Ask Our Doctors – Archive
Our Medical Directors are outstanding physicians that you will find to be very personable and compassionate, who take care to ensure that you have the most cutting-edge fertility treatments at your disposal. This is your outlet to ask your questions to the doctors.
Dr Sher,
I see you recommend three days of over lap of the Lupron and BCP, my RE does 5 days, is this possibly why I have a blunted response to initial stims?
I strongly doubt this explains the situation.
Perhaps we should talk.
Geoff Sher
Dr Sher,
I am 9 weeks pregnant with pgs tested embryo. I was recently transferred back to OB GYN who seems dubious of pgs results (“we THINK we have a normal embryo”). I know nothing in Medicine is foolproof but my understanding was that pgs inaccuracy was about 2-3 % and largely due to presence of mosaicism. Have I misunderstood? Thank you.
You are correct!
Good luck!
Geoff Sher
My husband and I just had our first failed IVF cycle. I did the long Lupron protocol and did not respond well. Antral count 14-17, Amh 1.69 and FSH 6.4. I started off on 10 units of Lupron then bumped down to 5. We stimmed with Gonal-F 375-225 and Menopur 150-225. We got 3 mature eggs and one fertilized. It was a very discouraging cycle as I have had the same number of mature follicles with much lesser drug when we did IUI. Our doctor is suggesting doing the flare protocol next but I am unsure. He hasn’t given me much confidence that we can get more eggs with the next cycle. We are trying to figure out what’s a good next step.
In my opinion, this could have been due to dosage and implementation m+ the amount of Menopur used in someHere 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 is replaced by 125mcg of an antagonist (Ganirelix or Cetrotide daily) . This is continued until the hCG (10,000u) trigger. An FSH-dominant gonadotropin such as Follistim, Puregon or Gonal-f daily is started with the period for 2 days and then the gonadotropin dosage is reduced and a small amount of menotropin (Menopur---no more than 75U daily) is added. This is continued until US and blood estradiol levels indicate that the hCG trigger be given, whereupon an ER is done 36h later. I personally would advise against using Lupron in “flare protocol” arrangement (where the Lupron commences with the onset of gonadotropin administration.
I strongly recommend that you visit https://www.drgeoffreysherivf.com. Then go to my Blog and access the “search bar”. Type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.
• The IVF Journey: The importance of “Planning the Trip” Before Taking the Ride”
• Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
. Agonist/antagonist Conversion protocol (A/ACP)
• 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:
ANNOUNCEMENTS:
1. About my Retirement by mid-2018:
After > 30 years in the field of Assisted Reproduction (AR), the time has finally come for me to plan on retiring from full-time clinical medicine within a year. If you are interested in my medical services prior to my retirement, I urge you to contact my concierge, Julie Dahan ASAP to set up a Skype or an in-person consultation with me. You can also contact Julie by phone or via email at 702-533-2691/ Julied@sherivf.com. You can also apply online at http://www.SherIVF.com.
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Geoffrey Sher MD
5320 S. Rainbow Blvd. Suite 302. | Las Vegas, NV 89118 |office: 702-478-1024
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“Believe…In a Successful Journey from Infertility to Family”
one with a lower than normal AMH.
Hello, I just recently took a beta-hcg blood test along with a urine pregnancy test 2 months after the last time I’ve had sex. The urine test came back negative, but I’m having trouble reading my blood test. It says that my hcg quantitative is in range with <1 mIU/ml with no out of range values, comparing it to a reference range of <4 mIU/ml. Does this mean that my hcg levels are too low and indicate a negative pregnancy? I haven't had sex since then, and my partner and I always use protection condoms/birth control. I haven't had any symptoms, and I may just be very paranoid. But to get some professional opinion on the beta-hcg blood test result would be great!
All this means is that there is NO implantation taking place…something you already know…regardless of the theshold (<4 versus <1).
FYI:
I know of no medical announcement associated with the degree of emotional anticipation and anguish as that associated with a pending diagnosis/confirmation of pregnancy following infertility treatment. In fact, hardly a day goes by where I am not confronted by a patient anxiously seeking interpretation of a pregnancy test result.
