Loading ...
Welcome to IVF Authority - World Renowned Resource for IVF Information
Egg Quality and Ovarian Reserve: The Effect of FSH and Inhibin Blood Levels
Dr. Geoffrey Sher Recommends- IVF Case Study # 9: Embryo Banking in an Older Woman With Recurrent IVF Failure and Diminished Ovarian Reserve
- IVF: Commonly Asked Questions, Fears and Concerns – Part 10: Do I Need an Egg Donor?
Loading ...
Phone:
702-892-9696
Fax:
702-892-9666
702-892-9696
Fax:
702-892-9666
It is likely that inhibin produced by the granulosa cells lining the cavity of early follicles signal an area in the brain known as the hypothalamus which produces small “releasing hormones” that direct the woman’s pituitary gland to regulate the production and release of FSH. This also explains why basal inhibin and FSH as well as the number of early follicles (antral follicles) represent reasonable measures of ovarian reserve, which in turn correlates with the woman’s potential to produce follicles on her own and/or in response to ovarian stimulation with fertility drugs.
High FSH and low inhibin/antral follicle count (AFC) in the first few days of a woman’s cycle suggests diminished ovarian reserve and serve as a warning that the woman will not likely produce an optimal number of mature follicles and eggs in response to ovarian stimulation. They also serve to encourage the use of a more aggressive, yet individualized approach to ovarian stimulation.
Most women develop diminished ovarian reserve about 6-8 years prior to the onset of menopause (that time the period is termed the “climacteric”) but in some cases this happens at a much younger age (i.e. “a premature climacteric”). Thus, the basal FSH, inhibin level, and AFC are quite good indicators of ovarian reserve and the number of follicles that are likely to develop, given an optimal protocol for ovarian stimulation. However, these parameters alone are not good predictors of subsequent egg and/or embryo quality. Rather it is the woman’s age and the protocol designed to effect ovarian stimulation that play the major role and here, these measurements of FSH/inhibin and AFC can assist in designing the ideal stimulation protocol.
Let me explain! Human eggs undergo degradation in quality over time, such that by age 39, an egg (ovulated or harvested at egg retrieval) will on average have about a 20% chance of being genetically/chromosomally normal. This is about one half the chance at age 35 and under. By the time she reaches her mid forties, that number will decrease by half again (i.e. reaching less than 10%). This “wear and tear” effect on egg quality is an inevitable consequence of the advancing “biological clock“. So, when it comes to egg quality, it is the woman’s age and the protocol of ovarian stimulation that are the most important determinants. You simply cannot stimulate a woman in her 40′s or for that matter a woman with diminished ovarian reserve using the same “recipe” (i.e. the stimulation protocol) as you would prescribe for a younger woman who has normal ovarian reserve. If you do not individualize the protocol of stimulation, you are highly likely to propagate the development of poor quality eggs that have a disproportionately increased likelihood of having chromosomal abnormalities.
Again….. the most important factors affecting a woman’s egg quality are 1) her age, and 2) ovarian reserve. While these two variables may be linked (women are more likely to develop diminished ovarian reserve as they get older), women sometimes do experience a “premature climacteric” and egg quality deteriorates with advancing age regardless of ovarian reserve. Thus, these two contributing factors should be seen as related, but independent variables.
So how then does age and/or diminishing ovarian reserve affect egg quality? First, as stated above, it is inevitable that with advancing age, egg quality will decline. Second, for follicles to grow and for eggs to develop normally (an essential prerequisite for proper genetic maturation), the tissue surrounding the follicle (ovarian stroma or theca) must produce testosterone. Stromal testosterone production requires luteinizing hormone (LH), which is produced by the woman’s pituitary gland and is also acquired through some varieties of injectable fertility medications (Menopur, Repronex and Luveris) given in the course of ovarian stimulation. The testosterone then gets carried in “bucket brigade” fashion to the granulosa cells lining the inside of the adjacent follicle(s). Here, under the influence of FSH, it gets converted to estrogen (mainly estradiol/E2). In the process, the follicle grows and the egg it harbors within undergoes vital developmental changes in preparation for final genetic maturation (“ripening”) that occurs with the spontaneous surge of LH that triggers ovulation (or following the administration of the hCG during ovarian stimulation).
Thus, a small amount of testosterone is needed for optimal egg quality (though too much testosterone can be harmful to the egg as I will discuss below). Eggs that have the genetic potential to transform into genetically “competent,” mature eggs will do so within 36 hours of the spontaneous pre-ovulatory LH surge, or following hCG-induced ovulation.
The important consideration here is that there should not be preovulatory over-exposure of the developing egg to testosterone, something that is most likely to happen when older women and/or those with premature diminution in ovarian reserve are prescribed a suboptimal protocol for ovarian stimulation. If there is overexposure to testosterone, egg development and subsequent egg/embryo quality can be severely compromised along with the chance of a healthy pregnancy. Since older women (>39 years) and women with diminished ovarian reserve tend to produce an excess of LH and have a tendency to over-produce testosterone, this is where the problem lies.
What does this all mean in the context of preparing a woman for a cycle of ovarian stimulation? First, it means that a young woman who has diminished ovarian reserve should still be capable of producing produce good quality eggs, albeit in a smaller number, provided that she gets prescribed an individualized and customized protocol that is designed to prevent over-production of ovarian testosterone. Conversely, an older woman with diminished ovarian reserve will, because of the inevitable effect of age on egg quality, produce a higher percentage of poor quality, genetically “incompetent” eggs.
Finally, when it comes to natural cycle IVF, it should be recognized that some women will produce up to 2 or 3 follicles. Some will be smaller than others, but even the smaller ones can yield eggs. However, as with regular IVF (with ovarian stimulation), the quality of her eggs will be inevitably be influenced by her age. Thus the success rate following natural cycle IVF in such cases will be very much lower than for younger women, especially if they have diminished ovarian reserve. The success rate with natural cycle IVF, even in young women, is only about 10% per cycle. In older women, it is under 5%. Furthermore, older women are more likely to have increased LH production. In addition, the LH they produce becomes more potent with advancing age and thus is much more likely to evoke a greater ovarian testosterone response with a negative effects on egg/embryo quality (and correspondingly on the likelihood of IVF success).
In summary, natural cycle IVF is a much less effective and successful form of IVF across the age spectrum. If it is used, it should be confined to younger, ovulating women who have a normal ovarian reserve.
131 Responses to “Egg Quality and Ovarian Reserve: The Effect of FSH and Inhibin Blood Levels”
Leave a Reply
Top Search Terms for In Vitro Fertilization
- Embryo Quality & Embryo “Competence” – Part III – Testing the Seed
- Embryo Quality & Embryo “Competence” – Part One: Planting a Good Seed
- The Needle vs. the Dish: Should ICSI Be Used in All IVF?
- Embryo Implantation: What Farmers Can Teach us About Growing Healthy Babies
- Acupuncture and IVF: Does it Improve Success?
Dr. Geoffrey Sher Recommends
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Dr. Geoffrey Sher Recommends
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Loading ...
Ask Our DoctorsA Question
Hi Dr Sher, Thanks for your very informative posts. I was interested to learn that overproduction of testosterone (from high levels of LH) is detrimental to egg quality. How does one know if they are producing too much LH- what are the normal levels and when should they be measured? Also, what are your views on the limited evidence that DHEA may improve egg quality given that some of it is converted into testosterone?
Thank you.
I just went through my 2nd failed IVF and already thinking of how to proceed with the 3rd. We started IVF due to male factor issues, but now the doctor is saying that my failed cycles likely point to egg quality issues. He is basing this on the fact that I have needed high does of follistim (up to 600 for 11 days) both cycles, and my E2 levels peaked (day 10/11) just around 1000 both times. However, my day 3 FSH has always been low and age is on my side. So my question is if you agree this is in fact an egg quality issue or just the wrong protocol? Both cycles resulted in 6-8 cell, top grade embryos at day 3 but of the 2 transferred each time, none resulted positively. Your thoughts??
Dear Dr Sher, can a high dose of FSH (eg 450IU) during Stim on a long down regulation cycle with only GnRH agonist compromise egg quality?
Does SIRM grade egg quality for eggs retrieved? I failed two cycles and my clinic told me my retrieved eggs were mature (having the polar body) but that was it. I dont even know the quality of them. Mature is such a vague description.
I know maximum E2 level before egg retrieval gives an idea of how many eggs there are in the ovaries but does it indicate egg quality as well? Thanks!
Hi Ashermans
There is no reliable way to measure the effect of LH on ovarian androgen production. Peripheral blood testing is not reliable.
Don't take DHEA, it is converted to Testosterone in the ovary.
Geoff Sher
Hi Melissa,
The answer is complex, Perhaps we should talk. Call800-780-7437 and set up a free phone consultation.
Geoff Sher
Hi Mum20neds,
The high dose of FSH alone should not adversely affect egg quality. Rather the woman's age and the protocol used for ovarian stimulation needs to be individualized.
Call 800-780-7437 so we can discuss.
Geoff Sher
Dr Dr Sher, thank you so much for your reply. I wish I live in USA to visit your clinic! I am in Australia. I am very impressed with your work and SIRM and. Your blog is very informative and educational.
Dear Dr Sher, I am 37 and have an AMH of 6.0 and normal Day3 FSH, and my response to 450IU of gonal F was good. I had 11 mature eggs retrieved. Quality aside, what sort of group would you put me in? Would I be considered as under diminished ovarian reserve to you?
My FS told me today that he would have me on antagonist (Gonal F and oragultron) next cycle but refused to alter the protocol to bring the antagonist injections closer to gonal F. He mentioned I was still considered within the normal pool of patients.
Hello Dr. Sher
I just had a retrieval procedur this morning with only 2 “empty” follicles found. I am 38, AMH is 5.6, FSH this cycle was 20. My RE suggests either trying a natural ivf, or lower dose of gonal f(this cycle I had been on 300ius. X 11days). She also suggested I start taking DHEA). I know my chances for this working are very low…but Dr.suggests that we try these other options before going the donor route. Any suggestions?
Hello Dr. Sher,
I have a few questions/concerns for you. I am 32 and my husband and I have been trying to conceive for over 2 yrs now, and we know I hold the infertility in our situation. I was diagnosed with stage 4 endo in Jan, 2011 after a lap (and my recovery was horrible!)…I guess it was so bad they couldn’t get it all cleaned up. We tried on our own for a few mths and then tried clomid for a few mths with a failed IUI cycle. Then we moved onto working with our RE and we tried our first IVF cycle in Nov, 2011, and unfortunately it was unsuccessful. We retreived 9 mature eggs and 5 of them fertilized, and we transferred 3 of them but none implanted. I’ve been diagnosed with a diminshed ovarian reserve along with the endo…my FSH fluctuates anywhere from 10-12/13. My RE suggested taking 50 mg of DHEA daily before we tried our IVF and my FSH dropped to 3.5, which shocked us, but it has went back up now (& I’m still taking the DHEA…should I stop?) My RE suggested that we ‘hydro-dissect’ the spots of my endo after our failed IVF cycle…he had a huge concern of using the laser again on and around my ovaries given their condition (my OB at the time performed my first lap). So we went through w/a second lap (but with no laser this time around in Jan, 2012) and we tried on our own for 2 months with no success. We just tried another IUI cycle a few days ago but for some awful reason, I woke up with a fever the morning of our IUI…we went through with it though, but now I’m so scared that it didn’t take. I’ve been taking my daily basal temp every AM and I now that once a woman ovulates, her temp raises above 98 degrees and my temp this AM was 97.2 (after the IUI)…so this tells me that I haven’t ovulated yet. And I’ve read that when your body goes through trauma like a fever (which I had all day that day) your body naturally reacts to that trauma and your ovulation is potponed…is this true? All in all, we’ve been trying SO hard to make this happen and we’re getting very drained financially and emotionally…and I just desperately need some restored honest faith. Any suggestions? Thanks!
