Hi Dr. Sher, a resolving functional hemorrhagic cyst was found during ultrasound for my modified natural (Letrazole assisted) FET. I had delayed ovulation and they performed an ultrasound and found the cyst. On Friday, ultrasound showed cyst was 36 mm, estrogen was 70, and today Tuesday it is 26 mm and estrogen is now 41, and I also got my period without any medication today. I have been given a choice of whether to start my FET this cycle or to delay it for my next period which may be a while given I have longer cycles. The modified natural FET has worked for me in the past. My Dr feels comfortable starting FET given my cyst is resolving but also said if I feel more comfortable, it is fine to wait till next cycle. Do you think the cyst will negatively impact endometrial environment for implantation or prevent Letrazole from maturing my follicles? Do you think it is better to wait till next cycle or it is fine to move forward with FET? Thank you so much for sharing your thoughts with me!
Ask Our Doctors
Supporting Your Journey
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.
-
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
Fill in the following information and we’ll get back to you.
Cyst at baseline for FET
Name: Peg T
Very respectfully, I would not enter an FET until the cyst is gone and you have had at least one interim natural cycle. I would also strongly recommend a medicated FET.
- FROZEN EMBRYO TRANSFER : ONE PREFERRED APPROACH AT SFS.
Two decades ago, when women went through IVF (in vitro fertilization), they usually had their embryos put in the uterus right after the eggs were collected in the same cycle (known as “Fresh” Embryo Transfer). Freezing embryos at that time was risky, with about 30% not surviving the process, and those that did had lower chances of successfully implanting and growing a healthy pregnancy compared to fresh embryos. This was because the slow freezing process led to ice forming within the embryo’s cells, harming them.
But things changed with a new, faster freezing method called vitrification. With vitrification, embryos are frozen so quickly that ice crystals don’t have a chance to form. More than 90% of embryos survive this process in excellent condition, just like they were before freezing, giving them a better chance to develop into healthy pregnancies.
Modern advancements in frozen embryo transfers (FET) have shown great promise, possibly even surpassing the success rates of transferring “fresh” embryos. This improvement likely isn’t because of the freezing process itself, but rather due to two key factors:
- a) FET often involves transferring blastocysts that have been carefully tested and selected through preimplantation genetic screening (PGS)/preimplantation genetic testing for aneuploidy ( PGT-A) , increasing the chances of a successful pregnancy compared to “fresh” transfers where such selection is not done.
- b) The hormone replacement therapy (HRT) used for FET helps prepare the uterus optimally for implantation, improving the overall conditions for a healthy pregnancy compared to the ovarian stimulation with fertility drugs used in Fresh IVF cycles.
Considering these factors, FET offers several clear advantages:
- Safe storage of extra embryos for future transfers.
- Flexibility to delay transfers for additional testing or to avoid complications.
- Preserving embryos for selective transfer in cases of advanced maternal age or diminished ovarian reserve (DOR).
- Convenience in assisted reproductive services involving third-party parenting, like egg donation or gestational surrogacy.
These advancements provide hope and options for couples seeking successful IVF journeys and healthy outcomes for growing families.
The advent of PGS/PGT heralded a major advance in IVF as it enables us to choose the healthiest embryos for transfer to the uterus, thereby significantly boosting the chances of a successful pregnancy. The performance of PGS/PGTA virtually mandates that advanced embryos ( blastocysts) be biopsied 5-6 days after fertilization and that an additional period of 10 days be allowed for genetic testing to be performed. It follows that such blastocysts be vitrified and stored for FET to be performed in a later cycle.
For women who are older or have a lower number of eggs (diminished ovarian reserve-DOR ), as well as those who have faced repeated pregnancy loss or IVF failure, PGS/ PGT-A can be a game-changer. It helps identify the best embryos for successful transfer. However, for younger women who tend to have normal egg reserves, and because of their youth produce a larger number of quality eggs/ embryos the benefits of PGS might not be necessary.
