Welcome to IVF Authority - World Renowned Resource for IVF Information

Welcome to IVF Authority Blog

Search by Topic

    Search by Date

      << Back to IVF Page

      • IVF Ovarian Stimulation: The GnRH Agonist / Antagonist Protocol

      Dr. Geoffrey Sher Recommends

      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      Phone:
      702-892-9696

      Fax:
      702-892-9666

      GnRH antagonists (e.g. Ganirelix, Cetrotide, Cetrorelix and Orgalutron) are currently used with many controlled ovarian hyperstimulation (COH) protocols. They are traditionally prescribed at the dosage of 250mcg daily from the 6th or 7th day of stimulation with gonadotropins. This is completely acceptable for younger patients (under 39 years) and for good responders to COH who have normal ovarian reserve (i.e. normal day 3 FSH, AMH, and Inhibin B blood levels). However, it can be disadvantageous in women who have elevated baseline luteinizing hormone (LH) levels (e.g. those with polycystic ovarian syndrome [PCOS], women over 40 years of age, and poor responders who have diminished ovarian reserve). In such cases, the abrupt pituitary suppression that rapidly follows administration of the GnRH antagonist, (when it is first administered several days after the COH begins), occurs too late in the cycle of stimulation to suppress LH before it begins adversely affect follicle and egg development

      Background Information

      One of the roles of LH is to promote male hormone (androgen) production through the connective tissue that surrounds follicles (the stroma or theca). The androgens (maily testosterone) represent the building blocks from which the follicle granulosa cells manufacture estrogen. While a small amount of stromal androgen is essential for optimal follicular growth and egg development, too much can compromise their development. Accordingly, unless the LH levels are regulated by the GnRH antagonist from early in the cycle of COH, the developing follicles and eggs of women who have chronically elevated LH levels can be overexposed to stromal androgens for several days before GnRH antagonist suppression is in effect. This can and does adversely influence egg/embryo quality and perhaps even endometrial proliferation in response to estrogen .

      The “Premature LH Surge”

      Presumably, the reason for the suggested mid-follicular initiation of high dose GnRH antagonist is to prevent the occurrence of the so called “premature LH surge”, a condition where high LH levels cause “follicular exhaustion” resulting in poor egg/embryo quality. But the term “premature LH surge” is a misnomer since it suggests a sudden unanticipated rise in LH that occurs as a “terminal event” or an isolated occurrence. In actuality, what happens is the result of a progressive escalation in LH (the so called “staircase effect”) that through a persistent rise in stromal androgens, ultimately exhausts the follicle and damages the egg irreparably.

      A more accurate term might be “premature luteinization.” Against this background, trying to improve ovarian response and prevent follicular exhaustion through administration of GnRH antagonist initiated late in the cycle of COH is like shutting the gate after the horse has already left the stable.

      As stated, the use of such “late–follicular” GnRH antagonist protocols in younger women or in women with normal LH and ovarian reserve will probably not produce such adverse effects. However, the more appropriate question might be: since such women are not at risk of premature luteinization, would they even require pituitary LH suppression? I doubt that they do! It is my position that some form of pituitary blockade, either in the form of a premenstrual GnRH agonist administration (e.g. Lupron, Buserelin, Nafarelin, Synarel. Decapeptyl) or GnRH antagonist (e.g. Cetrotide, Cetrorelix, Orgalutron, Ganirelix) is beneficial for older women, women with elevated LH, and for those with diminished ovarian reserve, undergoing COH for IVF. Only in this manner can the adverse effects of LH –induced ovarian androgen elevation on follicle/ egg development be averted.

      With GnRH agonist (e.g Lupron) down-regulation protocols (where the pituitary gland is first largely exhausted of LH before COH begins) the residual amount of LH in the circulation is minimal by the time COH with gonadotropins is initiated. The above-mentioned adverse LH-induced androgen effect is thereby largely negated.

      The agonist/antagonist conversion protocol
      The downside of prolonged GnRHa (e.g. Lupron) administration throughout the cycle of COH is that the GnRHa, by competitively binding with ovarian follicle stimulating hormone (FSH) receptors, can suppress ovarian response to gonadotropins. To counter this effect, we introduced the Agonist/Antagonist Conversion Protocol (A/ACP).

      With the A/ACP, only a low dosage (125mcg/day) of GnRH antagonist is injected daily. It is commenced at the onset of spontaneous menstruation, or after the onset of menstruation that follows the initiation of GnRH agonist (e.g. Lupron) therapy that is administered in a long-pituitary down-regulation protocol arrangement. We currently prescribe some form of the A/ACP for most of our IVF patients regardless of whether they are “normal responders” or “poor responders”. Results suggest a significant improvement in egg number, egg/embryo quality, as well as implantation and viable IVF pregnancy rates.