I am sorry to hear all you have been through. Indeed given your diminishing ovarian reserve and progressive endometriosis, time is of the essence. Frankly, unless you have ovarian endometriomas that needs surgical removal in preparation for (the only rational treatment in your case)IVF,or for symptomatic relief, you should not waste valuable time and energy on doing surgeries for the removal of endometriotic deposits and/or adhesions, as this will not improve outcome with IVF. IUI is also a waste of time, money and effort in women with advanced endometriosis (see below). You need immediate IVF and with it should go a very individualized approach to ovarian stimulation (see below). And when it comes to IVF, you also would benefit greatly from “Staggered IVF” with “embryo banking” (see below.
Also, since 30% of women who have endometriosis also have an immunologic implantation dysfunction, this also needs to be taken into the equation when designing a strategy (see below).
Please go to the search bar (above) and enter the following subjects into the bar. This it will take you to all the relevant articles I posted there.
1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
2. “Agonist/Antagonist Conversion Protocol”
3. “Immunologic Implantation Dysfunction” (posted on May, 10th and on May 16th respectively.
4. “IVF success: Factors that influence outcome”
5. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
6. “A stepwise approach to IVF at SIRM” (posted March,9th, 2012)
7. “Endometriosis”
8. ” IUI”
9. “Embryo Banking”
10. “Staggered IVF”
You should seriously consider calling 800-780-7437 or 702-699-7437 to set up a telephone consultation with me (which is free if you reside in the U.S.A or in Canada) so we might discuss your case in detail.
Sincerely,
Geoff Sher
Thank you for your quick response Dr. Sher, I truly appreciate it! I think I may call and set up a free phone consultation with you to ease my mind and discuss my situation with you more in detail. I have to admit, after skimming through most of the helpful articles you suggested for me, it seems as though there is hope for my husband and I to conceive (am I correct in saying this?…) We have a great relationship with our local RE and I feel like he’s working with us and our emotions/needs, but it seems as though there’s more protocal out there that was mentioned in some of the articles you listed above (& I don’t know why he hasn’t taken these factors into mind with me and my diagnosis). I don’t want to feel like I’m starting back at square one you know, but I also know that time is of the essence for us–I remind myself that every single day, which doesn’t help with the pressure/stress I put on myself. And the though of having to travel out to Las Vegas and stay our there for an amount of time, just honestly doesn’t seem feasible for my husband and I, but we do want a baby of our own more than anything in the world! But as I said, I think I’m going to set up a free phone consultation with you in hopes that it helps me feel better about my situation and my ever-growing desire to create a precious, miraculous life! As I said before, I desperately need some restored honest faith…this all is SO consuming!
Thank you very much!
Dr. Sher, I have a question…
I’m a healthy 34 year old with normal menstrual cycles. I’ve been told I have diminished ovarian reserve. My Day 3 FSH is 9. I’m trying to understand what this all means. Does this mean I would have to use egg donor since my FSH is on the high side? OR would I be able to get pregnant with my own eggs? Thank you!
Your age makes it possible to get pregnant with own eggs, even with diminished ovarian reserve. However time is of the essence and so is the need for an individualized protocol. Please go to the home page find the “search bar” in the right hand column of the home page on this blog . Type in the following subjects into the bar and it will take you to all the relevant articles I posted there.
1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
2. “Agonist/Antagonist Conversion Protocol”
3. “Immunologic Implantation Dysfunction” (posted on May, 10th and on May 16th respectively.
4. “IVF success: Factors that influence outcome”
5. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
6. “A stepwise approach to IVF at SIRM” (posted March,9th, 2012)
7. “Staggered IVF”
8. “Embryo Banking”
You might also consider calling 800-780-7437 or 702-699-7437 to set up a telephone consultation with me (which is free if you reside in the U.S.A or in Canada) so we might discuss your case in detail.
Geoff Sher
Hi Dr.Sher..
I was diagnosed with premature ovarian insufficiency a few months ago, after I started having pretty severe hot fllushes out of the blue. I just turned thirty six this week. My FSH has been as high as 73 then dropped to 7 within six week time, my other levels evened out as well. I started ovulating again ( they believe) and have had two cycles of timed monitored intercourse and this cycle my first IUI. My clinic has told me I am not a candidate for
fertility meds ( other than the etrace and prometrium) and that my options are to try to get pregnant unmediated with monitoring, or to move on to donor egg. Does this sound correct? I do not have fertility coverage and worry that maybe my options are being narrowed because of potential costs. Thank you for any advice you have, I am in the upstate NY area.
I concur wi9th that advice. However, if you wish, consider calling 800-780-7437 or 702-699-7437 to set up a telephone consultation with me (which is free if you reside in the U.S.A or in Canada) so we might discuss your case in detail.
Geoff Sher
Dera Dr. Sher, You have a great thing going on here. Its wonderful that you take the time to do this. Well I am a 35 year old mother of 6. Yes 6 and wanting more! I have suffered some great losses and this is very important to me. I had my first 5 normaly. Everytime I turned around I was pregnant. I tied my tubes in 2001 and then in 2005 did ivf and got a daughter. May 2005, 29 years old, my fsh was 7.2 and we got 18 good eggs.Only fertility problem was the blocked tubes. Now I am going to Cancun to do it again and will not be able to do it again. I can not afford to do it in Houston because it is just to high. I spent $9,000 on a tubal reversal that left me blocked so was a waist! So now I have had all my testing and now I have a amh level of 1.8 and my fsh level is 11.7. High for only being 35. Now I am wondering if I will responde well this time? My main worry is that they put me on the birth control pill and have me taking it for 5 weeks straight till i get in mexico for reservation reasons! This makes me scared that it will surpress me! This really my only option! I have tried everything else! Please tell me what you think of my case and what the birth control for those days will do to my cycle! Thank you so much for any help you can give!!!
Dr.Sher,
I am currently 28 years old. I have miscarried twice in the last year. When I went to the RE the only thing they could find was an FSH of 14 and AMH of .49. I was advised to take DHEA which I have been doing for the last 2 months. Now that I found your info on DHEA I am worried that I may have been harming myself more. I had one failed IUI. My doctor wants me to move to IVF soon. I am worried that it will not work for me. We have limited money and can only afford 1 or 2 cycles. Do you have any advice for me as I go forward?
You likely have significantly diminished ovarian reserve and need IVF before this runs out and you are left with no real options. And yes… In my opinion you should not use DHEA, but once you stop, any down-side disappears soon. However, please go to http://www.IVFauthority.com and when you get to the home page find the “search bar” in the right hand column. Type in the following subjects into the bar and it will take you to all the relevant articles I posted there.
“An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
“Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
“Agonist/Antagonist Conversion Protocol”
“Immunologic Implantation Dysfunction” (posted on May, 10th and on May 16th respectively.
“Embryo Implantation………” (Part-1 and Part- 2—-Posted August 2012)
“Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
You might consider calling 800-780-7437 or 702-699-7437 to arrange a video conference (or Skype) consultation (free of charge to those who reside in the United States or Canada). If need be, someone from SIRM-Patient Relations can contact you in advance of the consultation and assist you in setting this up through your computer. Such audiovisual interaction it is much more personable than a discussion by telephone. However, if you prefer the latter, this too can be arranged.
Geoff Sher
Dr. Sher,
I just turned 40. In May, my FSH was 8.3, AMH .55, E2 less than 12, TSH 1.975, Prolactin 10.4. I have tried 4 medicated IUIs (Follistim and trigger) and one IVF. I got pregnant on my second IUI but it was a very brief pregnancy. No luck on IVF. MY IVF protocol included BCP for 10 days, then Follistim (450) and Menopur (150) for 7 days. On days 8-13, I added in Cetrotide and an additional 75 Menopur. 7 decent sized follicles aspirated, 6 mature eggs retrieved, all deemed “poor” quality eggs. 4 fertilized, 3 “fair” embryos. All three transferred on Day 3, no pregnancy. I am curious if you would deem me to have DOR? My doctor has never specifically said I have DOR, but I am guessing I do. Thanks!
It sounds as if you have DOR. Might I recommend that you go to the home page on this site, find a “search bar” in the upper right hand column and type in the following subjects into the bar and it will take you to all the relevant articles I posted there.
“An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
“Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
“Agonist/Antagonist Conversion Protocol”
“Embryo Implantation………” (Part-1 and Part- 2—-Posted August 2012)
“Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
“IVF success: Factors that influence outcome”
“Staggered IVF”
“Embryo Banking”
You might consider calling 800-780-7437 or 702-699-7437 to arrange a video conference (or Skype) consultation (free of charge to those who reside in the United States or Canada). If need be, someone from SIRM-Patient Relations can contact you in advance of the consultation and assist you in setting this up through your computer. Such audiovisual interaction it is much more personable than a discussion by telephone. However, if you prefer the latter, this too can be arranged.
Geoff Sher
I have an AMH level of 0.4, ttc for 5 years before getting daughter through IUI that was converted from an IVF cycle.
My RE recently approved of my starting DHEA 25mg TID to improve my chances of ttc. I would like to use a natural IUI, maybe 2, before doing another IVF. –Due to the fact my insurance doesn’t cover treatments, and IVF was physically and emotionally draining. We conceived this July through using IVF and stimulation via the Rosenwax protocol, 450 Follistim and 150 Menopur, 3 mature follicles, one made it past day 3 and transferred day 5– but miscarried at 8.5 weeks, baby stopped growing at 6 weeks. I have endometriosis and have recently made dietary changes hoping to improve it, I may do another laproscopic surgery to remove my endo adhesions, (did one in 2009, daughter conceived 2010). My endo was staged at a 3, due to there being some on my ovary at the time (2009 before surgery).
What do you recommend as far as supplementation, surgery, is DHEA ok with endometriosis? Thank you so much!
I do not advocate the use of DHEA because it is a male hormone that is readily metabolized by the ovary to form testosterone. Excess testosterone is potentially harmful to egg development and in this regard, women such as yourself with diminished ovarian reserve are the most vulnerable. Frankly there are no supplements that have been proven to improve egg quality. The protocol used for ovarian stimulation is pivotal (see below).
Might I recommend that you go to the home page on this site, find a “search bar” in the upper right hand column and type in the following subjects into the bar and it will take you to all the relevant articles I posted there.