When it comes to creating a reserve of embryos through “Embryo Banking,” FET is mandatory and ground-breaking. Here, multiple IVF cycles are conducted over an extended period of time allowing for the collection and banking of a good number of advanced ( usually PGS/PGT-A tested) embryos ( blastocysts) for future dispensation. Once we’ve gathered a promising group of such embryos, well-timed FETs can be undertaken, significantly improving the chances of a successful pregnancy and reducing the risk of miscarriage.
Through these advancements, we are able to offer greater hope and possibilities to those on their journey to parenthood, making IVF an even more effective and accessible option.
Let’s break down the process to prepare the uterus for a frozen embryo transfer (FET) in simpler terms:
- Cycle Start: To begin, the recipient takes birth control pills (like Marvelon, Desogen ,Lo-Estrin etc.,)for about 10 days. The patient commences 0.75mg Dexamethasone daily OR 10mg prednisone BID at cycle start. This is continued to the 10th week of pregnancy (tailed off from the 8th to 10th week) or as soon as pregnancy is ruled out
- Hormone Kickstart: After 10 days, they start another medication called Lupron/Lucrin/decapeptyl/ Superfact/ Buserelin through a shot.
- Monitoring Progress: The doctors keep an eye on the progress by doing ultrasounds and blood tests to make sure things are on track.
- Boosting Hormones: Delestrogen 4mg IM is injected, twice weekly (on Tuesday and Friday), commencing within a few days of Lupron/Lucrin/Superfact, Decapeptyl-induced menstruation. Blood is drawn on Monday and Thursday for measurement of blood [E2]. This allows for planned adjustment of the E2V dosage scheduled for the next day. The objective is to achieve a plasma E2 concentration of 500-1,000pg/ml and an endometrial lining of >8mm, as assessed by ultrasound examination done after 10 days of estrogen exposure i.e., a day after the 3rd dosage of Delestrogen. The twice weekly, final (adjusted) dosage of E2V is continued until the 10th week of pregnancy or until pregnancy is discounted by blood testing or by an ultrasound examination. Dexamethasone/Prednisone is 0.75 mg is taken (as above) and oral folic acid (1 mg) is taken daily commencing with the first E2V injection and is continued throughout gestation.
- Antibiotic prophylaxis: Patients also receive Ciprofloxin 500mg BID orally starting with the initiation of Progesterone therapy and continuing for 10 days.
- Luteal support: commences on day-1 , 6 days prior to the FET, with intramuscular progesterone in oil (PIO) at an initial dose of 75-100 mg (-Day 1). Daily administration- is continued until late in the evening of Day 5 ( I suggest 10.00PM-11.00PM) . Daily PIO (75mg-100mg) is continued until the 10th week of pregnancy, or until a blood pregnancy test/negative ultrasound (after the 6-7th gestational week), discounts a viable pregnancy. Also, commencing on the day following the FET, the patient inserts one (1) vaginal progesterone suppository (100 mg) in the morning + 2mg E2V vaginal suppository (in the evening) and this is continued until the 10th week of pregnancy or until pregnancy is discounted by blood testing or by an ultrasound examination after the 6-7th gestational week.
- Timing the FET: This is performed as early as possible on the morning of Day-6
- Blood pregnancy Testing: Blood pregnancy tests are performed 13 days and 15 days after the first PIO injection was given
*Note: In cases where intramuscular progesterone administration is not well tolerated, we tend to use a vaginal gel known as Crinone8%. This gel is used twice a day (morning and evening) until the day of the embryo transfer.
- Preparing for Transfer: On the morning of the embryo transfer, we pause using the gel but resume it in the evening. The day after the transfer, we continue using the gel twice a day. . If the blood pregnancy tests show a positive result and 2-3 weeks later an ultrasound examination confirms a viable pregnancy, the Crinone 8% gel is continued twice daily up to the 10th week of pregnancy
Regime for Thawing and Transferring Cryopreserved Embryos/Blastocysts:
Patients undergoing FET with cryopreserved embryos/ blastocysts will have their embryos thawed and transferred by the following regimen.
