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My IVF Cycle Failed – What Went Wrong? Question #6: How much could my elevated FSH and/or low AMH levels have contributed?

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This is the sixth in a series of responses to common questions about Failed IVF Treatment.

Women with elevated basal (day 2-4) Follicle Stimulating Hormone (FSH) levels and/or low antimullerian hormone (AMH) levels often have diminished ovarian reserve (DOR). This means that they have a reduced number of eggs left in their ovaries and, as a consequence, are likely to be resistant to controlled ovarian stimulation(COS). Such “poor responders” often will require an aggressive protocol for COS in an attempt to make them yield more eggs at egg retrieval.

This having been said, it is important to realize that basal blood FSH/AMH levels predict the number of eggs present in the ovaries (ovarian reserve) and NOT necessarily the quality of the eggs at ovulation or egg retrieval (ER). So it is that low basal FSH and high AMH concentrations point to a normal or high ovarian reserve, and the likelihood of a high response to a modest protocol of COS.Conversely, a high basal FSH and/or a low AMH suggest a diminished ovarian reserve (DOR) and a blunted response to even high dosage COS.

In an effort to improve their yield of quality (“competent”) eggs at ER, women with DOR are often prescribed strong (high-dosage gonadotropin) protocols of COS. But here is where a word of extreme caution is appropriate: unless COS protocols that lead to increased follicular exposure to Luteinizing Hormone (LH) are avoided (e.g. “flare-agonist protocols,” clomiphene citrate/Humira and high dosages of LH-containing gonadotropins such as Menopur) in women with DOR, follicular growth and egg quality can be severely compromised by resulting high ovarian production of male hormones (androgens) such as testosterone. Moreover, in spite of best efforts, the egg retrieval (ER) will still yield fewer eggs, and this will reduce the odds of ending up with at least one “competent” (chromosomally normal) embryo for transfer. Simply stated, women with DOR require LH down-regulation in advance of initiating COS. Optimally, this requires prior suppression of LH using a combined birth control pill (BCP), followed by administration of an agonist (e.g. Lupron, Superfact, Nafarelin) initiated several days before to the onset of menstruation.This is followed by the initiation of FSH-dominant gonadotropin stimulation (e.g. Folistim, Gonal F, Puregon) as soon as the period begins. Such “Long Down-Regulation Protocols” can often be modified and improved by switching from an agonist to an antagonist (e.g. Ganirelix, Cetrotide, or Orgalutron) as soon as menstruation occurs (agonist/antagonist conversion protocol-A/ACP) and by adding low dose estrogen administration for 7-10 days prior to commencing gonadotropin stimulation (“estrogen priming”).

It is important to recognize that basal (FSH) levels will often fluctuate from month to month. A higher or lower FSH level does NOT mean that the woman will respond better if stimulated with fertility drugs in that cycle. Thus, there is no point in delaying treatment to a subsequent cycle in order to try first to bring down the basal FSH level. It simply won’t help, and will only put an extra burden on an already taxed biological clock. Remember, it is not possible to grow more eggs for recruitment by waiting for the FSH level to drop.

Some doctors advocate using low dosage gonadotropin protocols in cases of DOR, so as to put less stress on developing follicles /eggs. This is really a waste of time in my opinion. It is like saying that if five men cannot move a piano, we should take three of them away so as to put less stress on the piano. It simply makes no sense, and more importantly, it does not work.

So yes indeed, women with diminished ovarian reserve have a higher mountain to climb when it comes to IVF. However, this is more due to the fact that they yield fewer eggs, and NOT because the DOR causes poor egg quality. In addition, DOR compounds with advancing age and the older the woman, the poorer egg quality is likely to be. Dealing with DOR in a young women (under 39) is far more likely to be successful than would be the case for a woman in her mid-forties with a comparable degree of DOR.

Tags: amh, anti mullerian hormone, Diminished Ovarian Reserve, egg quality, FSH, IVF Authority

55 Responses to “My IVF Cycle Failed – What Went Wrong? Question #6: How much could my elevated FSH and/or low AMH levels have contributed?”

mum2oneds says:

June 2, 2011 at 12:25 am

Wonderful entry Dr Sher! You answered some of my questions! I have asked my FS about A/ACP protocol this week and he suggested to me that if it was so successful, why isnt it used all over the world?? Right now the popular protocols are Agonist Down Reg which I was on twice, and Antagonist, which he was going to put me on the next time. I could not convince him about premature lutuinistaion if the antagonist is given from 6th day onwards.