Testing urine or blood for the presence of human chorionic gonadotropin (hCG) is the most effective and reliable way to confirm conception. The former, is far less expensive than the latter and is the most common method used. It is also more convenient because it can be performed in the convenience of the home setting. However, urine hCG testing for pregnancy is not nearly as reliable or as sensitive e as is blood hCG testing. Blood testing can detect implantation several days earlier than can a urine test. Modern pregnancy urine test kits can detect hCG about 16-18 days following ovulation (or 2-3 days after having missed a menstrual period), while blood tests can detect hCG, 12-13 days post-ovulation (i.e. even prior to menstruation).
The ability to detect hCG in the blood as early as possible and thereupon to track its increase, is particularly valuable in women undergoing controlled ovarian stimulation (COS) with or without intrauterine insemination (IUI) or after IVF. The earlier hCG can be detected in the blood and its concentration measured, the sooner levels can be tracked serially over time and so provide valuable information about the effectiveness of implantation, and the potential viability of the developing conceptus.
There are a few important points that should be considered when it comes to measuring interpreting blood hCG levels. These include the following:
•All modern day blood (and urine) hCG tests are highly specific in that they measure exclusively for hCG. There is in fact no cross-reactivity with other hormones such as estrogen, progesterone or LH.
•Post conception hCG levels, measured 10 days post ovulation or egg retrieval can vary widely (ranging from 5mIU/ml to above 400mIU/ml. The level will double every 48–72 hours up to the 6th week of gestation whereupon the doubling rate starts to slow down to about 96 hours. An hCG level of 13,000-290, 0000 mIU/ml is reached by the end of the 1st trimester (12 weeks) whereupon it slowly declines to approximately 26,000– 300,000 mIU/ml by full term. Below are the average hCG levels during the first trimester:
o3 weeks LMP: 5 – 50 mIU/ml
o4 weeks LMP: 5 – 426 mIU/ml
o5 weeks LMP: 18 – 7,340 mIU/ml
o6 weeks LMP: 1,080 – 56,500 mIU/ml
o7 – 8 weeks LMP: 7, 650 – 229,000 mIU/ml
o9 – 12 weeks LMP: 25,700 – 288,000 mIU/ml
•A single hCG blood level is not sufficient to assess the viability of an implanting embryo. Caution should be used in making too much of an initial hCG level. This is because a normal pregnancy can start with relatively low hCG blood levels. It is the rate of the rise of the blood hCG level that is relevant.
•In some cases the initially hCG level is within the normal range, but then fails to double in the ensuing 48-72hours. In some cases it might even plateau or decline, only to start doubling appropriately thereafter. When this happens, it could be due to:
oA recovering implantation, destined to develop into a clinical gestation
oA failing implantation (a chemical pregnancy)
oA multiple pregnancy which is spontaneously reducing (i.e., one or more of the concepti is being lost) or,
oAn ectopic pregnancy which will either absorb spontaneously (a chemical-tubal gestation), or evolve into a full blown tubal pregnancy continue and declare itself through characteristic symptoms and signs of an intraperitoneal bleed.
•The blood hCG test needs to be repeated at least once after 48h and in some cases it will need to be repeated one or more times (at 48h intervals) thereafter, to confirm that implantation is progressing normally.
•Ultimately the diagnosis of a viable pregnancy requires confirmation of the presence of an intrauterine gestational sac by ultrasound examination. The earliest that this can be achieved is when the beta hCG level exceeds 1,000mIU/ml (i.e., around 5-6 weeks).
•Most physicians prefer to defer the performance of a routine US diagnosis of pregnancy until closer to the 7th week. This is because by that time, cardiac activity should be clearly detectable, allowing for more reliable assessment of pregnancy viability.
•There are cases where the blood beta hCG level is extraordinarily high or the rate of rise is well above the normal doubling rate. The commonest explanation is that more than one pregnancy has implanted. However in some cases it can point to a molar pregnancy
•Finally, there on rare occasions, conditions unrelated to pregnancy can result in detectable hCG levels in blood and urine. They include ovarian tumors that produce hCG, such as certain types of cystic teratomas (dermoid cysts) and some ovarian cancers such as dysgerminomas.
Geoff Sher
Dr Sher,
Can the endometrial scratch be done while I’m under anesthesia for the ER? We are planning on doing an FET in the cycle after the retrieval.
No! Besides, i am NOT a believer in it helping at all.
Geoff Sher