Day 2 (P4) | Day 6 (P4) | |
PN | Thaw | ET |
Day 3 Embryo | Thaw | ET |
Blastocysts frozen on day 5 post-ER | Thaw-FET | |
Blastocysts frozen on day 6, post-ER | Thaw-FET |
- Monitoring Pregnancy: Regular check-ups and tests are done to confirm if the pregnancy is successful.
_____________________________________________________________________________
Herewith are online links to 2 E-books recently co-authored with my partner at SFS-NY (Drew Tortoriello MD)……. for your reading pleasure:
- From In Vitro Fertilization to Family: A Journey with Sher Fertility Solutions (SFS) ; https://sherfertilitysolutions.com/sher-fertility-solutions-ebook.pdf
- 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\
Soy mujer de 48 años
Name: Tomasa Hernandez
Mi pregunta es será cierto k me pueden ayudarme para q mequedo empezada
Author
Please re-post in English!
Geoff Sher
Herewith are online links to 2 E-books recently co-authored with my partner at SFS-NY (Drew Tortoriello MD)……. for your reading pleasure:
- From In Vitro Fertilization to Family: A Journey with Sher Fertility Solutions (SFS) ; https://sherfertilitysolutions.com/sher-fertility-solutions-ebook.pdf
- 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\
Surrogacy
Name: Cindy Pena
We are interested in surrogacy. We have the surrogate, we are using our own eggs and have health insurance.
Author
IVF surrogacy is a remarkable process that allows individuals and couples to fulfill their dreams of parenthood, offering a path to hope and happiness. Let’s explore this transformative journey, step by step, emphasizing the positive aspects and the incredible possibilities it holds.
The Gift of Surrogacy:
IVF surrogacy is a beautiful partnership that involves the transfer of embryos into the womb of a surrogate mother, who generously offers her womb to nurture the baby. While she doesn’t contribute genetically, her role is invaluable in helping intended parents bring their child into the world. This collaborative approach, where the intended mother provides the eggs and the father contributes the sperm, or with the help of gamete donors, has gained social acceptance, promising a brighter future for those longing for a family.
Who Can Benefit from IVF Surrogacy:
IVF surrogacy can be a beacon of hope for two main groups:
- Women who, due to reasons such as a hysterectomy, disease, or a congenital absence of the uterus, cannot carry a pregnancy to full term.
- Women advised against pregnancy due to systemic illnesses like diabetes, heart disease, or hypertension.
Comprehensive Evaluation and Support:
Before embarking on this journey, all parties involved – the intended parents, the surrogate, and any gamete donors – undergo thorough clinical, psychological, and laboratory assessments. This ensures the well-being of everyone involved and addresses concerns such as sexually transmitted diseases, multiple gestations, miscarriages, and ectopic pregnancies. Open and honest discussions are key.
Choosing the Right Surrogate:
Selecting the right surrogate is a crucial step. Many couples opt for surrogacy agencies, while others turn to empathetic friends or family members to act as surrogates. It’s a heartwarming testament to the power of love and support within a community.
Screening and Support for Surrogates:
The health and well-being of the surrogate are paramount. Extensive medical and psychological evaluations, as well as counseling, are conducted to ensure her physical and emotional readiness. When friends or family members become surrogates, it’s essential to safeguard against any coercion, especially when younger family members are involved.
The Road to Pregnancy:
Once the surrogate is selected and prepared, the process continues with controlled ovarian stimulation for the egg provider and hormone therapy for the surrogate. The goal is to synchronize their cycles for a successful IVF treatment.
Preimplantation Genetic Sampling (PGS)/ Preimplantation Genetic Testing for Aneuploidy(PGT-A):
The use of PGS through next-generation gene sequencing is a groundbreaking approach. It involves a two-part process, allowing embryos to be tested while frozen, ensuring the highest chance of success when transferred.
Management and Follow-up:
Following the embryo transfer, the surrogate receives ongoing care and support with hormone treatments. A positive pregnancy test brings joy and optimism, and ultrasound examinations provide definitive confirmation. In the event of a negative result, hope remains as embryos can be frozen for future attempts.