      The A/ACP for poor responders
      The A/ACP has, however, proven to be most advantageous in “poor responders” with diminished ovarian reserve, where additional enhancement of ovarian response to gonadotropins may be achieved through incorporation of “estrogen priming”. We have reported on the fact that the administration of intramuscular estradiol starting about a week prior to commencement of COH often markedly enhances ovarian response (presumably by enhancing the sensitivity of ovarian FSH-receptors), and improves egg/embryo quality. We refer to l this as the A/ACP+ E2V.

      It is remarkable that while using the A/ACP + E2V in poor responders whose FSH levels were often well above threshold limits, the cycle cancellation has consistently been maintained below 10% (much lower than expected). Many such patients who previously were told that they should give up on using their own eggs and switch to ovum donation because of “poor ovarian reserve”, have subsequently gone on to achieve viable pregnancies using the A/ACP with “estrogen priming”.

      What are the downsides of the A/ACP? There is one potential drawback to the use of the A/ACP, in that prolonged administration of GnRH antagonist throughout the stimulation phase of the cycle compromises the predictive use of serial plasma estradiol measurements as an indication of ovarian response to COH. The estradiol levels tend to be much lower in comparison with cases where GnRHa alone is used, or where a “conventional” GnRH antagonist protocol is commenced 6-8 days following initiation of gonadotropin stimulation. The reason for the lower blood concentration of estradiol seen with prolonged exposure to GnRH-antagonist could be the result of subtle, antagonist-induced alterations in the configuration of the estradiol molecule, such that currently available commercial test used to measure estradiol levels are rendered less sensitive/specific.

      Accordingly, when the A/ACP protocols are employed, we rely much more heavily on the measurement of follicle growth by ultrasound than on the estradiol levels. Because of this downside, we confine the use of A/ACP protocols to normal and poor responders – refraining from using this approach in “high responders” who may be at risk of developing of severe ovarian hyperstimulation syndrome (OHSS) and in whom the accurate measurement of plasma estradiol plays a very important role in the safe management of their COH cycles.

      Tags: , , , , ,

      38 Responses to “IVF Ovarian Stimulation: The GnRH Agonist / Antagonist Protocol”

      1. ihavefavor2_wuah says:
        July 24, 2009 at 6:23 am

        Is there any Doctor that you know of that can grant this wish ?

        Wisher:lawenforcementwife
        Wish direct link :
        http://wishuponahero.com/wishes/?id=313987

        Hello Dr Sher, I came across this wish on WishUponAHero.com and I started to do some research to see if this wish could be granted. I googled and I came up with your site. If you can read this wish and know someone that could grant it please pass it on .Thanks! :) I posted the wish at the bottom of this message and I posted the direct link over this message.

        I WISH that we could find a good fertility doctor…

        My husband and I have been married for almost 7 years. We spent the first 3 years of our marriage trying to have a child. We ended up spending over $50K in treatments & medications, but finally in 2006 were blessed with a beautiful baby girl. We would love for our daughter to have a sibling. My wish is that we could find a fertility doctor to discount the rates or donate his time so that we may be blessed with another child. We have so much love to give. I have faith that God will find a way to make this happen. If anyone knows of any good doctors in Missouri please share your information with us. Thank you & God Bless!
        ~ Kelly ~

        Reply
      2. Geoffrey Sher, MD says:
        July 24, 2009 at 10:10 am

        Please contact the IVF support group the "InterNational Council on
        Infertility Information Dissemination (INCIID) about their INCIID the Heart program that provides free IVF to qualifying couples. Talk to Nancy Hemenway Phone # 703-346-8402.

        Good luck!

        Geoff Sher

        Reply
      3. Jamie says:
        June 7, 2010 at 9:41 pm

        Would you suggest the A/ACP + E2V protocol for a patient with Factor V Leiden?

        Thanks!

        Reply
      4. Geoffrey Sher, MD says:
        June 9, 2010 at 3:55 pm

        No reason not to! The thrombophilia is in no way related.

        Geoff Sher

        Reply
      5. exitray says:
        January 9, 2011 at 6:02 pm

        Dear Dr. Sher,

        I am beginning my second round of IVF shortly, and my doctor has prescribed a protocol that sounds similar to what you've described above. I would take 3mg Centrotide on day 2 of my cycle and begin Follistim around day 7, adding more Centrotide once the follicles reached about 14mm.

        I am 32, "lean" PCOS with insulin resistance, mild/subclinical hypothyroidism, and high DHEA-S levels. No male factor. With metformin and thyroid medication, I have begun ovulating normally but without pregnancy. We have had a year's worth of unsuccessful clomid/letrozole + IUI cycles and one IVF that resulted in a biochemical pregnancy (I responded well to that cycle, with 11 fertilized eggs but only one good quality blastocyst transferred on day 6). All my doctors have agreed that suppressing me prior to stimulation would be beneficial for egg quality, but I haven't come across a protocol that starts suppression on Day 2. Have you heard of this? Any ideas or suggestions as to a good approach?