“An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
“Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
“Agonist/Antagonist Conversion Protocol”
“Use of Nutritional supplements in IVF”
“Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
“IVF success: Factors that influence outcome”
“Staggered IVF”
“Embryo Banking”
“Egg Donation”
Consider calling 800-780-7437 or 702-699-7437 to arrange a telephone or Skype consultation (free of charge to those who reside in the United States or Canada). While an audiovisual (Skype) interaction is much more personable and preferable than a discussion by telephone, either will suffice.
Geoff Sher
Hi Dr. Sher,
I just went through a very aggressive protocol (600iu Folistim, .5 Menopur) for approx. 9-10 days only to get one 18mm follicle which yielded an immature egg which subsequently matured and fertilized but did not make it to a blastocyst.
I am moving now to doing Natural IVF and I wanted to know what you thought my changes were of being successful. I am 32, hypothyroid, have early stage endo as well as cysts and am currently using lovenox/aspirin for my clotting issue. Additionally, even with doing Natural IVF, should I also still do Intralipid therapy?
Thanks you for your input.
Dr. My AMH is .23 and FSH is 10.4. I have two failed IVFs – both are estrogen priming antganoist protocol. The first I produced 4 eggs – 3 mature and fertilized. The second was cancelled due to poor response. I was on 300IU Gonal F and 150 IU Menopur. What would do different in my case? I am 30 years old.
I would suggest that your protocol of stimulation be carefully reviewed and that you consider embryo banking (see below).
Please go to the home page of this blog (www.IVFauthority.com ). When you get to the look for a “search bar” in the upper right hand corner. Type in the following subjects into the bar and it will take you to all the relevant articles I posted there.
“An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
“Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
“Agonist/Antagonist Conversion Protocol”
“Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
“IVF success: Factors that influence outcome”
“Staggered IVF”
“Embryo Banking”
“Egg Donation”
Consider calling 800-780-7437 or 702-699-7437 to arrange a telephone or Skype consultation (free of charge to those who reside in the United States or Canada) so we can discuss your case in detail.. While an audiovisual (Skype) interaction is much more personable and preferable than a discussion by telephone, either will suffice.
Geoff Sher
Hi Dr Sher,
Last year we have started ivf due to male factor at my 39 years of age and FSH 6.5. I used 375 puregon, cetrotide and menogon(3 days) for stimming and had 16 eggs 14 mature and all fertilized with ICSI. I had 2 very good day3 embrios transferred and had a negative result. 3 months later, in my 2nd ivf, with the same protocol I had 18 eggs, 16 mature, 14 ferilized (RE said excellent quality eggs). I had 2 blasts transferred at day 5. And had a positive result and was pregnant with a singleton. At 18 weeks I had an amniosynthesis and had to stop the pregnancy at 20th week due to chromosome abnormality (me and my husband are tested fine genetically). 3 months postpartum I have tried a 3rd ivf, which is only 8 months after my positive ivf, always same protocol, I had 11 eggs, 5 mature eggs all fertilised, and had a day4 transfer of one morula and one cavitating embrio. I had a negative result. I am now prescribed DHEA 75 mg/die for 2-3 months. And my RE does not want to change protocol as we have catched a pregnancy with it. How do you think I am proceeding? thanks for any comments…
Hi Laura,
The selection of the IVF protocol while based on physiological principles is very much influenced by personal experience. I personally prefer to launch the cycle off a birth control pill, use “long protocols” with pituitary down regulation using an agonist (e.g., Lupron) and in cases such as yours, as soon as the post-Lupron period starts, switch from the agonist (Lupron) to daily administration antagonist such as Cetrotide or Ganirelix (the Agonist/Antagonist-Conversion Protocol, commence with daily rFSH (e.g., Folistim, Gonal F or Puregon) and limit menotropin usage (i.e., Menopur/menogon)….rather than menotropins and continue this until the hCG “trigger” ( using 10.000U of Novarel, Pregnyl or Profasi, or 500mcg of Ovidrel. In my experience, this is an ideal approach for someone like you. I do not recommend DHEA to anyone…not that it would necessarily harm a person with normal ovarian reserve, but I believe it tyo be deleterious to women who have DOR because it is metabolized to testosterone in the ovaries and too much testosterone can compromise egg development. I also perform blastocyst transfers almost exclusively because with very few exceptions, embryos that do not make it to blastocyst in the Petri Dish will not do so in the uterus either (had they been transferred earlier) and thus will not propagate a baby.
In your case, I would suggest a revamp of protocol and the use of CGH embryo selection with “Staggered IVF” and Embryo banking (see below).
Please go to the home page of this blog, http://www.IVFauthority.com and then find the “search bar” in the upper right hand column. Type in the following subjects into the bar and it will take you to all the relevant articles I posted there.
“An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
“Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
“Agonist/Antagonist Conversion Protocol”
“Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
“IVF success: Factors that influence outcome”
“Staggered IVF”
“Embryo Banking”
If you wish to discuss your case with me , feel free to call 800-780-7437 or 702-699-7437 to arrange a telephone or Skype consultation (free of charge to those who reside in the United States or Canada). While an audiovisual (Skype) interaction is much more personable and preferable than a discussion by telephone, either will suffice.
Geoff Sher
Dear Dr. Sher,
I was diagnosed with dimished ovarian reserve at 26. Fortunatley, I was able to conceive using iui at 28 years old and have a wonderful 3 year old. I am now 32 and we have been trying to have another child for almost 2 years. My day 3 fsh has been as high as 31. With 2 failed iui cycles to start, we quickly moved to ivf. My first two ivf cycles (using estrace primer, icis and assisted hatching)we used 4 viles of menapur and 4 viles of braville with no success. I produced 3 follicles the first ivf, leading to 1 embryo and no pregnancy. The second ivf I produced 2 follicles which did not fertlize. The last ivf attempt the protocol was different, because i had a cyst that would not quickly go away the re put me on lupron. he then used 5 viles of menapur and 300 units of gonal-f to stimulate. It took almost 14 days but we ended up with 2 follicles and 2 embryos, one of which implanted. Unfortunately it was diagnosed as a blighted ovum at 7 weeks with only an empty sac. So we are ready to move onto donor eggs, however we have been reading a lot about dhea and its positive effect on younger women with dor. We are willing to give my ovaries one last try using dhea but are just not sure if it is worth it. What are your thoughts on dhea and its effectiveness on woman with dor? What are your thoughts on our situation, should we try ivf with my eggs one more time, or move to donor eggs? I have found your articles very informative. Thank you for all of your hard work helping families grow.
Fondly,
Gina
Hi Gina,
Firstly congratulations on having been successful in spite of your DOR.
It is important to recognize that whatever you do now, your ability to produce enough “competent” eggs in a single attempt is very curtailed. If I were treating you I would thus be very focused upon the type of protocol used for stimulation (a huge factor) and would be looking at using embryo banking with CGH selection of embryos (see below). As for DHEA treatment, f, I personally would recommend against its use in women with diminished ovarian reserve (DOR)….see article on use of nutritional supplements in IVF (see below).
Please go to http://www.IVFauthority.com . When you get to home page, look for a “search bar” in the upper right hand corner. Type the following subjects into the bar, click on it and it will take you to all the relevant articles I posted there.
1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
2. “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
3. “Agonist/Antagonist Conversion Protocol”
4. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
7.“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
8. “IVF success: Factors that influence outcome”
9. “Staggered IVF”
10.“Embryo Banking”
11. “Egg Donation”
12. “Use of nutritional Supplements in IVF”
You might consider calling 800-780-7437 or 702-699-7437 to arrange a telephone or Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail.. While an audiovisual (Skype) interaction is much more personable and preferable than a discussion by telephone, either will suffice.
Geoff Sher
Dear Dr Sher, I am a just turned 45 year old who had a hysterectomy in 2002. My husband and I have been in contact with a surrogacy clinic. We want to have a child of our own using my eggs and his sperm. They told us it may be possible. Just two weeks ago I had blood test because I started feeling hot flashes. My FSH is 104.2 and my LH is 46.3. My doctor has not called me regarding these results. I started looking up the results on line and found that I have such high results that I am more than likely in menopause. I live in southern calif. should I even go any further with hopes of having a baby with the help of a surrogate ? PLEASE give me some information. Thanks
hi Angela,
I wish I could give you words of encouragement but alas, with the information you provided, the chance of success with your eggs, is very, very remote. perhaps you should consider using an egg donor.
So sorry!
Geoff Sher
Hi Dr Sher. This is Angela again. I forgot to mention I had 5 children natural with no complications before or after delivery. I had the hysterectomy because of uterine fibroids. I still have my Ovaries. I had a friend if mine do a ultrasound and she told me my ovaries look good, no cyst.
Hi Dr. Sher,
I have normal FSH, Low AMH, DR said that my eggs quality seemed to be good cause I had 2 mature eggs something was at around 1500, sorry, I forgot what he said it was and he said about 500 per egg is good and I had a level of 1500 per egg. I will be turning 42 very soon. I have a 5 year old daughter conceived naturally… no problems in conceiving, what are the chances of me getting pregnant naturally at my age? My cycles are 26 days and I normally ovulate around day 12 or 13. Thanks
Hi Jodi,
Your comments weren’t deleted, they were just waiting in the queue for approval. They have been posted now and Dr. Sher should respond shortly.
Best wishes,
Tom
Your chances of a natural conception is < 5% per month all things being equal. The question you should ask is do you have the time to depend on such low odds whenn your biological clock is moving ever more rapidly.
Good luck!
Geoff Sher
sorry, one other question, how is it possible to have normal FSH and low AMH? I thought they are supposed to measure the same thing?
Dr. Sher,
I have two kids 3 & 5, natural conception. Pregnant on first try both times. Decided to do pgd just for family balancing and on first ivf round found out I could be infertile? I’m 39 years old, FSH was normal 7.8 AFC supposedly normal but didn’t have much response to 300 gonal f, 75 menopur then added cetrotide later, stimmed for 10 days. 4 mature eggs retrieved, 2 fertilized, banked 2.
2nd Cycle, AMH less than .176. Bumped to 450 gonal f, 300 menopur, and .2 omnitrope on micro flare Lupron. Stimmed for 12 days….was told had 6-8 follicles. Only retrieved 4, 1 mature, would not fertilize. Defrosted 2 embies, tested Natera 24 chromosome, 1 normal that arrested day of transfer and one abnormal Edwards.
I’m out of money and time. Dr suggests egg donor? He says little no chance for me with own eggs.
Frankly, I would differ. You have sufficient ovarian reserve such that with some protocol change you might do much better. Please go to http://www.IVFauthority.com . When you get to home page, look for a “search bar” in the upper right hand corner. Type the following subjects into the bar, click on it and it will take you to all the relevant articles posted there.
1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
2. “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
3. “Agonist/Antagonist Conversion Protocol”
4. “Gender Selection and IVF”
5. “Egg Donations”
10.“Embryo Banking”
Consider calling 800-780-7437 or 702-699-7437 to arrange a telephone or Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail.. While an audiovisual (Skype) interaction is much more personable and preferable than a discussion by telephone, either will suffice.