Toward a Bright Future:
IVF surrogacy offers a path to parenthood filled with hope and possibility. As the field continues to evolve, the ethical guidelines will catch up. In the meantime, the focus is on collaboration and ethical practices to ensure the best outcomes for all parties involved.
The “two-out-of-three rule” –
—-where two of the three essential components (egg, sperm, and gestational component) should ideally come from the intended parents – guides the journey, ensuring the best chances of success and minimizing potential challenges.
In the realm of IVF surrogacy, there’s no shortage of hope, love, and optimism. It’s a journey that transforms lives and creates families, exemplifying the incredible potential of science and compassion.
Geoff Sher
_________________________________________________________________________________________________________________
Herewith are online links to 2 E-books recently co-authored with my partner at SFS-NY (Drew Tortoriello MD)……. for your reading pleasure:
- From In Vitro Fertilization to Family: A Journey with Sher Fertility Solutions (SFS) ; https://sherfertilitysolutions.com/sher-fertility-solutions-ebook.pdf
- 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\
Fertility at 41
Name: Heena Patel
Hello Dr Sher, I am a physician G3P2 who has gone through 6 cycles of IVF for my 3rd child. (My elder two are 11 and 9 who were naturally conceived and delivered NSVD). I have done luteal phase stimulation and low dose IVF as well as conventional dose. I am still eager to have a 3rd child but financially have now invested 2 years and many $$$. I would love to understand a possible protocol with a different medication regimen to improve egg quality with 7 eggs that have gone to testing all have been chromosomally abnormal. I am predominantly Whole Foods plant based, I have improved my sleep, my BMI is 22-23 and normal and my AMH is 0.85 last checked a year ago.
Author
Thank you for reaching out to me. We should talk. I recommend that you contact my assistant, Patti Converse at concierge@sherivf.com and set up an online consultation with me to discuss. In the meanwhile, please see below.
Geoff Sher
- ADDRESSING ADVANCING AGE AND DIMINISHING OVARIAN RESERVE (DOR) IN IVF
Understanding the impact of age and 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.
- 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.
- 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.
- 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.
- 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.
- 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 older women an those 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.
- Age and Ovarian Reserve: Chronological age plays a vital role in determining the quality of eggs and embryos. As women age, there is an increased risk of aneuploidy (abnormal chromosome numbers) in eggs and embryos, leading to reduced 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.
- 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 older women or those with DOR, ovarian stimulation protocols that down-regulate LH activity before starting gonadotropins are necessary to improve egg/embryo quality and IVF outcomes.
- Individualized Ovarian Stimulation Protocols: Although age is a significant factor in aneuploidy, it is possible to prevent further decline in egg/embryo competency by tailoring ovarian stimulation protocols. Here are my preferred protocols for women with relatively normal ovarian reserve:
- 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.
- 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
- Protocols to Avoid for Older Women or Those with DOR: Certain ovarian stimulation protocols may not be suitable for older women or those 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(PGS/T): PGS/T is a valuable tool for identifying chromosomal abnormalities in eggs and embryos. By selecting the most competent (euploid) embryos, PGS/T significantly improves the success of IVF, especially in older women or those with DOR.
Understanding the impact of advancing age and declining ovarian reserve on IVF outcomes is essential when making decisions about fertility treatments. Age-related factors can affect egg quality and increase the likelihood of aneuploid embryos with resultant IVF failure. Diminished ovarian reserve (DOR) further complicates the process. By considering these factors, 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.
__________________________________________________________________________________________________
Herewith are online links to 2 E-books recently co-authored with my partner at SFS-NY (Drew Tortoriello MD)……. for your reading pleasure:
- From In Vitro Fertilization to Family: A Journey with Sher Fertility Solutions (SFS) ; https://sherfertilitysolutions.com/sher-fertility-solutions-ebook.pdf
- 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\
Consultation for egg freezing
Name: Jiji Wang
Hello! Are you available for a remote consultation in the next couple weeks? Would love to speak at your earliest availability.
Thank you!
Author
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.