        Thanks for your thoughts.

        Jenny

        Reply
      6. mum2oneds says:
        May 25, 2011 at 10:32 pm

        Dear Dr Sher, your A/ACP protocol is rather long, mostly u would start with BCP and GnRH agonist and wait for a period before starting on GnRH antagonist then Stim. Could it be possible to start GnRH antagonist right after spontaneous menstruation and then Stim? Will it work too? U mentioned this option in another entry but overall I see that you seem to advocate the long treatment with BCP.

        I have failed two cycles so far with down regulation Agonist treatments, all embryos did not implant..seeming poor quality I assume. I am 37 and have lower ovarian reserve 6.0pmoL.

        Would appreciate your comments. Thanks!

        Reply
      7. tapka says:
        February 4, 2013 at 12:34 am

        Dear Dr. Sher,
        my protocol with Merional, Fostimon and Cetrotide injections brought 15 eggs, out of them 5 made it to the blastocyst stage after ICSI, 3 blastocysts were implanted and there was nothing to freeze. After the transfer I received the prescription for Progesteron 100 mg once daily but due to the mistake of pharmacy received only 50 mg daily. Blastocysts were transferred on 23/Jan/2013, BHCG on 01/Feb/2013 was less than 2. Until now (04/Feb/2013) I have no period. Is there a possibility that I am pregnant?

        Reply
      8. anna says:
        March 19, 2013 at 1:15 pm

        Hi Dr. Sher

        I’m 42yo and here is my history:

        1st IVF 2009 – 5 fert, d5et 2 blasts, bfn, Lupron, 225GF, 150M,
        2nd IVF 2010 – 13 embrios, d5et 2 blasts, DS, 225 gf, 75M
        3rd ivf 02/2012 – 2 embrios, chemical, 225 gf, 150M
        4th IVF 10/2012 – d3et, 3 embrios, BFN, EPP, 300gf, 75M,
        5th IVF 01/2013 – d3et, 4 embrios, BFN, BCP, MDL, 450gf, 150M,

        Follicle Stimulating Hormone 7.06 mIU/mL
        Anti-Mullerian Hormone (Quest 91000102) 1.74 ng/mL

        For my next cycle my RE sufggested the following: 6th IVF 2013 – co-culture, EEP, clomid, 450gf, 150M, PIO + E, AH

        What do you think of this protocol? Was protocol #5 what you would concider an Agonist / Antagonist protocol?

        Thanks,
        Anna

        Reply
      9. DD says:
        March 24, 2013 at 8:17 pm

        Hello Sir,

        Your blogs are great source of information. Unfortunately, I just found them a little late…so here is my question:

        I am starting my 1st IVF, I am 32 and was identified with high prolactin( 50 ) last year which is now in control around 7 with the medication. My husband is 33 and has been identified with 2% morphology, We had two unsuccessful IUI’s (Clomid and ovirdrel) and are now moving ahead with IVF. Rest, we seem to have no issues from all the tests done.
        My AMH- 2.04, FSH 6.1 and Estradiol 42.

        Here are my stims, from your article it seems I am on long protocol but would appreciate if you could provide your thoughts on stimulation medicines.

        BCP – Desogen – 3 weeks
        Lupron – 10 units from 17th day of BCP and then BCP ends on 21st day.

        Then I start 1 vial of menopur and 225 of follitism after 2 weeks of lupron. That day lupron goes down to 5 units and I continue all three till HCG shot…

        Does this sound good to you?

        Thank you!
        DD

        Reply
        • Geoffrey Sher says:
          March 24, 2013 at 9:24 pm

          Sounds pretty good to me as long as all other bases have been covered such as implantation issues. You have normal ovarian reserve and I would anticipate that you will produce a good number of eggs. By the sound of things you have an excellent chance of being successful.

          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. “Embryo Implantation………” (Part-1 and Part- 2—-Posted August 2012)

          6.“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)

          8. “IVF success: Factors that influence outcome”

          Good luck!

          Geoff Sher
          800-780-7437

          Reply
          • DD says:
            March 25, 2013 at 12:19 pm

            Thank you so much for your quick response and kind words. I forgot to mention that we will be doing ICSI.

            I have gone through all the articles you mentioned but I am not sure which tests I should be doing. I have done saline infusion sonogram already and everything looks fine. Also for mock transfer, my RE suggested since I have already IUI with her, there is no need to repeat that process.

            Shall I ask to get done the blood work done for immunologic i.e. CTL and NK cell and should we do PGD?
            Are there any other tests that you would think we should be doing for implantation checking?
            Appreciate all your answers. They mean a lot!

            DD

            Reply
            • Geoffrey Sher says:
              March 25, 2013 at 12:49 pm

              I cannot advise further. It would be intrusive. This is now between you and your RE.