Geoff Sher
Dear Dr. Sher-
I am 32 years old- and trying to conceive for three years. I have an AMH of .66 and an FSH of 7.7. My estradiol level is within normal limits. I recently had a failed IVF cycle, 300 Menopur 150 Follistim, and although everything looked textbook perfect, when they retrieved the 14 eggs, only 5 of them were borderline mature, and none fertized, even with the use of ICIS. I do not know what possibly went wrong. My doctor wants to put me on a more aggressive treatment, but I am wondering if it is a waste of money and I should just move to egg donor? Please advise, I am so desperate here.
If your husband has normal sperm parameters…at 32 years of age, the most likely explanation relates to ovarian stimulation. Perhaps the protocol used was not optimal, the timing of the hCG trigger was off or the type of hCG used was not ideal.
Please go to the home page of this blog, (www.IVFauthority.com). When you get there look for a “search bar” in the upper right hand column. Then type in the following subjects into the bar, click and this will take you to all the relevant articles I posted there.
1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
2. “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
3. “Agonist/Antagonist Conversion Protocol”
Consider calling 800-780-7437 or 702-699-7437 to arrange a telephone or Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail.. While an audiovisual (Skype) interaction is much more personable and preferable than a discussion by telephone, either will suffice.
Geoff Sher
Dr. Sher: I am 39 years old and have an AMH of 0.89. During my first IVF, I had 10 mature eggs retrieved. 4 fertilized, 2 arrested at Day 3 and 2 arrested at Day 6 at the morula stage. What IVF protocol would you recommend for me? Also, would you think that my 2 morulas would have benefitted from a Day 3 or Day 5 transfer? Thank you.
Those that never made it to blastocyst in the Petri dish would almost certainly not have made it in the uterus either. Go elsewhere on this blog and read the article I wrote on “An Individualized approach to Ovarian Stimulation for IVF”.
If you would like to discuss your case with me, consider calling 800-780-7437 and set up a Skype (preferably) or telephone consultation.
Geoff Sher
Hi Dr. Sher,
It’s nice that you take time to answer questions. I just turned 34 years old. I initially had an amh of .4 and later tested at .3. Obviously, this is extremely low. I am trying to do an egg freezing cycle with what time I have left. I have consulted with multiple physicians. The last one suggested a flare protocol with 600 Gonal-F, and low does of lupron through cycle, 12 day stim. The physician also suggested a prime with estrogen for 26 days. I am consideing going with this physician. However, I am a little worried about this because I have fibroids. The physician also wants me on dhea. What are your thoughts on the suggested flare protocol and estrogen prime. Would you do things differently, and why? The clinic is well renounded, but I am still trying to research and go with the place place for me. Thank you!
I respectfully suggest that a flare protocol in someone with diminished reserve is less than optimal (see below. Also, DHEA is not a good idea because it is metabolized to testosterone in the ovary and too much testosterone is not good for developing eggs….see below.
Please go to the home page of this blog, (www.IVFauthority.com). When you get there look for a “search bar” in the upper right hand column. Then type in the following subjects into the bar, click and this will take you to all the relevant articles I posted there.
1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
2. “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
3. “Agonist/Antagonist Conversion Protocol”
4. “Immunologic Implantation Dysfunction” (posted on May, 10th and on May 16th respectively.
5. “Egg freezing”
6. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
7.“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
8. “Fertility Preservation”
9. “Nutritional supplements in IVF”
Consider calling 800-780-7437 or 702-699-7437 to arrange a telephone or Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail.. While an audiovisual (Skype) interaction is much more personable and preferable than a discussion by telephone, either will suffice.
Geoff Sher
I am 43 and conceived naturally 3 times first time including maternal twins. Remarried and have been trying for 15 months resulting in two miscarriages. I have had bloods done and all came back fine. I have 28 day cycle, seem to ovulate day 14 , bbt and tests confirm this. I have no other health conditions , fit and healthy. I exercise but dont overdo and eat healthily too. My hubby is going for sperm test next week. I dont want to put him through this if it is more than likely down to my age. He has no children , is 43 and healthy.
No doubt whatsoever. Age is the factor that causes a rapid decline in egg quality and thus embryo competency. You are now experiencing “physiological infertility” and time is the rewal issue!! At 43 you need IVF and best…Egg Donation. If not the latter, then at the very least Embryo banking with Staggered IVF and CGH embryo selection (see below)
Please go to http://www.IVFauthority.com . When you get to home page, look for a “search bar” in the upper right hand corner. Type the following subjects into the bar, click on it and it will take you to all the relevant articles posted there.
1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
2. “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
3. “Agonist/Antagonist Conversion Protocol”
4. “Immunologic Implantation Dysfunction” (posted on May, 10th and on May 16th respectively.
5. “Embryo Implantation………” (Part-1 and Part- 2—-Posted August 2012)
6. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
7.“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
8. “IVF success: Factors that influence outcome”
9. “Staggered IVF”
10.“Embryo Banking”
11. “Egg Donation”
Consider calling 800-780-7437 or 702-699-7437 to arrange a telephone or Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail.. While an audiovisual (Skype) interaction is much more personable and preferable than a discussion by telephone, either will suffice.
Geoff Sher
Dr. Sher,
I am amazed that you are willing to give such wonderful advice and I may set up a phone consult with you. But first, I wanted to get your opinion on my chances of conceiving overall. I have a healthy almost 6 year old who was conceived on the first month of natural trying. At age 32 (3 years ago), and after trying for our second child for 18 months (squeeze in an awful hyperstim round of clomid and a chemical preg), I was diagnosed with Non-Hodgkins and subsequently treated with 6 rounds of RCHOP and a month of radiation to the chest. less than a year later, I became pregnant spontaneously, but was put on prog supp and had an allergic reaction. I had to stop taking it and the preg ended before 6 weeks. Now, we have been trying again since last May with no success. Last cycle I took Femara and did an IUI, with no success. The plan is the same for this cycle, but my RE wants us to consider injectables in a future month. My FSH was 15.5 and I only had 5 small follicles during my baseline u/s. I do not eat dairy and I am right now eating a plant based diet in the hopes that it will help. It has been a pretty rough few years. Any thoughts?
Thanks so much for your time.
Dr. Sher -
I first learned of my high FSH/low AMH dx in 2009 (15.7 and .1, respectively). We also have a male issue with low counts and motility. My first IVF (Oct. 2009) was the MDL which over-suppressed me and ultimately lead to cancellation. November 2009 was the antagonist protocol with letrozole, 300 Gonal F, and 300 Menopur resulting in 2 oocytes retrieved. One fertilized and one did not but the fertilized egg arrested prior to day 3 transfer. December 2009 I found myself pregnant…naturally but ended at 7 weeks when the heartbeat was lost. April 2010 we began IVF 3. Antagonist protocol again with letrozole, 450 Gonal F, and 150 Menopur. Two eggs retrieved, one fertilized. That fertilized egg became our son in December 2010 after a perfect pregnancy. We began treatments in 2012 after I finished nursing my son but have not attempted IVF as I now have an LH issue where my LH surges around CD6. Interestingly we ignored my LH surge in September and just triggered and attempted on our own at home. That cycle resulted in a miscarriage at 6 weeks. We are now researching for the best center in the USA to attempt one last cycle. I know there are many more things you would want to review but do you believe I’m a candidate for your clinic? I should mention I’m only 29.
Thank you in advance,
Mandy
Absolutely you are a candidate for SIRM. I work out of St Louis and Las Vegas. If you would like to talk to me, consider calling 800-780-7437 or 702-699-7437 to arrange a telephone or Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail.. While an audiovisual (Skype) interaction is much more personable and preferable than a discussion by telephone, either will suffice.
Geoff Sher
Hi, I just turned 41 a few months ago and have been trying to conceive for the past year and a half. My husband has had two sperm evaluations which have resulted in a count of 25 million the first time and 12 million the second time. Motility was between 63%-66% with progressive motility consisently being around 90%. Morphology has been between 1%-4%. Now with that being said, my day three labs were as follows, estradiol 61, LH 7, FSH 12, Tsh 1.7 and prolactin 16. I had an ultrasound done that showed my afc to be 4. I ovulate regularly with 26 day cycle. My question is this, is there any hope to conceive my own child or are my options only that of a donor egg? Are the sperm levels problematic, especially considering all other factors? Thank you so much for your time, it is much appreciated.
Even though you are 41Y and clearly have diminished ovarian reserve, it is possible that with the right protocol, embryo banking and staggered IVF with CGH embryo selection you might still be able to have your own genetic child through IVF (see below). This having been said, clearly egg donation is likely to prove most successful over the shortest time frame.
Please go to the home page of this blog, (www.IVFauthority.com). When you get there look for a “search bar” in the upper right hand column. Then type in the following subjects into the bar, click and this will take you to all the relevant articles I posted there.
1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
2. “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
3. “Agonist/Antagonist Conversion Protocol”
4. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
5.“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
6. “IVF success: Factors that influence outcome”
7. “Staggered IVF”
8.“Embryo Banking”
11. “Egg Donation”
Consider calling 800-780-7437 or 702-699-7437 to arrange a telephone or Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail.. While an audiovisual (Skype) interaction is much more personable and preferable than a discussion by telephone, either will suffice.
Geoff Sher
I commented a few days ago and have not received a response. I wanted to add that my husband has zero issues. I look forward to hearing from you soon. Thank you.
I cannot find your post Mia…so sorry!
Can you re-post and I promise to answer you stat.
Geoff Sher
I am amazed that you are willing to give such wonderful advice and I may set up a phone consult with you. But first, I wanted to get your opinion on my chances of conceiving overall. I have a healthy almost 6 year old who was conceived on the first month of natural trying. At age 32 (3 years ago), and after trying for our second child for 18 months (squeeze in an awful hyperstim round of clomid and a chemical preg), I was diagnosed with Non-Hodgkins and subsequently treated with 6 rounds of RCHOP and a month of radiation to the chest. less than a year later, I became pregnant spontaneously, but was put on prog supp and had an allergic reaction. I had to stop taking it and the preg ended before 6 weeks. Now, we have been trying again since last May with no success. Last cycle I took Femara and did an IUI, with no success. The plan is the same for this cycle, but my RE wants us to consider injectables in a future month. My FSH was 15.5 and I only had 5 small follicles during my baseline u/s. I do not eat dairy and I am right now eating a plant based diet in the hopes that it will help. It has been a pretty rough few years. Any thoughts? Thanks so much for your time.
Hi Mia,
I am so happy that you are in total remission and that you have a child. That certainly relieves a lot of pressure.
Clearly the treatment you had has taken a toll on your ovarian reserve, but clearly, you still have the potential to propagate eggs and thus the ability to have another baby. The problem is that although young, you have diminished ovarian reserve which requires a very individualized approach to ovarian stimulation, one that avoids over-exposure of your eggs to LH-induced ovarian testosterone.In my opinion, use of clomiphene and /or Femara by increasing LH will not serve you well.
Please read the articles listed below carefully and then indeed let us talk.
Please go to the home page of this blog, (www.IVFauthority.com). When you get there look for a “search bar” in the upper right hand column. Then type in the following subjects into the bar, click and this will take you to all the relevant articles I posted there.
1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
2. “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
3. “Agonist/Antagonist Conversion Protocol”
4. Use of the Birth Control Pill in IVF”
Consider calling 800-780-7437 or 702-699-7437 to arrange a telephone or Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail.. While an audiovisual (Skype) interaction is much more personable and preferable than a discussion by telephone, either will suffice.