_____________________________________________________________________________________________________
Herewith are online links to 2 E-books recently co-authored with my partner at SFS-NY (Drew Tortoriello MD)……. for your reading pleasure:
- From In Vitro Fertilization to Family: A Journey with Sher Fertility Solutions (SFS) ; https://sherfertilitysolutions.com/sher-fertility-solutions-ebook.pdf
- 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\
Consult with Dr. Sher
Name: Neha Kumar
Recommendation regarding future IVF treatment- 41 y.o Female with DOR; multiple IVF cycles; embryos don’t make it to blastocyst (only had 2 blastocysts) so far.
Author
I agree! This requires an online consultation;
I suggest you contact my assistant (Patti) and set this up with me. In the meanwhile, see below.
Embarking on the journey of IVF often raises questions about the likelihood of success and the quality of embryos. While it’s challenging to predict outcomes due to various factors, there’s hope and information to guide you.
Firstly, the key to fertilization potential lies in the chromosomal integrity of the egg. Women in their twenties or early thirties have a higher chance of having eggs with the required number of chromosomes for a healthy pregnancy. However, as age advances, this percentage decreases, emphasizing the importance of timely decisions.
Secondly, embryos that don’t develop into blastocysts are usually chromosomally abnormal and are not suitable for transfer, as they may lead to implantation issues or miscarriages. Not all blastocysts are guaranteed to be chromosomally normal, and this likelihood decreases with the age of the woman. Understanding this helps set realistic expectations.
While species and genetic factors play a role in egg quality, our choice of a controlled ovarian stimulation (COS) protocol also matters. Selecting the right COS protocol is crucial, especially for older women, those with diminished ovarian reserve (DOR), and those with polycystic ovarian syndrome. An individualized approach to optimize follicle growth and egg quality can significantly impact IVF outcomes.
In a natural ovulation cycle, hormonal changes are finely tuned to support healthy follicle development and egg maturation. When undergoing IVF, it’s essential to avoid disrupting this delicate balance. The Human Chorionic Gonadotropin (hCG) “trigger shot” should be carefully timed to enhance the chances of success.
In summary, understanding the influence of age, genetics, and COS protocols on egg quality is crucial for a successful IVF journey. The decision-making process becomes even more critical for older women or those facing specific fertility challenges. By embracing personalized approaches and staying informed, you can navigate the path of IVF with hope and optimism.
- ADDRESSING ADVANCING AGE AND DIMINISHING OVARIAN RESERVE (DOR) IN IVF
Understanding the impact of age and 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.
- 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.
- 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.
- 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.
- 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.
- 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 older women an those 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.
- Age and Ovarian Reserve: Chronological age plays a vital role in determining the quality of eggs and embryos. As women age, there is an increased risk of aneuploidy (abnormal chromosome numbers) in eggs and embryos, leading to reduced 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.
- 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 older women or those with DOR, ovarian stimulation protocols that down-regulate LH activity before starting gonadotropins are necessary to improve egg/embryo quality and IVF outcomes.
- Individualized Ovarian Stimulation Protocols: Although age is a significant factor in aneuploidy, it is possible to prevent further decline in egg/embryo competency by tailoring ovarian stimulation protocols. Here are my preferred protocols for women with relatively normal ovarian reserve:
- 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.
- 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
- Protocols to Avoid for Older Women or Those with DOR: Certain ovarian stimulation protocols may not be suitable for older women or those 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(PGS/T): PGS/T is a valuable tool for identifying chromosomal abnormalities in eggs and embryos. By selecting the most competent (euploid) embryos, PGS/T significantly improves the success of IVF, especially in older women or those with DOR.
Understanding the impact of advancing age and declining ovarian reserve on IVF outcomes is essential when making decisions about fertility treatments. Age-related factors can affect egg quality and increase the likelihood of aneuploid embryos with resultant IVF failure. Diminished ovarian reserve (DOR) further complicates the process. By considering these factors, 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.