Reply
One perfect emby says:

June 19, 2011 at 4:04 am

Just to let you know I had low ovarian reserve not due to age but due to endometriosis…I only had one egg retrieved even with 9 follicles looking possible and this one egg fertilised and I am now 4 weeks pregnant..so Im hoping this super strong emby sticks and is good quality as your briefing says and quality is better over quantity

Reply
Geoffrey Sher, MD says:

June 20, 2011 at 10:17 am

Sounds great! Good luck!
It just goes to show it is about quality, not quantity.

If someone would have said that with so few follicles your cycle should be cancelled…you would not be pregnant now.

Geoff Sher

Reply
Rebecca says:

September 22, 2011 at 3:26 am

Hello Dr. Sher:

Reading this post seems to give me some hope, which I hope is not misplaced. I am 38 yo, have a low amh of 1.2 (but I have relatively normal FSH, LH, and estridol levels: 7, 7 and 45-68 respectively). I have just had my second IVF cycle cancelled due to poor response. From the post, it seems like perhaps my RE did use a "COS protocols that lead to increased follicular exposure to Luteinizing Hormone (LH)". I posted a question on the the SIRM message boards east (but have not had any response and unfortunately the message boards don't seem to be working today) that fully details my experience ttc and the recent protocol used, but in short it was a "flare up protocol" which I responded to worse than the protocol used in my first IVF and worse than when I was simply on clomid for a couple months! We are thinking of coming to the states to do another IVF cycle (we are currently in Dubai, but are from NY), which is how I found SIRM website. We are not yet ready to give up or use donor eggs, but perhaps I'm kidding myself?

Thanks

Reply
Geoffrey Sher, MD says:

September 22, 2011 at 10:25 am

I think you assessment of your situation is "spot on". Please read the article I posted on this, on November 22nd 2010. I think you will find the information there, enlightening and supportive. Nether Short ("flare" protocols or clomiphene are good in causes such as yours where there is diminished ovarian reserve.These protocols drive up LH-induced ovarian testosterone production which in my opinion is the last thing you need.

Might I suggest that we have a telephone consultation to discuss your case ASAP. Call 702-892-9696 to set it up.

G-d bless!

Geoff Sher.

Reply
klbklyn says:

September 23, 2011 at 5:08 am

Hello,

I'm finding this blog to be the most comprehensive source available of real information on the process, choices and causalities of IVF…in language that's clear but doesn't patronize. Thank you for not assuming that the women undergoing ART therapy can't understand a word with more than 2 syllables!

Dr Sher, I would love your insight. I posted a question under 'what went wrong #5' but not sure if that strand is closed…can you let me know where I should be posting?

Thank you!

Reply
Geoffrey Sher, MD says:

September 23, 2011 at 12:03 pm

Thank you for your kind sentiments. I really enjoy doing these blogs and intend to continue.We already get >1000 visitors a day. Help me get the word out there via the the social media and word of mouth. The more people joining in the better!

I will go to Question 5 and see if I can respond there. Otherwise please re-post the question. The threads are never closed so It must have been an oversight on my part…Sorry!

Geoff Sher

Reply
Michelle says:

August 24, 2012 at 4:02 am

Hi Dr Sher, this is a fantastic blog I must say! I am 38, and have very low ANH (30, although it was taken on day 13 and not on day 3 so not sure if the test is reliable). TRied 1 “natural” cycle IVF last week, my RE aspirated a 13mm follicle, and it did have an egg inside, but unfortunately the quality was not good enought to go ahead with the fertilization. He now wants to try and improve my egg quality, so has put me on the following protocol: 12 days of Norditropin (a growth hormone, apparently fairly new in use of fertility, but said to improve egg quality. He says he has had a lot of recent success with it), then on cycle day 4 start with Femara (Letrizole) 5mg for 5 days. Scan on CD10 to check for follicles. Do you think this is a good protocol to try for someone in my situation?

Reply
- Geoffrey Sher says:
  
  August 24, 2012 at 10:03 am
  
  If (as it sounds) your doctor thinks you have diminished ovarian reserve (because that is why HGH is recommended by some), then I respectfully would not personally use that protocol. Please go to the home page on http://www.IVFauthority.com, find the “search bar” in the 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”
  
  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
  
  Reply
Michelle says:

August 24, 2012 at 4:04 am

Sorry, error in my post! I meant to say that my AMH is very low (30, although the FSH was taken on day 13 and not on day 3 so not sure if the test is reliable.