Geoff Sher
Hi,Im 25 of age now. I got married and Im facing Severe PCOD problem. I have undergone all Harmonal tests as suggested by our Gyno and all the reports are fine. But, my egg size is so less (less than 10mm)everytime I test. What might be the problem ? Do I need to undergo any other tests and are there any chances for me to get pregnant ? Please, guide me on this. Thank You so much for your time.
Undoubtedly this is a stimulation issue. However, I would need to know much more to be able to fully advise.Please go to the home page of this blog, (www.IVFauthority.com). When you get there look for a “search bar” in the upper right hand column. Then type in the following subjects into the bar, click and this will take you to all the relevant articles I posted there.
1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
2. “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
3. “Agonist/Antagonist Conversion Protocol”
4. “Polycystic Ovarian Syndrome (PCOS)”.
5. “Use of the birth control pill in IVF”
Consider calling 800-780-7437 or 702-699-7437 to arrange a telephone or Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail.. While an audiovisual (Skype) interaction is much more personable and preferable than a discussion by telephone, either will suffice.
Geoff Sher
Hi Sir,
Thanks for your reply. I’m living in Bangalore.
I’ve gone thru the links whatever you gave.
Before my marriage I used birth control pills for 1 year. I’m in treatment for the past six months.
Now my doctor advised me to take chromosome test.
So can you please tell me what is that test? and if suppose that test is negative then , is there a chance to get conceive ?
You will have to ask your MD what exactly he/she is planning to do. Are these tests on you and your husband or on the embryos you produce and what is the precise test being contemplated?
Good luck!
Geoff Sher
Dear Dr. Sher,
Thank you so much for your time and this wonderful site. I am 37.5 years old. One miscarriage a year ago and no luck getting pregnant since then. My spouse and I had a fertility workup and the only abnormality was FSH of 10.6. My obgyn put me on Clomid. Does it seem to you that Clomid to induce ovulation at 37.5 years old with an FSH of 10.6 will lead to a successful pregnancy and birth or would you recommend that I seek a different protocol? Thank you so much!
I should also mention that my BBT chart always shows a temp spike on Day 18 of a 28-day cycle and OPK are positive around Day 16 or 17 each month.
Thank you so much!
PS – I did read the article you wrote regarding NOT using Clomid over 35/with depleted ovarian reserve (is this the same as high FSH?) So, I’m curious as to your thoughts. Thank you so much!
You are quite correct, if the FSH is that high and especially if you also have a reduced AMH, I would NOT recommend clomiphene.
Geoff Sher
Copy!
Geoff sher
Thank you so much Dr Sher,
What are the chances that I could become pregnant with another protocol, such as IVF at age 37.5 with FSH of 10.6? I am trying to figure out if (statistically) it’s worth pursuing. Thank you!
I think your chances are quite good, actually!
Geoff Sher
Hi Dr. Sher,
I’ve enjoyed reading your responses. They have been very informative. I was hoping that you could weigh in on my case, as I am really confused by my recent bloodwork results. I will be beginning IVF soon, and up until a few days ago, it seemed that all of my blood work was normal. FSH=4.5; E2=28; LH=normal but can’t remember the value; TSH=normal. Then, my RE tells me that my AMH is very low at 0.32. Ultrasound shows that my AFC is 16. I am 33 years old and in overall very good health and have always taken very good care of myself, but I am devastated by the news of my AMH, as my doctor said that it implies that my eggs are of poor quality. Yesterday, the nurse told me that I have “bad eggs” and that our chances of success with IVF will thus be limited. I have always been led to believe that AMH was an indicator of ovarian reserve, not quality. My RE unfortunately tends to confuse me and not give clear answers to my questions. Can you please help me to better understand what this AMH implies? Does this actually mean that I have “bad eggs”, as I’ve been told? Also, my husband has low count, so we will be pursuing ICSI. Thanks in advance for your help!
No single test is infallible. With such a high AFC and a normal FSH/E2 on day 3, I would suspect that you do have adequate ovarian reserve. The only way to be certain is to go through a cycle and see.
Good luck@!
Geoff Sher
Thanks so much for the quick response! Are you able to clarify for me what you think it means in terms of egg quality though? That’s where I’m confused. Thanks again!
Hi, i am 30 I have mild stage 1 endometriosis, very good AMH, no PCOS. Partner has fantastic semen analysis and is age 33.
I had my first IVF cycle last month which failed.
I was started on gonal f on day 2 of cycle and took it for 7 days, cetrotide was introduced day 5, I was instructed to take ovitrelle and egg collection was done cycle day 11. They collected 7 eggs, most immature, only 1 egg fertilised and had a day 2 transfer.
My thoughts are the reason I produced so many immature eggs was because I was not kept on gonal f for long enough? Also my main consultant had me booked in for egg collection 2 days later but it was a stand in doctor that decided I was ready for ovitrelle slightly earlier.
I am disappointed as I think the cycle failed as I was brought in too early?
I would love to hear your thoughts, thank you
It is possible that you could be correct! However, I suggest that you also consider the possibility that you might have an immunologic implantation dysfunction (IID) related to uterine natural killer cell activation (NKa) since about 1/3 of women who have endometriosis (regardless of its severity) have this problem. It would require separate attention. (see elsewhere on this blog).
Good luck!
Geoff Sher
P.S. Please look out for my next blog (on Tuesday coming( which will be on endometriosis.
Hi Dr Sher
I am hoping with all my might that you can give me some sort of hope. I have been diagnosed with high FSH levels 11.0 and low AMH levels 0.16. Doc recommended IVF ICSI as hubby has retrograde ejaculation but with donor eggs as tests were not good. We tried IVF with my eggs but during stim with 5 75ui amps per day of menopur my first scan on day 6 showed nothing meaning not good response to stims.
Is there hope for me to have my own baby or should I go for donor eggs. I am 33 turning 34 in Aug 2013.
Hi Dr Sher
I forgot to add that I was taking DJEA for 6 weeks prior to stims. I took 3 ,25mg per day for 6 weeks.
Thanks Kimmy
Copy!
If you are under 40, there is hope. Please go to the home page of http://www.IVFauthority.com , find the search bar in the upper right hand column and then type in “An Individualized approach to ovarian stimulation for IVF” read this and then do the same with “Staggered IVF”, ” Embryo Banking” and finally “Traveling from Afar…..”.
Thereafter consider calling 800-780-7437 0r 702-699-7437 and set up a Skype consultation with me to discuss. I think I can help!
Geoff Sher
My day 3 testing showed my LH at 9.5 and my FSH at 5.7. I just turned 36 and have PCOS. My HCG also shows at 1.
Not sure what any of this really means. My doctor confuses me.
Perhaps we should talk Why don’t you consider calling 800-780-7437 or 702-699-7437 to arrange a Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail.
In the interim, please go to the home page of this blog, (www.IVFauthority.com). When you get there look for a “search bar” in the upper right hand column. Then type in the following subjects into the bar, click and this will take you to all the relevant articles I posted there.
1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
2. “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
3. “PCOS”
4. “Immunologic Implantation Dysfunction” (posted on May, 10th and on May 16th respectively.
5. “Embryo Implantation………” (Part-1 and Part- 2—-Posted August 2012)
6. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
7.“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
8. “IVF success: Factors that influence outcome”
Sincerely,
Geoff Sher
Thank you Dr Sher , for the advise I really do appreciate it. The time you take to answer every query is amazing. I will read the other articles. I am under 40. I am thinking of going to see an endocronologist to help balance my hormone levels, do ou think this will help me respond better to IVF?
Regarding calling you, please let me know what time will be suitable for you? I am in South Africa.
Thank you so much for all your assistance, Hubby and I really appreciate it.
You would need to call 702-699-7437 and set up a Skype consultation.
Geoff Sher
28 years old i just had all of my day 4 blood results back. I have a few questions, my FSH was 10.1 on day 4. Is it possible that it would be lower on day 3?
Also, my estradiol level was 45
my prolactin was 10.9
my LH was 11.1
and my AMH is 3.97
My RE is out of the country and I cant get any answers. Do i have DOR is it bad that my LH is higher than my FSH but why is my AMH good? Before my bloodwork, he recommened unmedicated IUI for DH and I for 5 cycles due to DH’s ED. I currently am on the cancellation list to get an appointment
Where do you reside because if the AMH was measured in ng/ml then you probably do not have DOR. If it was measured in picomols/L then you likely do…in spite of your young age.
Geoff Sher
I reside in PA. The nurse said my RE wants to see it above 1 and said mine is excellent.
Then it must have been in ng/ml and this is indeed excellent and you almost certainly do not have DOR, in my opinion. The fact that your LH is that high, makes me wonder if you might not have PCOS. Has this been investigated?
Geoff Sher
Thank you so much for the information. No, I don’t believe PCOS has been investigated yet. I have looked it up and I’m not sure that i have any other symptoms. I have normal periods between 29-33 days, I am not overweight and I have never missed a period. I also do not have any facial hair.
Hello Dr. Sher,
I’m 41 years old. I had an IVF cycle with:
Marvelon 1 month prior IVF
600 IU Gonal+ 300 IU Luveris for 11 days of stimulation
They retrieved 6 eggs, 4 of then were mature but NONE fertilized !!!
My doctors wants me now take Repronex 450 IU instead Gonal and Luveris.
What do you think?
Thank you .
Please go to the home page of this blog, (www.IVFauthority.com). When you get there look for a “search bar” in the upper right hand column. Then type in the following subjects into the bar, click and this will take you to all the relevant articles I posted there.
1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
2. “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
3. “Agonist/Antagonist Conversion Protocol”
Consider calling 800-780-7437 or 702-699-7437 to arrange a Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail.
Geoff Sher
I do not see this covered so I apologize if I missed it.
I’m curious about egg quality after IVF. I have chosen to have a Tubal Reversal and I am curious if egg quality and ovulation go back to normal, unharmed, after an IVF cycle or is there a “using up” of viable eggs or a waiting period needed for normalcy? IVF was 3 years ago, (age and heath aside) I am a high count folicle producer and very healthy middle age multiple egg dropper.
Thank You for your help…
Tamara
Indeed egg quality does revert to pre-IVF quality. But pray tell, in this day and age, why on earth would you do a tubal reversal where the success rates following tubal re-connection (reanastamosis) in cases of previous tubal ligation(a birth rate of +/- is 40-50% within 3 years of a successful surgery or about 2% per month and the risk of ectopic pregnancy is about 1:5. With IVF the success in a center of excellence following a single cycle of treatment is about the same as within 3 years of a tubal reversal and the risk of an ectopic pregnancy is 7 times lower. IVF is also far less invasive than tubal surgery and does not require general anesthesia, hospitalization, or a protracted time off work. Moreover by doing IVF and leaving the tubal ligation undisturbed ,the woman retains subsequent control over family planning without having to resort to using some other form of contraception. Surgery also requires a few days of hospitalization and subsequently a few weeks of convalescence and there is also a risk of post-operative complications, increased cost, time away from work, incapacitation, and significantly greater discomfort. The cost of a full cycle of IVF is in fact comparable to that of tubal re-anastamosis. Finally, when tubal re-anastamosis fails, you will need to revert back to IVF.
