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      • Ovarian Reserve: An Overview (A Guest Post by Drew Tortoriello, MD)

      Dr. Geoffrey Sher Recommends

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      It is my pleasure to introduce Drew Tortoriello, MD as a guest writer on my blog today. Dr. Tortoriello is the Medical Director of SIRM-New York and a close friend and colleague. He is an outstanding physician and is well qualified to address the topic of Ovarian Reserve.

      - Geoff Sher
      ————————————————————————
      The Concept of Ovarian Reserve
      In order to adequately counsel women experiencing infertility about their prognosis, as well as to determine which treatment might serve them best, reproductive endocrinologists routinely perform some screening tests to assess their patients’ ovarian reserve. What is ovarian reserve? It is basically an estimate of how many oocytes (eggs) are left in the ovaries, and that often translates into how many eggs we are going to be able to work with over the course of any given monthly treatment.

      The ovary, as miraculous a structure as it is, is unfortunately very wasteful. Every month it calls forth from within itself a troop of immature eggs, only one of which is destined to ovulate. Depending on how vast your ovarian reserve is, that starting “troop” can range from one or two, to sixty or seventy. The one egg that’s “chosen” to ovulate resides within an ever-enlarging ovarian follicle or cyst that is readily visible on ultrasound by mid-cycle. Ultimately when that dominant follicle gets big enough, say about 2 centimeters, it will rupture or ovulate. When all is perfect, the mature egg will then get picked up by the nearby fallopian tube, be fertilized by sperm, and make its way into the uterine cavity where it will burrow in and make a baby. All the other eggs that were recruited will die, a process called atresia. That’s why women are essentially devoid of eggs by age 50 despite only ovulating about 400 eggs over the course of their lifetimes.

      Ovarian Reserve Testing
      Ovarian reserve can to a very general extent be predicted by age; i.e. a woman in her forties will have very diminished ovarian reserve while a woman in her twenties should have excellent ovarian reserve. However, there is such a tremendous amount of individual variation that physicians and researchers sought other factors to help elucidate ovarian reserve better. Several hormones with predictive power have since been described and are now an almost indispensable part of fertility assessment.

      In addition to a depletion in egg number, there is a decrease in egg quality with time, and this is the major factor limiting success in older women. Egg quality refers in general to chromosomal normalcy, and age predicts relative egg quality better than ovarian reserve screening. Therefore, a younger woman with poor ovarian reserve testing will still have a better chance at getting pregnant than an older woman with the exact same results. Age is an independent predictor of IVF outcome and is more closely related to implantation and ongoing pregnancy rates than the hormonal reserve markers.

      The hormone most often used to gauge ovarian reserve is the day 2 or 3 FSH level. Think of FSH as the wake-up call for the ovary; if the ovary is responsive then the amount of FSH needed to get the ovary up and running is minimal (a good scenario). If the ovary is non-responsive (i.e. few developing follicles with a commensurately low level of estradiol and inhibin being made), then the pituitary gland tries to compensate for this by pumping out a large amount of FSH (a bad scenario). When the ovary completely runs out of eggs in menopause, the amount of FSH in the bloodstream is very elevated to the point where it can be over ten times that of a woman in her twenties.

      FSH is also an independent predictor of IVF outcome, correlating mainly with the number of retrieved oocytes. Recent studies have shown that young women with high FSH levels demonstrate lower numbers of growing follicles but can still achieve good pregnancy rates if oocytes and embryos are obtained. This highlights the premise that age reflects egg quality better than FSH levels do.

      Estradiol is usually measured simultaneously with basal FSH. Even if the basal FSH is normal, estradiol elevations greater than 70 pg/mL are also associated with poor response to ovarian stimulation. Elevated early follicular phase estradiol levels may indicate an inappropriately advanced stage of follicular development, a sign of ovarian aging whose clinical manifestation is a shorter menstrual cycle. This situation can also occur if the patient has misjudged her cycle timing or has an estrogen secreting (“functional”) ovarian cyst.

      A recent addition to the list of promising candidates for predicting ovarian response is anti-müllerian hormone (AMH), also known as mullerian inhibiting substance (MIS). MIS is produced in the ovary by granulosa cells of growing preantral and small antral follicles. MIS concentrations correlate well with antral follicle count and age and at the present moment seems to constitute the most sensitive marker of ovarian aging. Indeed, it has been shown that poor response in IVF is associated with decreased MIS levels. An added benefit of MIS assessment is that it does not fluctuate over the course of any given menstrual cycle so it can be drawn at any point irrespective of cycle timing.

      The antral follicle count or AFC is the number of antral follicles (small egg-containing ovarian cysts) visible by transvaginal ultrasound in the early follicular phase of the cycle. The AFC decreases with age and provides perhaps the best single prognostic indicator for poor response during IVF. A normal AFC for a woman in her twenties to thirties is somewhere in the range of 12 to 16. Women with polycystic ovarian syndrome (PCOS) often have AFCs greater than 50, and it is therefore not surprising that when challenged with gonadotropin medication their response in terms of egg number can be astronomical.