- STAGGERED IVF WITH PGS/PGT: A MAJOR BREAK-THROUGH IN THE TREATMENT OLDER WOMEN AND THOSE WITH DIMINISHED OVARIAN RESERVE
“Staggered (ST) IVF refers to the process whereby embryos are intentionally frozen and cryobanked for elective transfer to the uterus in a subsequent cycle”.
Doctors often start with less invasive treatments for women over 40 who have patent fallopian tubes before considering IVF. They prescribe fertility drugs and may try artificial insemination. The reason is that IVF is more expensive, but it’s also more likely to lead to a successful live birth. When we think about the true cost of having a baby, IVF can actually be a more cost-effective choice.
IVF has proven to be far more successful than other treatments, regardless of a woman’s age or the cause of infertility. For example, for women under 35 with healthy tubes and a fertile partner, the chance of having a baby through IUI is less than 15% per attempt. But with IVF, the chances rise to about 40-45%. This difference becomes even more significant as a woman gets older. For women in their mid-40s, the chance of success with IUI drops to less than 3%, while IVF offers a 10-15% chance.
This doesn’t mean all women with healthy tubes and fertile partners should choose IVF over other options. However, for women in their 40s or those with diminished ovarian reserve (DOR), time is precious, and IVF may be the best choice. As a woman ages, the risk of miscarriage and having a chromosomally abnormal baby, increases. At age 30, the risk of miscarriage is about 15%, and the chance of having a baby with Down syndrome is less than 1 in 1000. But in the mid-40s, the risk of miscarriage exceeds 40%, and the chance of having a baby with Down syndrome becomes 1 in 60-80.
Staggered IVF and Preimplantation Genetic Sampling /Testing (PGS/PGT) with/without Embryo Banking offers real hope to older infertile women and those with DOR, as an alternative to IVF or egg donation. It involves multiple IVF procedures, biopsy of potentially viable embryos for PGS, cryobanking the embryos until several blastocysts have been collected, and then conducting genetic testing using Next Generation Gene Sequencing (NGS). Once the PGS/PGT results are known, the woman can return in a subsequent cycle for the transfer of up to two PGS/PGT-normal embryos to her uterus. Embryo banking with Staggered IVF and selective transfer of chromosomally healthy embryos greatly improves the success rate per embryo transferred, reaching as high as 50%. It also reduces the risk of miscarriage by 5-6 times and minimizes the chance of having a baby with chromosomal birth defects like Down syndrome.
As a woman ages, the competency of her eggs declines rapidly, resulting in diminished ovarian reserve. This reduces fertility, increases the risk of miscarriage, and raises the likelihood of chromosomal birth defects. IVF maximizes the number of available eggs and allows for genetic testing of resulting embryos, improving outcomes. Staggered IVF, Embryo Banking, and PGS/PGT are excellent tools that enhance pregnancy rates, reduce miscarriage risks, and minimize the chance of chromosomal birth defects. We strongly recommend this approach for women undergoing IVF in the following situations:
- Older women (>39y),
- Women who (regardless of age) have DOR,
- Women with known transmittable genetic defects
- Chromosomal testing for gender selection,
- Women with recurrent pregnancy loss and
- Those with unexplained IVF failure
Embryo banking with staggered IVF and PGS/PGT represents a major breakthrough in the field of Assisted Reproduction ., one that offers hope primarily to older infertile women and those with diminished ovarian reserve. This method involves multiple IVF procedures, genetic testing of embryos, and cryobanking until several viable embryos are collected. By transferring only chromosomally healthy embryos, the success rate per embryo transferred can reach as high as 50%, significantly reducing the risk of miscarriage and chromosomal birth defects. For women facing the challenges of advancing age and diminished ovarian reserve, this advanced IVF technique provides an inspiring opportunity to improve pregnancy rates, minimize risks, and increase the chance of a healthy baby.
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Herewith are online links to 2 E-books recently co-authored with my partner at SFS-NY (Drew Tortoriello MD)……. for your reading pleasure:
- From In Vitro Fertilization to Family: A Journey with Sher Fertility Solutions (SFS) ; https://sherfertilitysolutions.com/sher-fertility-solutions-ebook.pdf
- 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\