Reply
ASR1980 says:

October 19, 2012 at 11:26 am

Thank you for this post Dr. Sher. I am 32 years old, trying IVF for the 1st time at SIRM. It appears as though I only have 1 follicle. 2 were seen but 1 might be my endomietrioma returning after sucking up my Follistim. I guess we will see at ER. My Dr. wants to move forward as I have had a lot of medical issues founded and cleaned up and my egg quality might be great. I am really nervous because I don’t know what to expect and I know time is of the essence. This post really helped me to not be as discouraged. Are there many cases where a woman gets pregnant from the one embryo retrieved. There are no male factor issues. Just me. Thanks in advance.

Reply
- Geoffrey Sher says:
  
  October 19, 2012 at 8:47 pm
  
  I have seen many, many woman whom produce 1 follicle/egg, get pregnant. If that is the best you can do, yo are wise to proceed.
  
  Good luck! Please keep me in the loop.
  
  G-d bless!
  
  Geoff Sher
  
  Reply
TNS29 says:

October 19, 2012 at 10:08 pm

I’m 29 and received blood test results back (FSH 11.8; AMH .25). I’m otherwise healthy and have regular periods. Needless to say I’m shocked. Thanks for this blog. It is extremely helpful and I’m just trying to gather as much info as I can while also trying to set something up with an RE locally. Any other blog posts you could point me too, advice or bottom line thoughts? Thanks so much

Reply
- Geoffrey Sher says:
  
  October 21, 2012 at 9:57 pm
  
  Clearly you have prematurely diminished ovarian reserve and time is of the essence in spite of your young age. You need an aggressive, but very individualized protocol of ovarian stimulation and IVF ASAP. Please go to to the home page of this blog , find the “search bar” in the right hand column and type in the following subjects into the bar. This 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”
  
  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
  
  Reply
- Geoffrey Sher says:
  
  October 22, 2012 at 9:04 pm
  
  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”
   “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”
  
  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
  
  Reply
Lisbeth says:

October 23, 2012 at 9:05 am

Dear Dr. Sher,

I also have high fsh/low amh due to cancer treatment almost 20 years ago. I have had 4 ivf cycles until now. With 3 of these cycles, elonva was used. Twice, I was stimulated only with elonva, the third time, the follicle had to be stimulated a little more, so a extra shot of puregon was used. The 2 times that only elonva was used, I got pregnant. Unfortunately I miscarried both times. I can’t find any information about elonva on this site. Do you think it’s possible that this product had something to do with my pregnancies? What further treatment would you advise me? (Despite the use of elonva, I’ve only had 1 embryo each time. So the treatment with elonva was only repeated because of the pregnancy result)

Reply
- Geoffrey Sher says:
  
  October 23, 2012 at 8:46 pm
  
  Elonva is a long acting recombinant DNA, FSH product. In my opinion, the results with this product have not beeen as promising as initially hoped for. I prefer short acting recombinant FSH (e.g., Folistim, Gonal-F, Puregon).
  
  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”
   “Gonadotropin Therapy 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)
  
  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
  
  Reply
Princess Chen says:

November 13, 2012 at 4:01 pm

Dr. Sher, I went to two expert :
The first one said that I have DOR and high FSH therefor he did not recommend IVF, instead he recommend egg donation. The second one said with my 19 FSH level said that I only need IUI but with low dosage of protocol. I had 3 failed IUI, all of these were with medications of lupron, bravelle and HCG for first (10 days), second (14 days) third (8 days) In all theses cycles I produced 2 follicles only. I gets matured.
Should I go with another IUI or I will proceed with mini IVF, I am 36 years old.

Thank you very much.

Reply
- Geoffrey Sher says:
  
  November 13, 2012 at 8:48 pm
  
  Respectfully, The success rate with IUI in women with DOR is very low and you do not have the time to waste doing this. You need IVF for sure, but whether and how well you will respond, even on an aggressive protocol will remain to be seen. If you fail to respond adequately, egg donation will be the only recourse.
  