      Several “challenge” tests have been designed that offer the theoretical benefit of measuring ovarian reserve in a dynamic, and perhaps more clinically representative way. The clomiphene citrate challenge test (CCCT) is the most commonly used of these and involves the administration of 100 mg clomiphene citrate on days 5 to 9, and the measurement of FSH levels on days 3 and 10. An abnormal test is defined as an abnormally high FSH on day 10. With basal FSH and the CCCT, a normal result is of little predictive value, but an abnormal result is predictive of poor outcome from infertility treatment. Given that the CCCT offers no clear advantage over and above a single basal FSH measurement, a basal FSH measurement seems adequate.

      When all is said and done, the best estimate of ovarian reserve is derived from actually treating a patient and observing her relative responsiveness to the medication administered. It therefore pays to monitor each patient very carefully over the first several days of treatment so medication can be adjusted accordingly.

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      25 Responses to “Ovarian Reserve: An Overview (A Guest Post by Drew Tortoriello, MD)”

      1. Sharon says:
        September 9, 2009 at 9:15 pm

        Thanks for posting this – could you comment on low AMH, PCOS and response to oral meds like clomid or femara? I was diagnosed with PCOS 2.5 years ago, conceived twins on our first clomid cycle last September (but lost them in the second trimester) and have been unable to conceive since the miscarriage. I respond to both femara and clomid (50 mg) with 1-2 follicles. This last month out of the blue, I ovulated early on my own and an AMH test came back at 0.6. I though AMH for PCOS patients was supposed to be high? All of a sudden I am facing DOR in the span of a few months. Is this possible or likely? What is my prognosis give my response to clomid/femara?

        Reply
      2. Geoffrey Sher, MD says:
        September 10, 2009 at 9:15 am

        Dr. Tortoriello responds:

        Diminished ovarian reserve is a possibility; not even PCOS patients maintain their high output forever. However, no one indicator of ovarian reserve is perfect; it is better to get a few tests done to get a more comprehensive overview. Regarding your AMH level, it does appear to be low for a woman with presumed PCOS, but the value is not consistent with poor ovarian reserve by most facilities standards. Also, the specific AMH assay used by different facilities can differ and one lab's 0.6 can be higher in another lab. It is important for your facility to compare their AMH values to patient outcome so they can counsel you appropriately. If your doctor scans your ovaries and they still have many small antral follicles (at least 7 per ovary), then your ovarian reserve should not be a big issue.

        - Dr. Tortoriello

        Reply
      3. Brigette says:
        September 21, 2009 at 2:09 pm

        I was diagnosed with DOR at age 32. I am now about to turn 35. I have had 3 unsuccessful IVF's in upstate NY. I had a positive pregnancy test on my second but my levels were low. My most recent cycle only yielded one embryo. I am debating on whether I should move forward with another IVF. I know my FSH is high but I have not received any other testing that you refer to in your article. Would SIRM consider me as a patient? Also, does SIRM use a woman's endometrial lining to develop a culture for the embryos and if so, does this add any benefit for women with DOR?

        Reply
      4. Geoffrey Sher, MD says:
        September 21, 2009 at 2:37 pm

        Of course we would be willing to accept you. Remember, it is NOT the ovarian reserve (as indicated by FSH,AMH,inhibin B etc) that determines egg quality.It is age and the protocol used for ovarian stimulation that determines egg quality. The eggs of women with DOR require a much more individualized protocol of stimulation.

        Please read other blogs on this site regarding factors that affect egg/embryo quality.

        Also feel free to call 800-780-7437 for a free medical telephone consultation with me to discuss, if you wish.

        Good luck!

        Geoff Sher

        Reply
      5. Brigette says:
        September 21, 2009 at 6:51 pm

        Thank you for your kind and prompt response. I didn't know this. I will call.

        Brigette

        Reply
      6. Soul says:
        October 12, 2009 at 12:13 pm

        Dr. Sher,
        I was diagnosed withe endometriosis two years ago at the age of 29. I'm 31 now with 6 unsuccessful IVF trials. My body only responds to Pureagon, producing 1 to 2 follicles i have a high Fsh level, and was wondering if this a case you would take on?

        Reply
      7. Geoffrey Sher, MD says:
        October 13, 2009 at 6:19 pm

        Please contact us for a free telephone consultation (see the invite at the top of the page).

        Geoff Sher

        Reply
      8. Auntie K says:
        December 21, 2009 at 8:01 pm

        Hi Dr. Sher,
        I just turned 28 years old and was told I have high fsh (tested only once which came back at 27) I also had my AMH tested and that came back extremely low. I wasn't given the exact number, but for some reason .1 is ringing a bell. Am I out of hope? What would you recommend? Thankfully my husband has good count, motility, etc.