              Good luck!

              Geoff Sher

              Reply
              • Geoffrey Sher says:
                March 25, 2013 at 4:58 pm

                The starting beta was very high so it could be that >1 took and is now in the process of spontaneously reducing. Time will tell.

                Good luck!

                Geoff Sher

            • Geoffrey Sher says:
              March 26, 2013 at 1:57 pm

              AS I indicated,

              I cannot immerse myself further. I would do those tests if I were you!

              Geoff Sher
              800-780-7437

              Reply
      10. Emily says:
        April 1, 2013 at 2:17 pm

        Hi Dr Sher,

        I am now on BCP and Lupron .5mg and I will be on this for a couple of days more when I will stop BCP and continue Lupron. My RE wants me to continue Lupron until i go to the clinic for the ultrasound scheduled for a specific day. Do you think this may work, continuing taking lupron even if i get my period until the day of ultrasound and then replace it with 125mcg antagonist the day of my ultrasound, same day when i start the gonadotropin therapy?
        Because my u/s is scheduled for a specific it is a good idea continuing with lupron while on my period?
        I understand you don’t intend to change my RE protocol but I would just like to know your opinion on this.

        Thank you very much,
        Emily

        Reply
      11. Julia says:
        April 3, 2013 at 1:18 pm

        Dear Dr Sher,

        I live in Canada and I will start my treatment soon with my local RE. He will have me on birth control pill and .5ml buserelin instead of lupron. During the stims I will be on 125 orgalutran, 200 puregon and starting day 3 of stims on 37.5 menopur. In your opinion, do you think it is better to use a pure LH form as Luveris instead of menopur that is combined with FSH or it should be the same? ( as 237.5 puregon and 37.5 luveris versus 200 puregon and 37.5 menopur).
        My FSH is 5.9 and LH 8.1 and I respond normal to the meds. Do you consider adding 37.5 menopur on day 3 of stims, a good choice or should I be just on puregon?
        On the A/ACP protocol there is still a risk of oversuppression and not responding well during stims or because we switch to an antagonist, this will not happen?

        Thank-you very much for your help,
        Julia

        Reply
      12. mary says:
        April 13, 2013 at 6:53 am

        hi dr sher, I am 37 and ttc for 10 yrs, my fsh is 11 and amh is 8.3, i have no other issues.I have just had my 2nd 1vf cycle, no eggs were retrieved. on the first cycle i got 3 eggs out of 9 follicles, i had a chemical pregnancy from that cycle.i used a short protocol for each cycle with a higher dose of gonal on the 2nd cycle.my re has recommended three protocols for my next cycle.1. estrogen priming then using femara for 5 days at start of stimulation then menopur,gonal f and cetrotide on day 7. 2. long protocol or 3. short flare protocol using synarel, please can you advise which you would recommend i use

        Reply
        • Geoffrey Sher says:
          April 13, 2013 at 8:53 am

          You are probably aware that I personally am against the use of short protocols for women who have diminished ovarian reserve because in my opinion, it causes increased LH which results in excessive ovarian testosterone which can adversely impact on egg/embryo quality. I prefer using the long pituitary down-regulation protocol referred to as the agonist/antagonist conversion protocol (A/ACP).

          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”

          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

          Reply
      13. Mary says:
        April 14, 2013 at 5:02 am

        Dear Dr Sher
        Thank you for your reply. Do you think using femara is useful. I know you don’t use clomid at all, but would you recommend femara?
        Thank you

        Reply
      14. Renee says:
        April 14, 2013 at 12:33 pm

        Dear Dr Sher.

        Thanks you so much for your informative articles.

        I am 40 with a low amh of 4. My husband and I have had 2 failed cycles of icsi. I have responded poorly in both cycles to different protocols used.

        The protocols I have responded poorly to were (i) the long protocol ( buserelin/ 300iu menopur) and (ii)’the short protocol (600iu gonal-f/ 75iu luveris followed by introduction of 0.25mg cetrotide 6 days after administration of gonal-f/ luveris). In both cases I had few weeks of combined pill first. In the case of the short protocol I was pre treated with dhea.
        Although I did manage to have a top quality day 3 embryo transferred in both cases ( with negative result), I am anxious to see if protocol and my response can be improved.

        I am interested in your A/ACP +E2V protocol but am concerned that I may experience ‘oversupression’ like I did in buserelin- long protocol.

        My questions are as follows:

        -Do you think I would be a suitable candidate for your protocol or is my ovarian reserve/ my response too poor to make much of a difference?

        - With your protocol is it possible to lower dose of gonal-f/ luveris (or menopur) and still acheive better response?
        Women like me tend to be hit with very high dose gonadotropins and I am concerned about the impact of same on egg quality. From your article, I am also concerned about dose of luveris used ( or LH contained in menopur) ie I am concerned re too much LH being used.