  One thing to bear in mind is that if you decide to try with own eggs, you need a very individualized and aggressive stimulation…probably an agonist/antagonist conversion protocol with estrogen priming (LA-10E2V…see below. You also should consider “Staggered IVF” with “Embryo Banking” 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”
   “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
  
  Reply
Emily says:

December 2, 2012 at 2:07 pm

Hi Dr. Sher

I have low amh and my two fsh readings have been 10 and 16.4 two months apart. I am 36. I had 11sh antral follicules on day3 last month and am healthy with good lining. there any hope for me through ivf? Thanks

Reply
- Geoffrey Sher says:
  
  December 2, 2012 at 2:48 pm
  
  Yes there is hope, but with diminished ovarian reserve it is important that the protocol for stimulation be individualized 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”
  
  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
  
  Reply
pinky says:

December 16, 2012 at 3:59 pm

My progesterone levels on day 21 of the cycle is 22.3 nmol/L. Does this level of progesterone on day 21 means LPD. Even on my BBT chart my temperature after ovulations are low the highest is 36.9 which is present only on day 21 and day 22 of the cycle other days my temperatures are low. If i measure during the day my temperatures are below 37c. my thyroid levels are normal. I have my hands and feet warms before ovulation and after ovulation my palms and feets become cold. My TSH, T4, T3 are normal. Normally my cycle length is 28 to 30 days (this is on sexual cycles) If I haven’t had sex in the month then my cycle length is 24 days. Every month after ovulation (day 13) after that from day (15 day) my tongue changes to some bitter taste, sleep disturbances, not good sleep, After my menses comes I feel healthy and good sleep. Is this LPD. My age is 41.6 years. I had one failed ivf cycle with only 2 embryos only. I am eligible for another IVF cycle. I think I am conceiving most of the months but that is not continuing in to pregnancy.(this is what I am thinking based on my symptoms) can you give advice on this. I am eligible for second IVF

Reply
- Geoffrey Sher says:
  
  December 16, 2012 at 7:04 pm
  
  A progesterone of 22ng/ml on day 21 is excellent. I think all the other symptoms are subjective. Indeed you should pursue another IVF cycle.
  
  good luck!
  
  Geoff Sher
  
  Reply
  - pinky says:
    
    December 17, 2012 at 3:48 pm
    
    My progesterone levels are 22.3 nmol/L, but in your reply it was 22 ng/mL. I think there is a lot of difference between nmol/L and ng/ml. This i have seen on internet. My progesterone levels are 22.3 nmol/L on day 21. Is this is a LPD.
    Thanks.
    
    Reply
    - Geoffrey Sher says:
      
      December 17, 2012 at 4:10 pm
      
      The level is on the low side…talk to your RE about increasing the progesterone supplementation.
      
      Good luck!
      
      Geoff Sher
      
      Reply
pinky says:

December 17, 2012 at 3:54 pm

In addition to the above reply,
I think 22.3 nmol/L is equal to 6.5 ng/ml on day 21 progesterone levels. Is this is a LPD

Reply
Rama says:

December 19, 2012 at 1:54 am

Dear, Dr. Sher,
I read your posts and came to known that after the age of 35 women are not recommended clomid. what is the reason. My age is 42 years and my doctor gave me clomid at age 41 because of my low progesterone levels. I took 50 mg just for 2 months then my progesterone went to 15ng/ml. After taking for two months i stopped clomid ( i used to get pain in the ovaries when on clomid)then I conceived about 5 months after stopping clomid, but miscarried. what happens if women over 35 takes clomid. Can i take clomid at my age 42. Can i get pregnant by using clomid.

Reply
- Geoffrey Sher says:
  
  December 19, 2012 at 10:42 am
  
  Hi Rama,
  
  For answers to these questions 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 “Use of Clomiphene” and thereupon “IUI” . You might also access 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”
  
  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
  
  Reply
Anne says:

February 7, 2013 at 9:25 am

Hi Dr. Sher,

I am 30 yo, diagnosed with DOR (3 day FSH 9.4, estradiol 81, AMH .8, AFC 14). I pursued IVF immediately, my protocol included estrogen priming with BID estradiol tabs for about 5 days prior to my period, then started stims on day 3 of my cycle-300 IU of Gonal-F, 150 IU Menopur and 250 ug Ganirelix from day 6-10 with HCG trigger shot on day 10. I had 9 follicles >1 cm and 9 follicles <1 cm with 8 eggs retrieved. 6 were fertilized via IVF, 4 frozen in pro nuclei stage, 2 elected to transfer on day 3. I was not told how my 2 embryos were looking until I asked and was told 'they are 4 and 5 cells, look good'. My question is-is it normal to transfer a 4 and 5 cell embryo and is this very successful? I feel this was a feeble attempt and have already decided that if this is a bust I should seek a second opinion. Thanks in advance if you are able to respond!