        Reply
      9. Geoffrey Sher, MD says:
        December 23, 2009 at 11:05 am

        Given your nyouing age and the fact that it is age and NOT%b vFSH that affects egg/embryo quality, you could well have a chance still. BUT time is the issue. I suggest you call 800-780-7437 without delay and set up a phone consultation with me. It is gratis.

        Happy Holidays.

        Geoff Sher

        Reply
      10. Mou says:
        July 14, 2010 at 2:34 am

        Hi Dr,

        My age is 27. Recently diagnosed with Complex OV Cysts on both ovaries. I have hair growth on my breast and cheek. period irregular. sometime miss it. gained bodyweight approx 82Kg. Do i have any hope of getting pregnant? please advise.

        Reply
      11. N says:
        July 15, 2010 at 10:55 am

        I just found this post and am wondering what a "normal" AFC would be for a 38 1/2 year old. I have 8-10 on my left. (Right ovary can not be found using ultrasound and is thought to be "out of eggs" or hiding)

        Reply
      12. Geoffrey Sher, MD says:
        July 20, 2010 at 4:20 pm

        Hi Mou,

        Of course it is possible. It all depends on the cause of the hormonal imbalance.

        Geoff Sher

        Reply
      13. Geoffrey Sher, MD says:
        July 20, 2010 at 4:21 pm

        Hi N,

        Given the number of antral follicles on your one side…it is likely that the other side is equally productive and that all is normal in your case.

        Reply
      14. firewife07 says:
        May 24, 2011 at 12:24 pm

        Hi Dr. Sher,

        I just found your blog article. I understand that AMH can be drawn anytime in your cycle BUT what about if you have a large ovarian cyst? I have a 5 cm functioning cyst seen yesterday (was 1.9 cm prior going ahead and starting a clomid/menopur/IUI cycle that was cancelled). Apparently the meds stimulated it to grow so it is now 5cm. My doctor wants me to do CD2 labs including FSH, Estradiol, and AMH. CD 2 will be within the next 3-4 days and I'm assuming the cyst will still be there by then. Will the presence of this function cyst affect the AMH level as well?

        Reply
      15. mum2oneds says:
        August 10, 2011 at 8:57 pm

        The ovary, as miraculous a structure as it is, is unfortunately very wasteful. Every month it calls forth from within itself a troop of immature eggs, only one of which is destined to ovulate. All the other eggs that were recruited will die, a process called atresia.

        Dr Sher,from this blog entry, I have pasted above some content. And I have a few questions.

        Every month naturally in a woman's body, a troop of eggs are recruited and only one matures and ovulates.

        1. Can that one egg, which ovulated, be a genetically abnormal egg?

        2. Can any or more of those in the troop which eventually die, actually contain an euploid egg?

        3. In an IVF cycle, are all the follicles that grow & develop, upon FSH stimulation, from the antral follicles from that month/cycle?

        4. Will doing IVF repeatedly (3 cycles & beyond)cause ovarian reserve to decline more rapidly, esp in already DOR women?

        I hope you caught the meaning of my questions. I am trying very hard to pose them in such a way that you know what I am asking. Thanks!

        Reply
      16. Geoffrey Sher, MD says:
        August 11, 2011 at 10:33 am

        Thanks for your question. Both Dr. Sher and Dr. Tortoriello are currently out on vacation with limited or no internet access, so their response may be delayed.

        Admin

        Reply
      17. Geoffrey Sher, MD says:
        August 15, 2011 at 11:07 am

        Dr. Tortoriello responds:

        1. Can that one egg, which ovulated, be a genetically abnormal egg? YES

        2. Can any or more of those in the troop which eventually die, actually contain an euploid egg? YES

        3. In an IVF cycle, are all the follicles that grow & develop, upon FSH stimulation, from the antral follicles from that month/cycle? YES; SOME ARE TOO SMALL TO BE NOTED THOUGH AT THE ONSET OF THE CYCLE BUT LATER ACCUMULATE FLUID AND ARE VISIBLE.

        4. Will doing IVF repeatedly (3 cycles & beyond) cause ovarian reserve to decline more rapidly, esp in already DOR women? NO; YOU LOSE WHAT YOU WOULD HAVE LOST ANYWAY

        Reply
      18. Vespagirl42 says:
        October 13, 2011 at 7:36 pm

        Hi Dr. Sher:

        What would you say to a 39.5 year-old-woman with the following day 3 results:

        FSH = 7.14 miU/ml
        Estradiol = 39.5 pg/ml
        LH = 7.5 miU/ml
        AMH = 8.13 ng/ml
        Inhibin B = 92.9 pg/ml

        AFC = 9 in one ovary and 12 in the other.

