power, and being aware of these aspects empowers you to take control of your reproductive journey.

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• INTRAUTERINE INSEMINATION : THE PRO’S AND CON’S

Intrauterine insemination (IUI), the injection of sperm into the uterus by means of a catheter directed through the cervix, has been practiced for many years. The premise of this procedure is that sperm can reach and fertilize the egg more easily if placed directly into the uterine cavity. In the early ‘60s, physicians were injecting small quantities of raw, untreated semen (sperm plus seminal plasma) directly into the uterus at the time of expected ovulation. However, when more than 0.2 ml of semen was injected into the uterus, serious and sometimes life endangering shock-like reactions often occurred. It was subsequently identified that the reason for such reactions related to the presence of prostaglandins within the seminal plasma. This led to the practice of injecting small amounts (less than 0.2 ml) of raw semen. However, the pregnancy rates were dismal and side effects, such as severe cramping and infection were rampant.

As early as 1982, I began to recognize the potential advantage of washing and centrifuging raw semen to separate sperm from the seminal fluid, and thereby remove prostaglandins that cause most of the problems. I subsequently introduced and reported on IUJ in the journal, Fertility and Sterility (April 1984).

Reasons for IUI:

• Using frozen donor sperm: To prevent the transmission of HIV and other sexually transmitted diseases, donated semen is frozen and stored for at least six months. After retesting for HIV, the thawed semen is used for insemination. Since freezing sperm can reduce its effectiveness, the semen is processed for IUI. Fertility drugs may not be needed if the recipient is ovulating normally.
• Using the husband’s sperm: If a husband has difficulty with sexual function or timing, his sperm may be collected and processed for IUI.
• Insufficient cervical mucus: Sometimes, the cervical mucus can create a barrier that prevents sperm from passing through. This can be due to physical problems with the mucus, cervical infection, or anti-sperm antibodies. In most cases, IUI can be done during natural cycles, unless the woman has problems with ovulation. However, if infertility is caused by anti-sperm antibodies in the cervical mucus, IUI will not be effective, and in vitro fertilization (IVF) should be considered.
• Abnormal ovulation: In some cases, when a woman needs fertility drugs to induce ovulation, combining IUI with the medication can improve pregnancy rates.

SELECTING THE OPTIMAL CONTROLLED OVARIAN STIMULATION (COS) PROTOCOL FOR IUI

Oral Fertility Drugs:

Oral fertility drugs like clomiphene citrate (Serophene) and Letrozole (Femara)are gentle ovarian stimulants that are typically recommended for younger women with normal egg reserves but who face issues with ovulation, mild sperm problems, or unexplained infertility. In cases of unexplained infertility, the American Society for Reproductive Medicine (ASRM) suggests starting with 3-4 cycles of ovarian stimulation and intrauterine insemination (IUI) using clomiphene or letrozole. Using clomiphene or letrozole alone, timed intercourse alone, or IUI alone does not significantly improve the monthly chance of conceiving with unexplained infertility. It is the combination of these oral stimulants with IUI that can increase the pregnancy rate.

1. Clomiphene citrate (Serophene/Clomid) is the most commonly prescribed agent for inducing ovulation in women who do not ovulate regularly, those with dysfunctional ovulation, and women with unexplained infertility. When used in young women with these issues and sufficient ovarian reserve, the viable pregnancy rate is reported to be between 6% and 10% per cycle of treatment. Clomiphene is also used to prepare women for intrauterine insemination and in vitro fertilization (IVF). Clomiphene’s popularity stems from its low cost, ease of use, and low risk of severe complications such as ovarian hyperstimulation syndrome (OHSS). The treatment usually starts with a daily oral dose of 50 mg for 5 days, but it can be increased to as much as 200 mg per day, starting on cycle day 2, 3, 4, or 5. Typically, a spontaneous LH surge occurs about 8-9 days after the last 50 mg dosage. In some cases, a trigger of 10,000 IU of hCG can be given when there is at least one ovarian follicle measuring 18-20 mm in size. Clomiphene works by inducing ovulation through its “antiestrogen effect.” By blocking estrogen receptors in the hypothalamus (a part of the brain), it tricks the brain into perceiving low estrogen levels. In response, the hypothalamus stimulates the pituitary gland to release an increased amount of follicle-stimulating hormone (FSH), which then stimulates the growth and development of ovarian follicles. This ultimately leads to a surge in pituitary LH release, followed by ovulation from one or more of the larger follicles. As the follicles grow, they release more estrogen into the bloodstream, completing the feedback loop initiated by the hypothalamus in response to the anti-estrogen effects of clomiphene. Before prescribing clomiphene to a woman, several factors should be considered carefully: Clomiphene is less effective than gonadotropin therapy and its effectiveness decreases with age. It is best suited for younger women (under 35 years) with normal ovarian reserve, as they are more likely to respond by producing multiple follicles. At least two sizeable follicles should develop during clomiphene treatment to ensure proper cervical mucus production and the development of a receptive uterine lining.