        3. Do you do skype consult for international ( European) clients who are not in a position to travel to the states?!!!!

        Many, many thanks.

        Reply
        • Geoffrey Sher says:
          April 14, 2013 at 2:18 pm

          No! In fact you would be an ideal candidate for the estrogen priming with an aggressive A/ACP stim. However, please expect it to take an additional few days to respond on the E2 priming approach .

          Geoff Sher

          Reply
      15. Renee says:
        April 16, 2013 at 2:04 pm

        Many thanks for that info Dr Sher.

        Regarding my second icsi cycle ( short antagonist protocol) just looking at my bloods- my baseline serum LH was 0.9IU/L and 5 days into stimulating with 600iu gonal-f/ 75iu luveris, serum LH rose to 1.4IU/L . So, reflecting what you said in your article there was a LH surge.
        By day 8, following cetrotide administration on day 6, the LH level dropped to 0.7IU/ ml.
        Im concerned however, that overall, alll the serum LH levels measured are very low.
        Are such low LH levels normal or typical with diminished ovarian reserve?
        Does the kind of rise in serum LH I experienced with this protocol typify what you expect ?

        Many thanks.

        Reply
        • Geoffrey Sher says:
          April 16, 2013 at 2:23 pm

          Frankly it does not look too bad…but I do not use short antagonist protocols in women with DOR.

          Geoff Sher

          Reply
      16. mary says:
        May 6, 2013 at 3:24 am

        Dear Dr Sher,
        Please can you give your opinion.For my next ivf protocol the flare up protocol has been recommended. I responded poorly to previous cycles. the last one retrieved no eggs. my amh is 8.3 and fsh 11. The protocol uses synarel and gonal f and menopur. Do you think i will respond better to this protocol. would i benefit from estrogen priming before my next cycle? how long do you use estrogen priming treatment? Thank you

        Reply
        • Geoffrey Sher says:
          May 6, 2013 at 9:05 am

          No! I am not a fan of the “flare protocol at all” (see below) and estrogen priming will have no benefit in your case.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. “Embryo Implantation………” (Part-1 and Part- 2—-Posted August 2012)

          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)

          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

          Reply
      17. mary says:
        May 7, 2013 at 12:38 pm

        thank you Dr Sher, I’m just confused as to why you say that estrogen priming would have no benefit?

        Reply
        • Geoffrey Sher says:
          May 7, 2013 at 1:36 pm

          I did not imply that it will have no benefit, but it will not benefit everyone. It will in my opinion only benefit Very poor responders with severely diminished ovarian reserve.

          Geoff Sher

          Reply
        • Geoffrey Sher says:
          May 8, 2013 at 5:38 am

          I introduced estrogen priming but have found that it only benefits those with SEVERE DOR.

          Geoff Sher

          Reply
      18. Kathy says:
        May 10, 2013 at 3:29 pm

        Greetings Dr. Sher,
        Have you ever heard of a Ganirelix/Microflare protocol? It requires bcp for three weeks overlapped and followed by ganirelix. After 6 days on the ganirelix and after baseline info collected the stims start (Menopur 75 2x a day and Gonal-F 300 2x a day). What are your thoughts on this protocol? I thought it was the agonist/antagonist protocol, but it does seem like it is.

        Reply
        • Geoffrey Sher says:
          May 10, 2013 at 11:00 pm

          Ganirelix and other antagonists” do not cause a flare. It suppresses FSH and LH very rapidly. Lupron (and other agonists) by expunging FSH from the pituitary gland cause a “flare effect”. I respectfully do not agree with starting a stimulation coming off a BCP without 1st overlapping with an agonist such as Lupron or Buserelin. See the article I wrote on “use of the BCP in IVF” , elsewhere on this blog.

          Feel free to call 800-780-7437 if you would like to discuss further via a Skype consultation with me.

          Geoff sher

          Reply
      19. Valerie says:
        May 20, 2013 at 10:53 am

        Hello. Is estrogen priming for women with DOR and low to mid-level response to gonadotropins harmful when there is also a diagnosis of Endometriosis?
        Thank you,
        Valerie

        Reply
      20. Jennifer says:
        May 22, 2013 at 4:27 pm

        I have low Amh .10 and fsh in the last two years of 9 and 11. 2 resting follicles each side. 1st Ivf cancelled with only 2 produced from 225 menopur and glonal. Trying Seattle for 2nd try 8 months later would I benefit from estrogen priming and long pituitary down regulation protocol? I am 38.