        My doctor wants to re-run the test because the AMH level is out-of-whack. She said it indicated advanced PCOS. I've never been diagnosed with anything and have always had regular periods. Do you think there is major cause for concern, or that something simply went wrong with the initial testing?

        Reply
      19. Clara says:
        August 9, 2012 at 8:47 am

        We live in New York. I am 46 and I have 8 to 9 follicles each cycle. We are looking for a new clinic due to our current clinic missed my good eggs on 2 cycles already. Is it a common thing that doctor can miss ovulation on patients? My hormone is usually good for my age (FSH about 8 or 9 on day 4). I respond well with hormone injection. Cannot take clomid as I usually created cysts. Do not feel good physically with birth control. December 2010, 3 eggs retrieved, 2 successfully fertilized, 1 embryo as 10 cells on day 3 fertilization, 1 as 8 cells. Then transfer with negative pregnancy. Jan 2012, I had 5 follicles retrieved and 1 fertilized as day 5 expanded blastocyst. on Day 13 cycle (day before retrieval was E2: 1684, FSH: 7, LH: 2, P4: 6. My history looks like only 1 or 2 good eggs successfully fertilized. July 2012 E2: 687, FSH 12, LH 5, P4: 2 (follicles 21.5 mm, 14, 14.5, 16, 10, 9.5) Endo: 13. The doctor at our current clinic missed my ovulation again. We are looking for another clinic for mini IVF, do you accept me as a patient because I know your clinic has some age limit on mini IVF. Thanks a lot.

        Reply
        • Geoffrey Sher says:
          August 9, 2012 at 4:05 pm

          Age is the most important factor that impacts egg/embryo quality. The ovarian reserve as determined by the FSH/E2/AMH on day 3 is merely a measure of how many eggs there are likely to be. At 46 with own eggs the odds of a successful IVF are VERY low, in the low single digit range…I am afraid. The endometriosis adds another component, namely a 30% chance of an immunologic implantation dysfunction. You need a K-562 target cell test to measure uterine natural killer cell activity (see below. And you should be looking at egg donation in my opinion.

          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)
           “endometriosis”
           “Immunologic Implantation Dysfunction” (posted on May, 10th and on May 16th respectively.
           “IVF success: Factors that influence outcome”
           “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
           “Egg Donation”
           “Egg Donation with St-IVF
           “Embryo Banking”

          You might consider calling 800-780-7437 or 702-699-7437 to set up a web-based video conference or 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

          Reply
        • Geoffrey Sher says:
          August 10, 2012 at 8:34 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)
           “AAge and IVF outcome”
           “Agonist Antagonist conversion protocol”
           “IVF success: Factors that influence outcome”
           “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)
           “Staggered IVF”
           “Egg Donation”
           “Egg Donation with St-IVF
           “Embryo Banking”

          You might consider calling 800-780-7437 or 702-699-7437 to set up a web-based video conference or 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

          Reply
      20. Tiffany says:
        August 30, 2012 at 5:19 pm

        I left a Sher clinic today being told that I have reason to be concerned because my FSH level was 11.2 I am thirty one years old and feel very discouraged. The doctor basically said I have the eggs of a fifty year old woman and that my brain is telling my body that my eggs are older than my chronological age. My husband and I have been trying to conceive for almost seven years. I am having a hard time understanding could this level truly be the cause for our infertility? Any advice is welcomed.

        Reply
        • Geoffrey Sher says:
          August 31, 2012 at 4:36 pm

          It is a cause of diminished ovarian reserve, but if you act quickly, it is no reason to suspect that your eggs are poor. Age is in your favor.

          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?”
           “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

          Reply
      21. T Brunes says:
        February 18, 2013 at 2:57 pm

        I was just told by my RE that I should give up on IUI and IVF because my blood test results just came back and they are bad. AMH was less than .1 and FSH at day 3 was 10 once but also 20 another time. I am 42, no children, had 1 chemical. Nothing wrong but my age. HSG clear no endo etc. Is IVF or IUI out of the question? He seemed like a nice man and was trying to put me out of my misery. ALso…….i have a script for Femera. Will it hurt to take them anyway with timed intercourse using an OPK this cycle until I have made up my mind on whether or not to give up on the IVF dream?

        Reply
        • Geoffrey Sher says:
          February 18, 2013 at 4:22 pm

          I strongly agree with your RE. IUI is highly unlikely to work in your case4. You probably need to be considering IVF at the very least and possibly going to egg donation.

          Sorry, but that is the truth.

          Geoff Sher

          Reply

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      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
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      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
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      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
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      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
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      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
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      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
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      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
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      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
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      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
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      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
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      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
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      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
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      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
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      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
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      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
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      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
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      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
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      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
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      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
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      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
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      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
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      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
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