• Clomiphene should not be used for more than three consecutive cycles in a row. Using it for more cycles can be ineffective and even work as a contraceptive. The anti-estrogenic effects of clomiphene can affect cervical mucus and thin the uterine lining over time. After three consecutive cycles, it is recommended to have a resting cycle before considering another clomiphene cycle.
• Clomiphene is not suitable for older women or those with diminished ovarian reserve (DOR). The release of LH caused by clomiphene can lead to excessive testosterone production in the ovaries, which can hinder egg development. Women with DOR are particularly vulnerable due to overgrowth of ovarian connective tissue, where testosterone is produced.
• About 20% of clomiphene cycles may result in “trapped” ovulation, where the egg remains stuck in the follicle despite hormone changes suggesting ovulation. This can affect the chances of a successful pregnancy.
• Women with long gaps between their periods (over 45 days) may not respond well to clomiphene and may benefit more from injectable gonadotropins

2. Letrozole (Femara) is a medication used for inducing ovulation as part of the IVF process. It works by blocking a certain enzyme called aromatase, which leads to a decrease in estrogen levels and an increase in follicle-stimulating hormone (FSH) secretion. This helps in the growth of ovarian follicles and the production of estrogen. Unlike clomiphene, another medication used for ovulation induction, letrozole does not have anti-estrogen effects on the body, so it does not dry up cervical mucus or make the uterine lining less responsive to estrogen. However, letrozole, like clomiphene, can increase the production of luteinizing hormone (LH) from the pituitary gland, which can result in higher levels of testosterone in the ovaries. While some testosterone is necessary for follicle and egg development, too much of it can hinder their growth and increase the risk of abnormal eggs. Therefore, it might not be advisable to use letrozole or clomiphene in IVF cycles, especially for older women or those with diminished ovarian reserve (DOR) who tend to have higher LH activity. Letrozole can still be used in women who have absent or dysfunctional ovulation not related to DOR, and it can be an alternative to clomiphene in some cases to avoid issues with the uterine lining. The usual starting dose of letrozole is 2.5 mg taken orally daily for 5 days, starting on day 2, 3, 4, or 5 of the menstrual cycle. The dosage can be increased to 5 or 7.5 mg if necessary. Some studies suggest that letrozole may be more effective than clomiphene for treating infertility in women with polycystic ovary syndrome (PCOS), resulting in higher rates of ovulation without significant differences in birth defects.

Common side effects of both clomiphene and letrozole: include hot flashes, sweating, nausea, tiredness, diarrhea, and joint pain.

Injectable Fertility Drugs: .

While the cost and  risk of side effects such as severe ovarian hyperstimulation syndrome (OHSS)  using injectable fertility drugs such as gonadotropins to prepare for IUI are definitely far greater than when oral agents re used for controlled ovarian stimulation (COS),  they are in my opinion nevertheless preferred for IUI. The success rate using such drugs is probably 20-30% higher than when clomiphene or letrozole are used. Therefore, in the hands of Physicians well-schooled in the use of gonadotropins therapy, this is by far a better approach than using oral agents.