        Reply
        • Geoffrey Sher says:
          May 22, 2013 at 4:44 pm

          Yes, you need a very aggressive agonist/antagonist conversion protocol with estrogen priming. You should also seriously consider Staggered IVF with embryo banking starting ASAP (see below).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. “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

          Reply

      Leave a Reply

       
      Financial Risk-Sharing: Reducing the Cost of Having a Baby

      In the United States, the richest and most technically advanced nation on earth, millions of couples remain involuntarily ... Read more

      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      Case Study: Hydrosalpinx (Blocked/Fluid Filled Fallopian Tubes) and IVF Failure

      RL, a 31-year-old woman, presented with a 7 year history of inability to conceive, in spite of 2 prior fresh and 1 frozen IVF ... Read more

      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      Why IVF Pregnancies Are “Higher Risk”

      While many IVF pregnancies will progress normally and without any increased risk to mother or baby, there is little doubt ... Read more

      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      Recurrent Unexplained IVF Failure with “Good Quality” Embryos

      The following is a case study of a recent patient that came to me for treatment.  CJ, a 34 year old, and her husband RJ ... Read more

      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...

      Top Search Terms for In Vitro Fertilization

      Dr. Geoffrey Sher Recommends

      Embryo Quality & Embryo “Competence” – Part III – Testing the Seed
      This is the third and final post in three part series on embryo quality. In the prior two posts, I outlined the intrinsic/physiological factors and the clinical factors that can impact embryo “competence”.  In this post, I will discuss the rol... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      Embryo Quality & Embryo “Competence” – Part One: Planting a Good Seed
      “At 45 years of age the incidence of aneuploidy is likely to be nine in ten.” Several weeks ago, I posted an article about endometrial receptivity and its effect on IVF success. This, as I noted, was the “Soil” component of the “See... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      The Needle vs. the Dish: Should ICSI Be Used in All IVF?
      The introduction of Intracytoplasmic Sperm Injection or ICSI has made it possible to fertilize eggs with sperm derived from men with the severest degrees of male infertility. What’s more, pregnancy rates achieved by this method of fertilization are... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      Embryo Implantation: What Farmers Can Teach us About Growing Healthy Babies
      I often refer to the conception process in terms of a “seed/soil” relationship.  Just as a plant can’t grow and thrive without first assuring that both seed and soil are good, neither can a pregnancy be successful without both the seed (e... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      Acupuncture and IVF: Does it Improve Success?
      Acupuncture involves the insertion of thin needles into the skin along so-called meridians (energy channels). It has been used in China for centuries to regulate and treat many health disorders including ailments involving the female reproductive sys... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      My IVF Cycle Failed – What Went Wrong? Question #17: Why Didn’t I Get Pregnant When I Used a Young Egg Donor and Had Good Quality Embryos?
      This is #17 in a series of answers to common questions about failed IVF. For women whose advancing age and/or ovarian resistance make having a baby with their own eggs unfeasible or unlikely, IVF using donated eggs from a young donor (under 35 years)... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      My IVF Cycle Failed – What Went Wrong? Question #15: Might My Mental State Have Played a Role?
      This is the 15th in a series of responses to common questions about failed IVF There is little doubt that stress and emotional lability plays a role in the normal physiological/hormonal regulation of the menstrual cycle.After all, Eskimos often stopp... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      Understanding Immunologic Implantation Dysfunction Part 1: Setting the Stage for Selective Immunotherapy with Intralipid and IVIg
      It is an unfortunate reality that many IVF programs attach little importance to factors that affect embryo implantation in general, and immunologic implantation dysfunction (IID) in specific (see below). Perhaps the lack of attention given to evaluat... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      IVF: Coping With the Emotional Roller Coaster Ride
      Procreation – and with it the ability to achieve immortality by living on through one’s children – is one of the most insatiable human needs. This strong natural urge exerts tremendous pressure on couples unable to have a baby. And ... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      DQ alpha/HLA Sharing: Does It Always Lead To Reproductive Failure?
      It is not unusual for couples who share DQ alpha/HLA similarities to first give birth to a healthy baby only to subsequently develop infertility, recurrent IVF failure or recurrent pregnancy loss. Such couples find it hard to comprehend how after hav... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      Dr. Geoffrey Sher Recommends