Reply
- Geoffrey Sher says:
  
  February 7, 2013 at 2:38 pm
  
  I respectfully suggest that the protocol used for ovarian stimulation might need revision. As for the embryos, those less than 6 cells on day 3 are often of poorer quality.
  
  I strongly suggest that you 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”
  
  9. “Egg Donation”
  
  Might I recommend that you 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) 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
  
  Reply
saanya21 says:

March 4, 2013 at 5:28 pm

Hello Dr .about me i am only 27 mother of 2 kids and planning to go IVF/PGD/ICSI for GS.all tests came normal for me.

I have a question that my AMH came back very high at 14.do you think is it normal or abnormal ?

why did it came back so high even i donot have PCOS?what makes it so high?

what should i do prior to my cycle to make it low although i will be on bcp pills for 6 weeks with(lupron,gonal f)
pleas help thanks alot

Reply
- Geoffrey Sher says:
  
  March 4, 2013 at 6:04 pm
  
  It depends whether that value was expressed as ng/ml (in which case it would be high) or as pmols/L (in which case it would be normal)
  
  Geoff Sher
  
  Reply
saanya21 says:

March 4, 2013 at 8:47 pm

yes it was expressed as ng/ml.

why did it came back so high even i donot have PCOS?what makes it so high?all of my other results are normal . i am really worried

what should i do prior to my cycle .what to do to make it low .Although i will be on bcp pills for 6 weeks with(lupron,gonal f)
pleas help thanks alot

Reply
- Geoffrey Sher says:
  
  March 4, 2013 at 10:57 pm
  
  I do not think in the hands of a competent IVF specialist who knows how to individualize protocols and is familiar with “coasting” to prevent hyperstimulation…you need be concerned.
  
  good luck!
  
  Geoff Sher
  
  Reply
saanya21 says:

March 5, 2013 at 8:55 pm

thanks for answering and helping me .i still have few questions(about me 27 => AMH 14 ng/ml,two kids going for GS)

1.if everything is fine.periods normal all other tests are normal then why my AMH came so high?what makes it so high example one’s diet etc?is there a reason behind it .

2.also does high AMH means the egg quality will be compromised?does the high AMH makes eggs bad even if someone doesn’t have PCOS?

please answer my questions.i will be very grateful.God bless u

Reply
- Geoffrey Sher says:
  
  March 5, 2013 at 9:17 pm
  
  Firstly, a high AMH does not mean that eggs are compromised. Rather it is that women with PCOS who sometimes do have a problem with egg quality, often have high AMH’s. All this means is that you will likely be a very high responder and whoever manages your stimulation better be familiar with handling such cases and specifically on how to implement “prolonged coasting ” (see elsewhere on this blog) in the event that you indeed do hyperstimulate.
  
  Good luck!
  
  Geoff Sher
  
  Reply
Kristen says:

March 6, 2013 at 11:25 am

Hello Dr. Sher,
I am 33 years old with am AMH of .16, but normal FSH (5.7). What do you think my prospects of conceiving with IUI? I am having a hard time finding information about normal FSH/low AMH. Normally they seem to go hand in hand. Thank you for any insight you can provide.

Reply
- Geoffrey Sher says:
  
  March 6, 2013 at 2:17 pm
  
  If it turns out that the AMH is correct and the FSH is wrong, and you inde4ed have diminishing ovarian reserve (DOR) then IUI is the wrong way to go. You need IVF. I suggest you have your inhibin B level tested and have an antral follicle count done. This might clear up any confusion.
  
  Geoff Sher
  
  Reply
Wanda says:

March 6, 2013 at 5:38 pm

Hi Dr. Sher,

First I’d like to Thank you for your services, passion and support. Your knowledge and the patience you have with us is priceless. Thank you so much.

My question is the following: I’m 41 and after 3mths of DHEA (Dr. Instructed due to FSH at 82miu/ml in Oct.) and 21-days of BCPs, doctor states my tests now show E2=208, LH=6.3, FSH4.3 on Day 3. The doctor cancelled my treatment and stated I needed egg donor.