The Risks of Multiple Births with COS in women undergoing IUI.  in IUI:

When women ovulate normally, they usually develop multiple follicles in their ovaries, which contain eggs and supporting cells. However, only one or two of these follicles will actually mature and release an egg, while the others do not reach this stage. This natural process is called “selection.” In women who ovulate normally, the selected follicles will be larger than the others. Once these selected follicles release eggs, the remaining follicles cannot ovulate. As a result, women who ovulate normally do not have a significantly higher chance of having multiple pregnancies with three or more babies. On the other hand, women who do not ovulate at all or have dysfunctional ovulation may develop multiple follicles at the same rate, resulting in the release of several eggs at once. This increases the chances of pregnancy but also raises the risk of multiple pregnancies. Interestingly, almost all cases of high order multiple pregnancies (more than twins) associated with fertility drug use have occurred in women who do not ovulate normally. Therefore, the risk of having high order multiple pregnancies only applies to women with absent or dysfunctional ovulation. These women should receive counseling about the potential complications of premature birth and the option of selective reduction of pregnancies during the third month. Another option to avoid this risk altogether is to choose in vitro fertilization (IVF), where the number of embryos transferred to the uterus can be controlled to limit the number of potential babies.

Intrauterine insemination (IUI) can be a valuable fertility treatment if used appropriately and selectively for the right reasons. The use of fertility drugs should not be seen as necessary for all IUI cases, and IUI itself should not be considered a mandatory step before opting for IVF.

Intrauterine insemination (IUI) can be a valuable fertility treatment if used appropriately and selectively for the right reasons. The use of fertility drugs should not be seen as necessary for all IUI cases, and IUI itself should not be considered a mandatory step before opting for IVF.

________________________________________________

ADDITIONAL INFORMATION:

Herewith are  online links to 2  E-books recently  co-authored with  my partner at SFS-NY  (Drew Tortoriello MD)……. for your reading pleasure:

1. From In Vitro Fertilization to Family: A Journey with Sher Fertility Solutions (SFS) ; https://sherfertilitysolutions.com/sher-fertility-solutions-ebook.pdf

1. Recurrent Pregnancy Loss and Unexplained IVF Failure: The Immunologic Link ;https://drive.google.com/file/d/1iYKz-EkAjMqwMa1ZcufIloRdxnAfDH8L/view

For more than 50 years, scientists have been working to perfect the art of freezing and storing a woman’s eggs, also known as “egg banking”. Although there have been challenges, the progress has been both amazing and is promising. 

Since the birth of the first “frozen egg baby” in the mid-1980s, we’ve celebrated than 6,000 -7000 births worldwide from thawed eggs. However, this is a relatively a small number when compared to the 5-6 million IVF babies and 1.5- to 2 million babies born from transferred frozen embryos during the same time.

Recently, there have been significant improvements in using frozen eggs to create embryos. Presently,  success rates are comparable to that  using frozen embryos especially when the latter have been screened for competency, using preimplantation genetic testing (PGT/ preimplantation genetic testing for aneuploidy ( PGT-A). Interestingly, currently, eggs are not screened using these techniques before they are frozen.

Let’s talk about who can benefit from this incredible advancement:

• Fertility Preservation (FP) for Women: FP is like a beacon of hope for women looking to preserve their fertility for the future. The potential demand for FP using frozen eggs is estimated to be 4-6 times higher than traditional IVF. This can be a lifeline for:
  • Women facing the possibility of losing their ovarian function due to approaching menopause, planned ovary removal, or medical treatments like radiation or chemotherapy.
  • Women planning to delay childbearing due to career aspirations, not being ready for a permanent relationship, or concerns about their biological clock.
  • Couples Opposed to Embryo Freezing: For couples who have ethical or religious concerns about freezing embryos, the option of freezing eggs brings hope and aligns with their beliefs.

As technology continues to evolve, we are moving towards a future where egg freezing is both safe, reliable, and accessible to all. It allows individuals to make informed decisions about their future and family planning. However, a word of advice: Women should consider freezing their eggs at a younger age (below 35 years) when their eggs are at their healthiest. Older women, especially those over 39, should approach this with caution as the “competency” of their eggs declines with age.

Imagine having the chance to fulfill the dream of having a family through a wonderful solution called egg banking. This amazing process involves storing healthy eggs that are later used to help women struggling with infertility to have a baby through IVF and embryo transfer.

In the United States, around 20,000 IVF procedures using donated eggs happen each year, making up about 15% of all IVF cycles. People are seeking affordable options for IVF, with many traveling abroad \for lower-cost treatments.