Please go to the home page of this blog, (www.IVFauthority.com). When you get there look for a “search bar” in the upper right hand column. Then type in ” IVF verses tubal reversal” into the bar, click and this will take you to the relevant article.. Also read the following there: a
1. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
2.“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
8. “IVF success: Factors that influence outcome”
Consider calling 800-780-7437 or 702-699-7437 to arrange a Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail.
Geoff Sher
Dr. Sher,
My husband and I have been married for 13 years and have been trying the majority of our marriage to have a baby. While I have PCOS and my husband had average sperm count at about 10 million with good mobility, what so you think our chances would be to continue doing rounds of IUI? We have been able to get pregnant on our own 10 times in our marriage. The last time we made it to 4 months which was our longest pregnancy. We are currently using one of your clinics an as much as I would like to say we hae been happy, I don’t feel like our questions are being answered any where near as in depth as you have answered these on the blog. My husband and my insurance pays zero of our procedure so we are paying out of pocket while we were prepared to do for a few rounds of IUI but if there is ok chance for us to conceive this way we would like to start saving so that we can consider IVF in the future. We recently started intralipids and are hoping that will help with the miscarriages. This first round of IUI we had 4 mature eggs at the follicle scan: 19, 17, 16, 16. I l home had one more night of follistim and then the next night did ovidril for schedule IUI the next day. I understand that there are significantly lower odds with IUI than IVF but surely there is some more blood work or something that should be done before we do this next IUI that is Scheduled for Monday? In the past I had to use progesterone in the beginning. I know the issue with that is that an unhealthy pregnancy might stick when it would otherwise result in miscarriage. At this point we are worried that the intralipids won’t be enough to help fight off the natural killer cells. We also are worried this this IUI won’t take either although I have 4 eggs again this time, not as large but am doing follistim 3 more nights before trigger shot and then 36 hrs later IUI; currently the eggs were 13,14,15,15. 10 years ago we tried to do an IUI cycle by my eggs never got bigger than a 10 or 11 so after 5 months of trying we quit. Not that we are 33 and my eggs are growing with the same drug that I used before, I’m looking for best guess. Have things changed enough that we should try a 3rd IUI if this doesn’t take or should we start our savings for an IUI. Also, I keep reading about success rates with back to back iui’s in same cycle. Over all I am not sure this is much different that us having inter course 24 hrs later, just wanted your opinion as to whether that is something one of your clinics would consider. Lastly, we wondered your thoughts on donor sperm? 10 million before washing seems low in reference to other numbers I have read and if that’s all it would take for us to be parents we are on board. I also wondered your thought about IVF, IVF and the possibility that the pregnancy would stick? Due to the physical investment, emotional, and financial, I feel like we would need to have some kind of guarantee that the chances are great. Thank you for any insight you can give. I apologize that I don’t know my numbers that everyone else is listed, but they were never given to me so that I could have a better understanding. I don’t want to feel as if the next IUI won’t work on Monday, but it is starting to feel like even if it didn’t we would probably get little or not information as to why that happened which makes the process harder to continue to invest in.
I can help here. With your husband’s oligospermia and your repeated failures with IUI, you definitely need IVF . Success rate will depend on your age and ovarian reserve. We could discuss all this later. Please go to the home page of this blog, (www.IVFauthority.com). When you get there look for a “search bar” in the upper right hand column. Then type in the following subjects into the bar, click and this will take you to all the relevant articles I posted there.
1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
2. “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
3. “PCOS”
4. “Immunologic Implantation Dysfunction” (posted on May, 10th and on May 16th respectively.
5. “Embryo Implantation………” (Part-1 and Part- 2—-Posted August 2012)
6. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
7.“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
8. “IVF success: Factors that influence outcome”
9. “ Male Factor Infertility”
10.“ICSI”
11. “Intrauterine Insemination (IUI)”
Consider calling 800-780-7437 or 702-699-7437 to arrange a Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail.
Geoff Sher
Hello Dr Sher,
I did my first IVF in 2011 with an FSH level of 11.3 coupled with male factor infertility and I got pregant within the first cycle. The result of that pregnancy is an adorable son that I love to bits. I am clocking 34 years in about 2 months and i’m about to go down that road again but my FSH has risen to 17.3 and my Doctors are not encouraging. What advice do you have for me on this and what are your experiences like on similar issues.
Your age is in your favor. It is all about whether or not you will respond sufficiently but ultimately it will be about the protocol of stimulation used. Please go to the home page of this blog, (www.IVFauthority.com). When you get there look for a “search bar” in the upper right hand column. Then type in the following subjects into the bar, click and this will take you to all the relevant articles I posted there.
1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
2. “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
3. “Agonist/Antagonist Conversion Protocol”
4. “IVF success: Factors that influence outcome”
5. “Staggered IVF”
6.“Embryo Banking”
Consider calling 800-780-7437 or 702-699-7437 to arrange a t Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail.
Geoff Sher
I am 43 and had a miscarriage starting on 5 feb because i was keen to try again, i had a bood test for ovarian fertility AMH i think and had a message today on the answer machine to say it was 10.25 so in the low range. I wondered if it could be affected by the fact that i am still in the process of a natural miscarriage and also will they still go ahead with my ivf or are they likely to say no. They had thought my PCOS would mean i would have had a high result but sadly it doesn’t seem they were right about that.
thanks
sarah
IT DEPENDS WHAT UNITS THE AMH WAS MEASURED IN. PLEASE CLARIFY.
GEOFF SHER
I am in the uk so i think it’s PMOI/L they said on the phone message low fertility range.
Then I understand! It is low.
Geoff Sher
could it be affected by the miscarriage which is still ongoing, and are they likely to still let me try ivf?
thanks
sarah
Dear Dr. Sher-
I would like some advice regarding the correct protocol for IVF for my particular situation. I am 38. My AMH is 0.57, and my last antral follical count was 22 total – but it has been lower (it was only something like 8 immediately following my first IVF cycle when my FSH spiked to 25). My husband has had a vasectomy reversal, and continues to have low sperm counts, and poor morphology. Taking these factors into consideration (primarily my age and indications of DOR) we decided to maximize our chances with IVF, and not waste any time on IUI’s. In January we did a cycle of mini IVF that began with two weeks of birth control, followed by 50mg daily of clomid from CD2 to CD11, and 75u follistim from CD5 to CD11. I triggered with Synarel on CD12, and retrieved on CD 14. Initially a had quite a few follicles – at my last US, at least 6 were over 18mm, and I had a number of smaller ones in the 10, 12, 13 range. One seemed to be dominant at 23mm. All in all, I was pleased with this response given the minimal stimulation, and was hopeful we would have several embryos to work with.
We were in for a big disappointment however — at retrieval, we only got 4 eggs, 1 was mature and fertilized immediately, the other 3 immature and fertilized after a day in culture. However, all of them arrested development before blastocyst,and none of them were transferred.
I took a couple of months off and have now begun another cycle. I was on bcp’s again for 5 weeks. on CD2 I had 22 follicles under 10mm, my Estrogen was 22, FSH 5, LH 3, and progesterone 0.6. I thought this looked pretty good to start. on CD4, I started taking 2.5 mg letrozole 2x daily. On CD5 I added 25mg Clomid. On CD6, I added 75u of follistim. At today’s US ( CD 9, after 3 days of follistim)I had 4 follicles on my left 13, 13.5, 14, and 11. On the right I had 8, and 7<7.
I am writing because I am troubled by the thought that I am not doing what is necessary to maximize my chances of having competent eggs. I know that this is going to be the biggest hurdle, and I am worried that I will end up with few eggs, or many immature eggs like last time. I have also been taking 50mg DHEA daily (started only this cycle), but after reading your posts, I am going to stop it immediately.
In the past they have suggested I can use menopur as an alternative to follistim (I never did, I had follistim on hand)- but if I understand you correctly, this would be a mistake for me because of my age and the fact that I do not want excess LH. So stick with Follistim only correct?
I had another consultation with a different RE who wanted to put me on a microflare protocol because she said this would give me better results, but the conversation honestly left me more confused. On the one hand, I seem to be getting decent sized follicles with very low levels of stimulation (good right?), but last time the eggs turned out to be immature — very bad! Do I need more stimulation? A longer time stimulating to let more eggs grow? A different protocol all together? Or is this just the best that I can do given the eggs I have to work with? I want to have more than one child, so I had hoped to have enough embryos to freeze for later – but last time I didn't even have any to transfer. Afterward, I was told not to get my hopes up that there will be enough to freeze, and we should just try fresh transfers instead. Is this the smartest thing for me to do? Are fresh transfers more successful than frozen ones? Should I be trying to go through several retrieval cycles and bank my embryos instead? Or should I just be re-adjusting my expectations?
Help!
Gretchen
Hi Gretchen,
Wow…what a saga! I respectfully but strongly disagree with the protocols you have been on. All of them disregard the fact that with diminishing ovarian reserve, the last thing you need (in my opinion) is increased LH-induced ovarian androgens, most specifically, testosterone. The use of clomiphene, letrozole, microflare-agonist protocols or Menopur (which contains LH/hCG), because they all do just that and thus (especially in cases of DOR) should in my opinion preferably not be used…….Not to mention taking DHEA which metabolizes to androgens. The resulting increased ovarian testosterone could in my opinion compromise egg development and increase the likelihood of aneuploidy in the eggs. This will reduce maturation and also lead to follicle egg retention and a reduced egg harvest at ER.
In my opinion using mini-IVF is also less than optimal given the DOR. After all, exerting “less force on a heavy rock will not enhance the chance of moving it”.
In my opinion, you need a long pituitary down-regulation protocol. preferably an agonist antagonist conversion protocol (see below) and then a trigger with 10,000U of uHCG (rather than 250mcg of Ovidrel or an agonist such as Nafarelin). You also should be considering Staggered IVF with Embryo Banking (see below).
Please go to the home page of this, my blog, http://www.IVFauthority.com . When you there , look for a “search bar” in the upper right hand corner. Type the following subjects into the bar, click on it and it will take you to all the relevant articles posted there.
1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
2. “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
3. “Agonist/Antagonist Conversion Protocol”
4. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
5.“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
6. “IVF success: Factors that influence outcome”
7. “Staggered IVF”
8.“Embryo Banking”
Might I suggest that you call 800-780-7437 or 702-699-7437 to arrange a Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail.
Geoff Sher
I have high Ih and fsh level at sge 34. I went to see a FS and they state it could be premenopausal. What type of treatment can I do to e my own childo . I’m so hurting right now. I need some help.
Please responde.
Hi Tiara,
I do not have enough information to be helpful here.
Sorry!
Geoff Sher
could it be affected by the miscarriage which is still ongoing, and are they likely to still let me try ivf?
thanks
sarah
Sorry…but I cannot find your original post. Please re-submit it so I can respond to this question.
Geoff Sher
Thank-you. I will call to discuss.
Gretchen
Copy and thank you!