Do you think the Agonist/Antagonist Conversion Protocol will possibly work for me? With staggered IVF?

Your recommendation is important to me. Thank you for your time in advance.

Reply
- Wanda says:
  
  March 6, 2013 at 5:48 pm
  
  Also, I will happily Skype with you if the option is available.
  
  Thank you again Dr. Sher.
  
  Many Blessings.
  
  Reply
  - Geoffrey Sher says:
    
    March 6, 2013 at 9:50 pm
    
    Absolutely,
    
    Call 702-699-7437 to set it up.
    
    Geoff Sher
    
    Reply
- Geoffrey Sher says:
  
  March 6, 2013 at 9:48 pm
  
  I suggest we talk. In the interim read up on the agonist/antagonist conversion protocol and on Embryo Banking and Staggered IVF (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. “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”
  
  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
  
  Reply
Wanda says:

March 7, 2013 at 10:15 am

Thank you. I left a message for the Skype appt.

I’ve also read all but one of the articles. Finishing it now.

Reply
M Bense says:

March 9, 2013 at 6:05 am

Hello Dr.Sher,
I find your articles so informative and I have a couple of questions. I am 36 with an AFC of 18, FSH 11 and AMH below .3. They Dr seemed confused when she saw the AFC of 18 but didn’t ask to have the AMH re tested. Just this month she had me try Femera, bravelle, ovidrel. I responded well and ovulated 2 mature eggs but did not get pregnant via IUI this month. My E2, progesterone and LH are all normal. My questions are, do you think moving forward this mix of drugs is right for me? We only have 4 vials left of the same sperm that was used for our sons and once they are gone we will stop trying. And if not what should I be doing differently? I realize IVF would give me a greater chance but we already have 2 children and have decided to try IUI and if it doesn’t work we accept that and move on. Thanks in and advance for your time, advice and fabulous articles.

Reply
- Geoffrey Sher says:
  
  March 9, 2013 at 8:48 am
  
  Your low AMH is bothersome. It could be a false indicator but if not then you (in spite of a normal AFC/FSH) could have diminished ovarian reserve. In that case, I would become more aggressive and go to IVF because of the biological clock and I would change the protocol of stimulation (see the article on this blog, titled…”An Individualized Approach to Ovarian Stimulation for IVF”, posted on November 22nd, 2010.
  
  Call 800-780-7437 if you would like me to Skype you to discuss your case.
  
  Geoff Sher
  
  Reply
M Bense says:

March 9, 2013 at 2:07 pm

Thanks so much for you quick response! It’s something for us to consider but if we were to decide to continue on with IUI what drugs would you recommend? I will take you up on your offer to Skype and give you a call this week.
Thanks again!

Reply
- Geoffrey Sher says:
  
  March 9, 2013 at 10:40 pm
  
  let’s talk!
  
  Geoffrey Sher
  
  Reply
Grace says:

April 3, 2013 at 3:33 pm

Dr Sher, I am hoping you can solve a mystery for me (since my RE said she has never seen this before)
I am 32 (1 blight ovum, TTC 2 yr, unknown infertility cause, day 4 AMH: 1.5, FSH 7.7, estradiol 58, TSH 4.6).
# 1 IVF: was OCP–> gonal F 150mcg then 225mcg & cetrotide with poor stim results: one ovary had 2-3 large follicles + few smalls but the other ovary had couple tiny follicles. my RE said she has never seen this before. WHY WOULD THERE BE SUCH PROMINENT ASYMMETRY? any thoughts? when I had my baseline ultrasound, it was the same. one side already had one large follicle, other side had tiny follicle.

Also a new (popped up in 2 days) huge endocervical polyp was found on my last US thus IVF cycle was cancelled. ISN’T THAT WEIRD ALSO? would love to hear your thoughts !!!!
God Bless!

Reply
- Geoffrey Sher says:
  
  April 3, 2013 at 9:48 pm
  
  In my opinion it is because you came directly of the BCP and on to stimulation. That prevented proper progression from pre-antral to antral follicles as a result of the BCP suppressing premenstrual elevation in FSH. The latter is needed to make this conversion without which, the response to stimulation will be blunted. Women on BCP need to take an agonist on top of the BCP for a few days prior to menses in order to promote antral follicles without which response to stimulation will often be blunted and discordant.
  