• Donor Egg Banks: Recently, frozen egg banks have emerged, offering access to eggs that haven’t been genetically tested. While using fresh donor eggs is a bit more successful than using frozen ones (around 40-50% versus 30-35% success rate per embryo transfer), the difference is very small . However, many frozen eggs may not survive the thawing process to become embryos, which affects the success rate. To improve success rates, most egg banks suggest buying at least six eggs at a time, each costing about $3,000.

In the United States, the cost of IVF using frozen donor eggs is high, prompting many to seek treatment in other countries ( “Medical tourism”). A significant part of this cost is associated with donor stipends and agency fees. This is why there’s a real need for a better way to access healthy donated eggs for IVF.

Conclusion:

The in vitro fertilization (IVF) market in the United States is rapidly growing and is approaching a value of $25 billion. The demand for egg banking, especially for Fertility Preservation (FP), is expected to be two to three times greater than conventional IVF. If even 10% of this potential FP market is tapped within the next five years, it could result in an annual industry worth over $3.5 billion. This shows the incredible potential of egg banking in making family dreams come true.

This amazing  journey of advancements is paving the way for new hopes and dreams. It’s about giving people choices and the power to decide when and how to shape their families. Egg banking is not just about preserving eggs; it’s about preserving dreams and the possibility of a beautiful tomorrow.

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ADDITIONAL INFORMATION:

Herewith are  online links to 2  E-books recently  co-authored with  my partner at SFS-NY  (Drew Tortoriello MD)……. for your reading pleasure:

1. From In Vitro Fertilization to Family: A Journey with Sher Fertility Solutions (SFS) ; https://sherfertilitysolutions.com/sher-fertility-solutions-ebook.pdf

1. Recurrent Pregnancy Loss and Unexplained IVF Failure: The Immunologic Link ;https://drive.google.com/file/d/1iYKz-EkAjMqwMa1ZcufIloRdxnAfDH8L/view

If you are interested in having an online consultation with me, please contact my assistant, Patti Converse at 702-533-2691 or email her at concierge@sherivf.com\

I would never presume tom tell your doctor what to do with regard to your stimulation.

I can tell you that regardless of protocol, the chance of propagating euploid (“competent”) eggs at 45y is very slim (!:2o eggs or so will end up being viable). Obviously if in addition you have diminished ovarian reserve (A low AMH) the number of extractable eggs will be reduced. This reduces that chance at a successful outcome further. I am not a believer in ovarian PRP.

If you insist upon using your own eggs in spite of the realization that you ideally need donated eggs, then the protocol used for ovarian stimulation becomes your prime challenge.

I am unable te recommend  a specific protocol without having access to much more information.

I suggest yo call my assistant, Patti at 702-533-2691 and set up an online consultation with me to discuss

Geoff Sher.

___________________________________________________

ADDITIONAL INFORMATION:

Herewith are  online links to 2  E-books recently  co-authored with  my partner at SFS-NY  (Drew Tortoriello MD)……. for your reading pleasure:

1. From In Vitro Fertilization to Family: A Journey with Sher Fertility Solutions (SFS) ; https://sherfertilitysolutions.com/sher-fertility-solutions-ebook.pdf

1. Recurrent Pregnancy Loss and Unexplained IVF Failure: The Immunologic Link ;https://drive.google.com/file/d/1iYKz-EkAjMqwMa1ZcufIloRdxnAfDH8L/view

If you are interested in having an online consultation with me, please contact my assistant, Patti Converse at 702-533-2691 or email her at concierge@sherivf.com\

If they were frozen on day-3…indeed you could do that. But if they were frozen as blastocysts, the thaw-biopsy-refreeze can damage the embryos.

Good luck

Geoff Sher

ADDITIONAL INFORMATION:

Herewith are  online links to 2  E-books recently  co-authored with  my partner at SFS-NY  (Drew Tortoriello MD)……. for your reading pleasure:

1. From In Vitro Fertilization to Family: A Journey with Sher Fertility Solutions (SFS) ; https://sherfertilitysolutions.com/sher-fertility-solutions-ebook.pdf

1. Recurrent Pregnancy Loss and Unexplained IVF Failure: The Immunologic Link ;http

1. s://drive.google.com/file/d/1iYKz-EkAjMqwMa1ZcufIloRdxnAfDH8L/view

If you are interested in having an online consultation with me, please contact my assistant, Patti Converse at 702-533-2691 or email her at concierge@sherivf.com\