      CGH Embryo vs. Blastocyst vs. Cleaved Embryo
      IVF Success Rate Reporting – Are We There Yet?
      Please join me on Wed, February 6 at 8:30pm Eastern for a live webinar where I’ll discuss this topic in detail and take your questions. For more information or to register, click HERE ————- I have, for many years, tak... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      IVF Success Rate Statistics: The Time Has Come to Revise the Present Reporting System
      IVF programs currently report their outcome statistics in a number of categories: a)      Number of IVF cycles initiated in a given year b)      Number of single and multiple pregnancies that occurred c)      Number of cycles that res... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      Mother Gives Birth Using Daughter’s Eggs: Was It “Ill Conceived”?
      I wish to share a very interesting case with you; one that I’m pretty sure will meet with the approval of some and evoke criticism by others. Before I even tell you about it, let me say that I and my team thought long and hard before going ahead wi... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      IVF Authority - Dr. Sher's Blog
      Gender Selection in IVF: What Is Its Place?
      Couples have for centuries sought to influence the gender of their offspring. More than seven centuries ago the ancient Chinese developed a birth calendar said to be able to predict gender on the basis of when conception occurred. Later, the ancient ... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      Acupuncture and IVF: Does it Improve Success?
      Acupuncture involves the insertion of thin needles into the skin along so-called meridians (energy channels). It has been used in China for centuries to regulate and treat many health disorders including ailments involving the female reproductive sys... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      Understanding Immunologic Implantation Dysfunction Part 2: A Rational Basis for Selective Intralipid & IVIg Immunotherapy in IVF
      ALLOIMMUNE VS. AUTOIMMUNE DYSFUNCTION Alloimmune Implantation Dysfunction Every human being has two DQ-alpha genes. One is contributed by the father and the other by the mother. In a small percentage of patients undergoing IVF, paternal-maternal DQ-a... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      Understanding Immunologic Implantation Dysfunction Part 1: Setting the Stage for Selective Immunotherapy with Intralipid and IVIg
      It is an unfortunate reality that many IVF programs attach little importance to factors that affect embryo implantation in general, and immunologic implantation dysfunction (IID) in specific (see below). Perhaps the lack of attention given to evaluat... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      DQ-alpha Matching in IVF: The Controversy, How It Affects Outcome, & How to Treat!
      IVF patients, especially those who find themselves inexplicably repeatedly failing treatment after treatment are no longer willing to blindly accept platitudes from those who would ignore the role of immunologic causes of IVF failure while unable to ... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      Unexplained Infertility: True Diagnosis or Cop Out?
      For about 10% of all infertile couples, the cause of the infertility cannot be readily determined using conventional diagnostic methods. Such cases are often referred to as “unexplained infertility.” The truth, however, is that in most su... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      Egg Banking of Genetically (CGH)-Tested Eggs Could Change The Face Of IVF-Ovum Donation
      For more than a quarter century, medical scientists have attempted to defy the biological clock by freezing a woman’s eggs to preserve her fertility. Most of these efforts have failed. Consider the fact that since the birth of the world’s 1st “... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      Case Study: Hydrosalpinx (Blocked/Fluid Filled Fallopian Tubes) and IVF Failure
      RL, a 31-year-old woman, presented with a 7 year history of inability to conceive, in spite of 2 prior fresh and 1 frozen IVF attempts, where a total of six good quality blastocysts had been transferred to her uterus.  Her husband PL, had normal spe... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      Recurrent Unexplained IVF Failure with “Good Quality” Embryos
      The following is a case study of a recent patient that came to me for treatment.  CJ, a 34 year old, and her husband RJ (age 35) presented to me with a six-year history of infertility. Based on semen analysis, RJ, who had initiated two pregnancies i... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      Karmann and Ryan’s Journey – My Approach to Their Treatment
       Please refer to last week’s blog post, where Karmann tells in her own words her struggles with recurrent miscarriage – nine miscarriages to be exact – and her long journey  of heartbreak, disappointment, and finally – hope.... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      Wennerlinds
      Karmann and Ryan – Nine Miscarriages, Then Hope!
      In observation of National Infertility Awareness Week (NIAW), I wanted to share the touching story of a couple that I first met last year – after they had already experienced 8 years of heartbreak and frustration.  Their story is representativ... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      IVF in a Same-Sex Male Couple: A Case Study
      Background: About two years ago, I received a call from a gentleman that I will call “John”. John was a movie producer who stated that he and his partner “Brian” had been in a monogamous same-sex relationship for 7 years and each wanted to si... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      Recurrent Molar Pregnancy Treated By “IVF Genetic Chess”
      Background: Maria (fictitious name), a childless 34-year-old Hispanic lady, presented with a history of having had five (5) successive spontaneous pregnancy losses at 7 weeks gestation, all due to hydatidiform moles. Four (4) of these losses were ... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      Case Study: Donor Egg IVF in a Post Menopausal Woman