  Go to the home page of http://www.IVFauthority.com and find the followiung articles:
  
  1. “Use of the birth control pill in IVF”
  2. “An individualized approach to ovarian stimulation for IVF”
  
  Give me a call if you want to talk.
  
  Geoff Sher
  800-780-7437
  
  Reply
Yoshio says:

April 8, 2013 at 1:50 pm

Hi Dr. Sher, I hope you can give us some hope. My wife is 38 yeas and 11 months old. She has a low AMH (0.25) although other hormone levels are in a normal range (FSH = 6.88, LH = 2.59, E2 < 20, measured on the day 2 of her menstrual cycle). We have tried 1 IVF cycle, however, this cycle was cancelled because of poor quality of embryos. The stimulation was performed with 450 IU of Gonal-F / day and 150 IU of Menopur / day starting from the day 2 of her menstrual cycle for 11 days. Ganilerix was started from the 6th day of the stimulation. Then ovulation was induced by injecting 10000 UPD units of Novarel. After 35 hours from the induction of ovulation, 8 eggs (1 egg was immature) were retrieved from 10 follicles. Eggs were fertilized by conventional insemination and 5 eggs were confirmed to be fertilized after 24 hours (day 1). However, only 3 embryos showed division and all these 3 embryos were poor quality (fragmentation and uneven cell size) on the day3. They decided to postpone the embryo transfer to the day 6. On the day 6, none of the embryo showed formation of blastocyst, and then the cycle was cancelled without embryo transfer.
Since my wife has a low AMH level (0.25), we were concerning about egg quantity upon retrieval but not the quality. I looked for the possible reason and I found this webpage. Your theory that premature LH exposure compromises the egg quality opened my eyes. I thought this fits well with my wife’s case, therefore, we made an appointment to see your doctor. Before that, I would like to study a little more. I am wondering if you could introduce any paper about LH or LH-induced testosterone cause aneuploidy? I am working in a research institute so I have access to most of scientific journals.
I really hope the treatment your doctor will solve our problem. Thank you very much in advance.

Reply
- Geoffrey Sher says:
  
  April 8, 2013 at 5:15 pm
  
  I think this is possibly a stimulation issue. It is especially important in women with diminished ovarian reserve to be very strategic in selecting the ideal protocol for stimulation.
  
  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
Elena says:

April 18, 2013 at 1:43 pm

Hello! I have never posted on the board but today I am in despair. After trying IVF at Shady Grove, my cycle was canceled 7 days after meds due to poor response (2 follicles, low estradiol). 5 weeks later and I did not have my period. went in today to see what’s going and after blood work and ultrasound, the doctor and the nurse decided i am menopausal!!! Overnight? Yes, I had high FSH (28 when they measured it 2 months ago), but never missed a period in my life and have no other symptoms. Many women on the boards report missed periods after cancelled IVF but that’s not the cause to call it menaupause (I am 38). The doc said my estrogen levels were low today, then the nurse called and said my progesterone is low. And NOW they booted me out of IVF all together saying no point in trying. I feel that they are not willing to listen to me and apply some logic here. After pumping me with really expensive meds (flare protocol) for 7 days, they gave up overnight. I am beyond dumbfounded! Thanks for your advice in advance.

Reply
- Geoffrey Sher says:
  
  April 18, 2013 at 2:44 pm
  
  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
Elena says:

April 20, 2013 at 7:50 pm

Dr. Sher,
I am 36y/o, G2P1 (1 early m/c at 5wks over a yr ago) and have been TTC since. AMH=0.3, AFC=6, FSH=6.8. Husband w/ normal sperm analysis. My TSH over the past 4 yrs has risen steadily: 0.9 to 1.9 to 2.43 most recently. T3 and T4 normal. My ANA is 1.2. My identical twin sister has hypothyroidism (Hashimotos) and was able to conceive during her 2nd IVF cycle. The difference between her failed and successful IVF cycles was that they gave her Decadron before the embryo transfer on the 2nd cycle (as part of a research trial).
Should I have a TRH (thyroid releasing hormone)-stimulation test done to confirm subclinical hypothyroidism? SHould I have my antithyroid antibodies and antiovarian antibodies drawn? Should I be on a low dose synthroid? Should I be on prednisone or IVGG? Do I have any chance conceiving naturally with these meds?
Thank you for advice you have!
-Elena

Reply
- Geoffrey Sher says:
  
  April 20, 2013 at 9:38 pm
  
  Already addressed elsewhere.
  
  Reply

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