Geoff Sher
I am 43 and had a miscarriage starting on 5 feb because i was keen to try again, i had a bood test for ovarian fertility AMH i think and had a message today on the answer machine to say it was 10.25 so in the low range. I wondered if it could be affected by the fact that i am still in the process of a natural miscarriage and also will they still go ahead with my ivf or are they likely to say no. They had thought my PCOS would mean i would have had a high result but sadly it doesn’t seem they were right about that.
thanks
I am in the uk so i think it’s PMOI/L they said on the phone message low fertility range
could it be affected by the miscarriage which is still ongoing, and are they likely to still let me try ivf?
thanks
sarah
I doubt it was due to the miscarriage being in progress…but retest in a few weeks and see!
Geoff Sher
I am a 34 yrs old. My FSH from last year in July 2012 was at 4, Nov 2012 was at 12.9. Feb 2013 it was at 7.3 and just this month it peaked up to 25.3. I had done a long lupron ivf protocol in Dec 2012/Jan 2013 which i only produced 2 follicles so the Dr gave us the option to convert it into an iui and resulted in a negative. Do you think I should move right into Donor Egg or try a different protocol using my own eggs.
No, because you are young and age is the major determinant of egg “competency”. However, to optimize the yield and the quality of such eggs/embryos you definitely need an aggressive but strategic protocol of stimulation (see below) before it is completely too late. had you been significantly older…then OD would have been your only recourse and ultimately, that might eventually prove to be needed. Please read the articles below carefully and focus on the approach to ovarian stimulation and on “Staggered IVF” and “Embryo banking”.
Go to the home page of this blog, http://www.IVFauthority.com . When you get there, look for a “search bar” in the upper right hand corner. Type the following subjects into the bar, click on it and it will take you to all the relevant articles posted there.
1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
2. “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
3. “Agonist/Antagonist Conversion Protocol”
4. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
5.“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
6. “IVF success: Factors that influence outcome”
7. “Staggered IVF”
8.“Embryo Banking”
9. “Egg Donation”
Consider calling 800-780-7437 or 702-699-7437 to arrange a Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail
Geoff Sher
I am 33 years old and have an FSH of 18 and Estridol of 120 on CD4. I have had 5 miscarriages in under 2 years, and have had no problems getting pregnant – because of this they have only just checked my levels now. My RE’s office has dismissed my concern about my high FSH, but I’m worried that I have a new problem on my hands other than RPL. Everything I’ve read says high FSH means it’s hard to get pregnant. I am really confused about what may be going on!
An elevated FSH at baseline is suggestive of diminished ovarian reserve. However even women with DOR (especially if like you they are young), will still ovulate spontaneously and can and do conceive. Remember age impacts egg/embryo quality and ovarian reserve…impacts the number of eggs recruited for each cycle. What is clear is that if you have DOR, time is an essential consideration and you need to be very proactive. I say this because a common cause of recurrent pregnancy ,loss is implantation dysfunction. This is often immunologic (please see below)
Please go to the home page of this blog, http://www.IVFauthority.com . When you get there, look for a “search bar” in the upper right hand corner. Type the following subjects into the bar, click on it and it will take you to all the relevant articles posted there.
1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
2. “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
3. “Recurrent pregnancy Loss (RPL)”
4. “Immunologic Implantation Dysfunction” (posted on May, 10th and on May 16th respectively.
5. “Embryo Implantation………” (Part-1 and Part- 2—-Posted August 2012)
6. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
7.“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
Consider calling 800-780-7437 or 702-699-7437 to arrange a Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail
Geoff Sher
Hello Dr Sher,
I am 30 and have recently been diagnosed as having reduced ovarian reserve. I had very high FSH on one test and then normal another time but I had very high oestradiol results which made my second FSH result not a true reflection. I have also had 2 AMH tests and both came back with a very low fertility result.
Please could you tell me if the low quantity of eggs that I have left would likely be of poor quality? As I am 30 I would have expected that they could still be of good quality.
Kind Regards,
Laura
Hi Laura,
It is age rather than ovarian reserve that influences egg quality. There is however a very important caveat namely; . That is that that the protocol used for ovarian stimulation in women with diminished ovarian reserve can play a role in affecting egg quality.
Please go to the home page of http://www.IVFauthority.com. When you get there look for a “search bar” in the upper right hand column. Then type in the following subjects into the bar, click and this will take you to all the relevant articles I posted there.
1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
2. “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
3. “Agonist/Antagonist Conversion Protocol
Consider calling 800-780-7437 or 702-699-7437 to arrange a Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail
Geoff Sher
Dear Dr. Sher:
I am a 39 yo Asian-American w/ a BMI of ~25.5/26 who has been trying to conceive on and off for the past 3 years. Historically, I have had no major health problems and no gynecological problems, generally very good health (no smoking, drugs, very limited alcohol, etc.), regular 26-28 day menstrual cycles, regular LH surges detected ~cycle days 11-13 (although, more recently, my MPs have been varying from my history – not sure if that is a factor at all). Here is my relatively recent history including 2 natural pregnancies (both miscarried), 2 planned IUIs, and 2 IVFs that were converted to IUIs (all unsuccessful to date), and, finally, my current IVF protocol that has just begun…
July 2011: Pregnant naturally after about 6 actual months of TTC (both my husband and I had to travel quite a bit for work, so we weren’t physically together!). Miscarried at 7 weeks.
Jan 2012: My husband and I began seeing a RE. Day 3 baselining included FSH @19.6, E2 @43.5, plus a HSG which checked out just fine, and shortly after the HSG, I became pregnant (but miscarried @ 6 weeks w/ a peak E2 of 192.5 on Day 31).
Mar 2012: Planned IUI#1 – IUI FSH. Stimmed w/ 150u GonalF for 4 days, then 150u of Follistim for 3 days, 250mg Ovidrel as trigger, then 100mg of Endometrin for ~2 wks. On day 5 of actual stims, 1 follie was sighted @ 12.62. Difficulty visualizing via U/S due to a fibroid. Peak E2 detected on Day 8 of stim @184.2 (then 155.7 on 7th day of stim).
Apr 2012: Planned IUI#2 – IUI FSH. Stimmed w/ 200u Follistim for 4 days, then upped to 300u for 3 days, used Ovidrel as the trigger again, then Endometrin for ~2 wks. Started w/ 3-4 follies <10mm in both ovaries (so 6-8 total). By Day 5 of stim, 0-2 follies (<10mm) in both ovaries. By Day 7, 4 total follies sighted (2 per ovary @ 14.64, 9.27, 9.21, and 9.85). Peak E2 on Day 8 of taking stims @ 373.3 (and was 131.3 on Day 5 of stims).
May – Jun 2012: IVF Attempt #1 – IUI OCP / LM / Flare – ART Agonist Suppression. ~3 weeks of Loestrin birth control pills (BCP) – this appeared to have over-suppressed me and my MP arrived 2 weeks later than expected. Simple left ovarian cyst @15mm found after stopping BCP (and E2 @37.7). Then began 20mcg microdose leuprolide (lupron) 1X/day, plus 300u GonalF night + day for 19 days. Difficulty visualizing U/Ss due to fibroid, but by Day 6 of stim, E2 was <25 and 0-2 follies (<10mm) in both ovaries. Day 8 E2 @ 33.2; Day 11 E2 @ 62.1. Day 17, E2 finally up at 207.4 w/ 2 follies sighted (14.67 + 14.48). Day 19 E2 @ 208.5 with 4 sizable follies (17.36, 15.22, 12.43, 15.6), plus 3-6 more follies that were <10mm. Started agonist on Day 19. Day 20, time of trigger, 5-6 total follies sighted (17.94, 14.17, 13.5, 7.08, 15.6, 9.99). Peak E2 detected on Day 19 = 208.5, then interestingly enough, it went slightly down the next day, Day 20, to 205.5. The actual IUI procedure then occurred on Day 22 (was this too late?).
Jul – Aug 2012: IVF Attempt #2 – IUI Estradex; ART – Antagonist Suppression. Prepped w/ ~2 weeks of 2mg luteal micronized estradiol tablets (Estrace) 2Xs/day right after my CD13 LH surge was detected. Then started 9 days of stims w/ 450u Follistim + 150IU Menopur + 0.25 dexamethasone @ 1X/day, combined w/ 250mcg Ganirelix on Days 8-9 of stim. Starting E2 @ 59.9 after 12 days of the Estrace. At this point, my fibroid had grown quite large (to ~7cm) and was complicating the U/Ss quite a bit – they often couldn’t visualize my R ovary at all. 5-9 follies originally sighted. Day 5 E2 @121.5; Day 8 E2 @349; Day 10 E2 @ 381 and at that point, could only visualize 1 follie @ 18.4. IVF converted to IUI on Day 12. Retrieval not even possible at this point bc of the location and size of my fibroid.
Sep 2012: 2nd baselining on CD3 yielded FSH @ 9.3 (significantly lower than before) and E2 @ 56.2. At this point, my RE let me know she didn’t know what else to do w/ me and especially wanted me to see a fibroid specialist to discuss next steps on treatment of that fibroid. We spent most of the fall then getting 2nd opinions and seeing yet more specialists.
Dec 2012 – Mar 2013: Successful laparoscopic myomectomy performed mid-Dec, independent hysteroscopy checked-out just fine in mid-Feb 2013 (very minimal scar tissue which lyased during the procedure), was prohibited from having intercourse at all during this entire time of recovery. In April 2013, we tried naturally and we were unfortunately denied insurance coverage for another round of IVF.
Today: Self-financing IVF Attempt #3 – Estrogen Patch Protocol – ART w/ GnRH Antagonist. Just started this in early May. Ten days post-natural LH surge, I started wearing 0.1mg estrogen patch (changing it every other day for 3 days w/ the last patch staying on once my MP arrived, so wore a patch for a total of 12-13 days). The day after I started wearing the patch, I started cetrotide injections for 3 consecutive days only. My MP then arrived. On CD2 of my MP, baseline ultrasound checked out just fine, and I started 300u GonalF that night, followed by 300IU Menopur in the AM 12 in size sighted at this point – 1 in each ovary. Hospital does not count or measure those follies <12 and I not my husband are allowed to see the screen in real-time during my U/S (much to our dismay). I realize it is early yet, but I am inclined to cancel before I reach the next major stage so that I can be refunded the remaining stages’ costs – particularly if E2 does not rise in conjunction w/ decent follicular development.
I would love to get your commentary – particularly on my current protocol (as well as the prior 2 IVFs and 2 IUIs if relevant), and, your advice on my next steps based on the info you have here.
I’m certainly not a specialist in this field, but I feel like the Menopur dosage is too high and the proportion of GonalF + Menopur should be different where I am taking more GonalF and less Menopur (given what you’ve written about its conversion to testosterone and the negative impacts that overexposure may have on egg quality). What could be causing the current low E2 levels? Also, no one has come out and said it (much to my dismay), but I am categorizing myself as a low responder – would you agree – and, I am very motivated and interested in a highly individualized protocol, as you say, because at 39 years and 3 months old, I can feel my body changing – as expected, my MPs were a bit whacky 3 months post-myomectomy but they’ve also been getting shorter, lighter/scantier in flow, and I’ve been experiencing new sharp breast pain for a few days (whereas before, I rarely had cramping – maybe dull cramping for 1-2 days, and dull breast soreness).