      Mary (fictitious name), a 54 year menopausal woman, presented at SIRM-Las Vegas for IVF using an egg donor. She had been menopausal for 7-plus years and had NOT been on any hormone replacement therapy. Mary gave a history of having undergone IVF with... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      Case Study: Endometriosis Presenting as “Unexplained Infertility”
      I consulted with a 36 year old lady (whom I will refer to as “Sandra”) and her partner, about 18 months ago. She and her husband of 5 years had been having regular unprotected intercourse throughout this time and had been unable to conceive. Sand... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      Case Study: Pelvic Tuberculosis, Hypothyroidism, and Immune Implantation Dysfunction
      About 18 months ago I saw an Asian Indian couple who presented with a very interesting history. The female partner (whom I will refer to as DB) had regular menstrual cycles and normal ovarian reserve, was ovulating regularly and had a fertile male pa... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      Dear Dr. Sher: A Healthy Baby Followed by Multiple Miscarriages
      This is the second in a series of posts taken from questions that have been submitted to me via email, website, or discussion boards.  This question is from a patient who had a healthy baby from her first pregnancy, but then went through a period of... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      Karmann and Ryan’s Journey – My Approach to Their Treatment
       Please refer to last week’s blog post, where Karmann tells in her own words her struggles with recurrent miscarriage – nine miscarriages to be exact – and her long journey  of heartbreak, disappointment, and finally – hope.... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      Why Did My IVF Fail? Part 2 – Uterine Receptivity and Transfer Technique
      This is the second part of a two-part post on IVF failure. In my January 22nd post, I discussed what I often refer to as the “seed” variable in the “seed/soil” relationship – the embryo. This week’s post will address the “soil” variab... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      My IVF Cycle Failed – What Went Wrong? Question #19: Why Do I Keep Having Chemical Pregnancies and Miscarrying?
      This is the 19th in a series of answers to common questions about failed IVF. Early pregnancy loss – whether due to miscarriage or chemical pregnancy – is due to two major factors. In more than 70-80% of cases the cause is attributable to... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      My IVF Cycle Failed – What Went Wrong? Question #18: My Fertility Clinic Reports a High Success Rate – How Could I Have 2 Failed Cycles In A Row?
      This is no. 18 in a series of answers to common questions about failed IVF. While it is true that IVF failure can be due to preventable factors, it is as important to understand that optimal medical care does not always equate with an optimal outcome... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      My IVF Cycle Failed – What Went Wrong? Question #17: Why Didn’t I Get Pregnant When I Used a Young Egg Donor and Had Good Quality Embryos?
      This is #17 in a series of answers to common questions about failed IVF. For women whose advancing age and/or ovarian resistance make having a baby with their own eggs unfeasible or unlikely, IVF using donated eggs from a young donor (under 35 years)... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      My IVF Cycle Failed – What Went Wrong? Question #16: Why did my hCG levels stop rising properly?
      This is the 16th in a series of answers to common questions about failed IVF. Immediately following implantation, the root system (trophoblast) of the embryo begins to release the pregnancyhormone, human chorionic gonadotropin (hCG) into the surround... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      My IVF Cycle Failed – What Went Wrong? Question #15: Might My Mental State Have Played a Role?
      This is the 15th in a series of responses to common questions about failed IVF There is little doubt that stress and emotional lability plays a role in the normal physiological/hormonal regulation of the menstrual cycle.After all, Eskimos often stopp... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      My IVF Cycle Failed – What Went Wrong? Question #14: Could it Have Been Due to Inadequate Hormonal Support After the Egg Retrieval & Embryo Transfer?
      This is the 14th in a series of answers to common questions about failed IVF. In vitro fertilization establishes an abnormal hormonal environment in the uterus.In some cases (especially older women and those with a diminished ovarian reserve), high o... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      My IVF Cycle Failed – What Went Wrong? Question #13: Did the Number of Embryos I Had Transferred Play a Role?
      This is the 13th in a series of answers to common questions about failed IVF. Virtually everyone recognizes that pregnancy with multiples (especially triplets or greater) is associated with a high incidence of premature delivery that has serious cons... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...
      My IVF Cycle Failed – What Went Wrong? Question #12: Might the Timing of Embryo Transfer – Day 2-3 (Cleaved) vs. Day 5-6 (Blastocyst) Play a Role?
      This is the 12th in a series of answers to common questions about failed IVF. (Note: I’ll be hosting a live video chat on Aug. 2 on the topic of Failed IVF where I’ll discuss the issues addressed in this series of posts and take your ques... more
      1 Star2 Stars3 Stars4 Stars5 Stars
      Loading ... Loading ...

      Ask Dr. Geoffrey Sher

      PST: Pacific Standard Time
      CAPTCHA Image

      Enter Code*:
      Reload Image
      Business Hours
      Mon - Fri ( 9a - 5p ) PST
      CALL US TOLL FREE : (866)428-3222
      Ask Our Doctors
      A Question

      Latest News and Events

      Denton Mom Gets First Mother’s Day Thanks to SIRM..
      WMBD: Dr. Gary Horowitz on Endometriosis
      Couple Celebrates Mother’s Day Thanks to SIRM-Dal..
      Dr. Fisch Leaving SIRM
      Webinar with Dr. Sher – Immunologic Causes of Inf..
      Fox News: Dr. Sher Discusses Possible Hope For Infertil..
      Southwest moms share their stories of trials and tribul..
      7 Simple Things You Can Do to Increase Infertility Awar..
      Karmann and Ryan – Nine Miscarriages, Then Hope!..
      Farewell Robert Edwards and Thank You!