Any thoughts, hard facts, opinions, hopeful points you can make are deeply appreciated at this point – you are doing “God’s work” here and I applaud your commitment to directly responding to folks here – you are straightforward, fact-based, and clearly state your opinions when you have them – it is refreshing and wonderful, and I can only imagine how much time it takes on top of your consults, surgeries, research, and general practice management. So… a deep and enormous note of thanks in advance from my husband and me if you could respond…
Hopeful but realistic in Boston,
C + B
Addressed elsewhere!
Geoff Sher
I’m sorry – the 4th paragraph from the end of my original post got garbled. Regarding my current protocol I am in: 2 follies >12mm have been detected after taking the GonalF and Menopur for 7 days at this point. Also, I meant to write that neither my husband nor I are allowed to see the U/S screens in real-time much to our dismay, so I do not know how many follies are coming up that are <12 mm at this point…
Hi Cate,
There is so much to comment on that it is not really ideal to do so here.
1. You clearly have diminished ovarian reserve and at 39 with DOR, IUI is in my opinion not only unlikely to be successful but because the chances are so small and you have little time left, I personally would not have recommended it at all.
2. Your protocols used for IVF were in my opinion not optimal. I would recommend an an agonist/antagonist conversion protocol with estrogen priming, but even then it is very “late in the day” and you might not respond adequately. It is however in my opinion your best last hope other than an egg donation approach.
3. Your repeated miscarriages are probably embryo related but raise the question of an immunologic implantation dysfunction (see below)
4. As I said, you probably need egg donation but if you wish to,try with own eggs, I would strongly recommend Staggered IVF with embryo banking (see below) as your best option and….starting very soon.
Please go to the home page of this blog, http://www.IVFauthority.com . When you get there, look for a “search bar” in the upper right hand corner. Type the following subjects into the bar, click on it and it will take you to all the relevant articles posted there.
1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
2. “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
3. “Agonist/Antagonist Conversion Protocol”
4. “Immunologic Implantation Dysfunction” (posted on May, 10th and on May 16th respectively.
5. “Embryo Implantation………” (Part-1 and Part- 2—-Posted August 2012)
6. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
7.“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
8. “IVF success: Factors that influence outcome”
9. “Staggered IVF”
10.“Embryo Banking”
11. “Egg Donation”
12. Recurrent Pregnancy Loss”
13. Use of the birth control pill in IVF”
14. Uterine Fibroids”
Consider calling 800-780-7437 or 702-699-7437 to arrange a Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail
Geoff Sher
PPS. I should also share with you that my husband’s sperm has checked out completely fine 3X in the past 1.5 years with the exception of a borderline abnormal morphology that came up in 1 of the 2 test results (and it was still a bit low but considered w/in normal range in a retest). Also, I have undergone extensive chromosome testing which came out fine and am still waiting to hear back from the vascular specialist on additional tests he had done last week re: my elevated anticardiolipin issue.
See below!
Geoff Sher
Hello Dr. Sher,
I have just recently turned 35 and am experiencing many difficulties in trying for our second child. Here is my story:
February 2009 conceived our first child after trying for 4 months. Delivered a healthy daughter in November 2009.
August 2011: Early miscarriage – 5.5 weeks
Began trying again in December of 2011, fell pregnant in April 2012. Severe pain in June 2012, ovarian torsion causing the removal of my left ovary. Discovered baby had no heartbeat.
In December 2012 began seeing RE. Discovered very low amh of 0.24. 2 rounds clomid IUI-BFN. On second round of low dose injectable/IUI produced 3 mature follicles. BFP but just miscarried again at 5.5 weeks.
My RE gave me little hope using my OE and said I had very little chance of IVF working.
Would love your expert opinion; do I have bad eggs, or could this be an issue with implantation?
Thank you so much!
Kind Regards,
Julie
I think Staggered IVF with Embryo banking and CGH embryo selection is a viable option to try. Since you are 35 and still relatively young, the right protocol could still yield good eggs. That having been said, egg donation is of course a surer thing.
Please go to the home page of http://www.IVFauthority.com. When you get there look for a “search bar” in the upper right hand column. Then type in the following subjects into the bar, click and this will take you to all the relevant articles I posted there.
1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
2. “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
3. “Agonist/Antagonist Conversion Protocol”
4. “Immunologic Implantation Dysfunction” (posted on May, 10th and on May 16th respectively.
5. “Embryo Implantation………” (Part-1 and Part- 2—-Posted August 2012)
6. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
7.“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
8. “IVF success: Factors that influence outcome”
9. “Staggered IVF”
10.“Embryo Banking”
11. “Egg Donation”
12. “Gestational Surrogacy”
13. “IVF Success Rate Statistics: The Time Has Come to Revise the Present Reporting System”
Consider calling 800-780-7437 or 702-699-7437 to arrange a Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail.
Geoff Sher
Thank you so much for your quick response. My local RE is suggesting a low stim IVF with Femara/Follistim (I believe very similar to what was used with the IUI cycle). With my low amh and one ovary, is that the best type of protocol? I also have only had the amh test and the lupus anticoagulant test. Are there additional tests that you would recommend due to the recurrent miscarriages I have had?
Again, thank you very much for your response, it is truly appreciated.
Kind regards,
Julie
Good luck!
Geoff Sher
Hello Dr. Sher:
I am 36 almost 37. I had one failed IVF last year. I did get pregnant but miscarried at 6 weeks. I was told that I had low ovarian reserve but it was not explained to me at that time what that really meant. I also have only 1 tube due to eptopic as well as a tubal reversal done about 3 years ago. They were able to retrieve 4-6 eggs but I was told that the shell surronding was very hard for them to break in to??? the 2 embryos they were able to fertilize were implanted and only 1 took. but the blood tests indicated that the pregancy was not going to be successful. My HCG levels were very low but did double.
I am very disappointed because I am not sure that I was given the correct protocol for my situation. I did not know alot about IVF I simply went on what I was told. However, after he failed attempt I begin to research IVF with what I was told. I would like to try again, but want to make sure that I have the correct information and understand what my chances of conceiving is. Any information on my situation or how I should proceed would be appreciated. I am thinking about taking natural herbs DHEA, royal jelly etc. I also had to wear estrogen patches during this process.
Hello Shay,
Sorry I missed this post. It sounds like you do have diminished ovarian reserve and as such I personally would not recommend DHEA. It converts to testosterone in the ovaries and too much of the latter can be harmful to egg/embryo quality. This is most particularly the issue when it comes to older women and those with diminished ovarian reserve (DOR).
Given your DOR, you need a very strategic and individualized approach to ovarian stimulation and should also consider Staggered IVF with Embryo banking (see below).
Please go to the home page of this blog, http://www.IVFauthority.com. When you get there, look for a “search bar” in the upper right hand corner. Type the following subjects into the bar, click on it and it will take you to all the relevant articles posted there.
1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
2. “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
3. “Agonist/Antagonist Conversion Protocol”
4. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
5.“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
6. “IVF success: Factors that influence outcome”
7. “Staggered IVF”
8.“Embryo Banking”
9.“Metaphase CGH versus Array CGH: Which one?
Consider calling 800-780-7437 or 702-699-7437 to arrange a Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail
Geoff Sher
Consider calling 800-780-7437 or 702-699-7437 to arrange a Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail
Geoff Sher
Hello Dr Sher,
I am 35 years old. Got married at the age of 23 and got divorced after four years. During this four years we tried for a baby but i never conceived. when we consulted a doctor, she didnt explain to me much about my problem. but i underwent some scanning and they used to monitor my eggs. i could see in the report, the eggs size getting bigger, but of course under medication. We discontinued the treatment after an year.
I was dating another guy after my divorce and now i got married to him. Surprisingly, during my time with him, we had occasional sex, and i got conceived once. When the baby was 52 days old, i went through MTB as there was no other choice then.
Now we are married and we want a baby, i am 35 now and he is 31. My periods was irregular from the beginning. But when i was 29, it became regular.
Now again it is going hay wire, my tubes are normal my abdominal scan says my ovaries and uterus are normal. TSH is normal.
i doubt my eggs have some problems.. just an assumption. please help me doctor. i conceived once, do i have any chance for it now?
I invite you to call 800-780-7437 or 702-699-7437 to arrange a Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail
Geoff Sher
Dear Dr Sher
I’ve just turned 46, have had 2 miscarriages over last two years (both pregnancies natural). My AMH is under 1 and FSH 14. My periods are irregular 25 to 37 days though I ovulate regularly day 15/16. Donor eggs are not an option for us.
I’ve been taking HGH and melatonin as I was told this improves egg quality. I stopped taking DHEA a couple of months ago due to side effects. I’ve recently had a hysteroscopy and laproscopy and tubes are clear. I have moderate adenomyosis .
I’ve read on the Internet success with mini ivf protocol in the USA. I’m in Australia and have asked clinics here about the procedure but it appears different clinics have such differing understanding of the procedure.
I just had an ivf cycle cancelled. I was told I’d undergo a mini ivf cycle but ended up being stimmed for 13 days – 3 days 150 gonal f, 4 days 300 then 6 days 600 gonal f. Had 4 follicles but only one grew to 1.8 others remained small.
Is there anything you can recommend?….I’m not ready to give up.
Thankyou
Marie
Hi marie,
I am afraid that at age 46, the only real option is IVF with egg donation. I hesitate even to recommend the only option that would offer a glimmer of hope because even that would be very slim. However, if egg donation is totally out then all in my opinion that is left would be “Embryo banking” of CGH-selected embryos with “, “Staggered IVF” (see below).
Please go to the Home page of this blog, http://www.IVFauthority.com. When you get there, look for the “search bar” in the upper right hand corner. Type the following subjects into the bar, click on it and it will take you to all the relevant articles posted there.
1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
2. “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
3. “Agonist/Antagonist Conversion Protocol”
4. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
5.“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
6. “IVF success: Factors that influence outcome”
7. “Staggered IVF”
8.“Embryo Banking”
9. “Egg Donation”
Consider calling 800-780-7437 or 702-699-7437 to arrange a Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail
Geoff Sher
Dr. Sher,
I am 26 years old and have been diagnosed with DOR. My AMH is .28 and my cycle day 3 antral follicle count was 7. My husband also has sperm morphology of less than .3%. We have tried 3 IUIs and all have failed. We conceived naturally this past March but miscarried at 7 weeks due to a blighted ovum. Our RE thinks that IVF would not be worth our time and resources because she said that women with my condition do not respond well to the IVF meds. What are your thoughts? Is there any hope for us to conceive a child of our own?
I respectfully disagree. You need IVF. IUI is just wasting valuable time in my opinion. You should consider aggressive st5imulation with embryo banking and Staggered IVF.
Please go to the home page of this blog, http://www.IVFauthority.com. When you get there, look for a “search bar” in the upper right hand corner. Type the following subjects into the bar, click on it and it will take you to all the relevant articles posted there.
1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
2. “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
3. “Agonist/Antagonist Conversion Protocol”
4. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
5.“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
6. “IVF success: Factors that influence outcome”
7. “Staggered IVF”
8.“Embryo Banking”
Consider calling 800-780-7437 or 702-699-7437 to arrange a Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail
Geoff Sher