18 Responses to “Ovarian Stimulation For IVF: High-Responders vs. Poor Responders”

1. Auntie K says:

   November 11, 2009 at 5:56 pm

   Hi Dr. Sher. I'm hoping you can help me. I just turned 28 and was told I have high fsh. I only had it tested once and it came back at 27. The thing that bothers me the most was our RE immediately said donor eggs & adoption. He wasn't willing to work with me. Our second opinion appointment with another doctor went slightly better, but he still wasn't hopeful. He did an ultrasound of my ovaries to check things out. Said my uterus and lining looked excellent. He saw that my right ovary was small in volume, but to his surprise my left ovary looked great and actually had 4 follicles.

   Is there something to help me? RE #2 said possible IUI with injectables, but wasn't 100% I thought IVF was better for women with high fsh??

   Can you please give me some more information and hope??

   Reply
2. Geoffrey Sher, MD says:

   November 11, 2009 at 9:16 pm

   Respectfully, in my view IUI is not the right aproach.The success rate is too low nad you are about to run out of time. You need IVF ASAP and with what refer to as an agonist/antagonist conversion protocol with estrogen priming (LA10-E2V). Read up on this elsewhere on this blog. You mkight not respond sufficiently but it is your BEST hope. If you don't respond to this protocol you will need donor egg. Don't expect to produce many follicles, but because you are young, and aside from the protocol of ovarian stimulation used, age is the main determinant of egg/embryo quality, you might have a chance…but you won't get there with IUI.

   Feel free to set up a free medical telephone consultation to discuss this with me. Just click on to the appropraiter link at the top right hand corner of this page.

   Geoff Sher

   Reply
3. Auntie K says:

   November 15, 2009 at 12:44 pm

   Dr. Sher,
   I have one more question. Another hormone level just came back high. 17 oh progesterone? I've never heard of this before. What does it do? What are the causes? Is it treatable? I know it can also be a cause of infertility, but was hoping you could tell me more.

   Reply
4. cinman says:

   November 25, 2009 at 9:50 am

   hi
   thank you very much for your detailed writings
   my wife is 32 year old and we tried 4 time IVF
   first 2 ivf tries were 4 years ago and long time agonist step down protocol they use.third time they tried antagonist protocol.this time it is 4th and doctor tried low dose long protocol
   all ivf tries happened as : low quality embryos
   and I am 33 years old male and I have very severe olygospermia and we have male factor
   my wife is high responder and always over than 15 eggs are happening..third try (antagonist cycle ) was 34 eggs.last was 16
   here is our question
   we want to try one more
   what is your suggest ?
   antagonist or agonist ?
   long or short protocol ?
   what should be the dose of FSH analogues ? ( 75 U ? 100 U ? 150 U =)
   should we use oral contraceptives before cyclus ?
   how can we stop high responding ?
   our E2 levels always higher than 3500 Iu on tenth day after mens
   we have never faced early OHSS
   and we appreciate what you answer
   regards

   Reply
5. Geoffrey Sher, MD says:

   November 26, 2009 at 4:00 am

   There nare 2 issues nto be considered here. The first is the protocol of ovarian stimulation needs adjustment to try and avoid egg quality issues and the second is your husband's sperm function. This needs to be carefully evaluated and, if possible improved. While helpful, the information provided is insufficient to base advice on. To address these requires that we communicate by way of consultation.

   Geoff Sher

   Reply
6. shelly says:

   March 8, 2010 at 11:57 am

   Dear Dr. Sher,

   I am 34 year old, my husband is 37. We just finished the second IVF (after 2 IUIs), which failed. We know of a male factor infertility (low count, low motility, and fragmented), but now we are told we need better eggs. First IVF – 6 eggs, 5 matured, transfer of all 3 fertilized (all grade B, two 8-cell and one 7-cell). Second IVF – 9 eggs, transfer of all 3 fertilized (2 grade A 8-cell and one grade B 6-cell). We now also learned of an ovarian resistance so next cycle will be without the lupron and 325 units Gonal-F (last time 725 units but with lupron). Any suggestions?

   Reply
7. SBreezy says:

   July 2, 2012 at 2:21 am

   Hello dr sher

   im currently 25 and was interested in invitro fertilization because i wanted multiples and my number of multiples is a bit high so im not going to disclose that yet but i wanted to know which hormones work the best at getting multiple healthy mature eggs or does it depend on the woman? I was researching the number of mature eggs that can be retrieved to try and get a certain number of fertilized eggs that will become blastocysts so i was wondering waht hormone would get me the most amount of eggs and if so could i get say 55-60 eggs retrieved and see how many fertilize and then how many turn into healthy blastocysts in order for me to get enough implanted.

   Reply
   • Geoffrey Sher says:

     July 6, 2012 at 3:32 am

     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)
      “Agonist/Antagonist Conversion Protocol”
      “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)

     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
8. Ashley says:

   July 6, 2012 at 11:32 am

   Hi Dr. Sher – I’m nearly 31. DH is nearly 30. We were pregnant successfully on our own in 2010, but lost the baby @ 16 weeks due to partial molar pregnancy. I have undergone 5 IUI’s plus 1 cancelled IUI due to a cyst. 4 out of 5 IUIs were on letrozole, one cycle on Gonal-F+Ovidrel. We started Antagonist IVF with stims on 6/21. Stimmed on Gonal-F 300 for 3 days, upped to 450 for 9 days after that. Cetrotide was started on my 9th day of stims and was continued for 5 days. Triggered on Tuesday night with 40 units of Lupron. Retrieval was on Thursday morning (Today). Lupron trigger was used because of the anticipated high response given previous cycles and AMH level (which the doc described to me as a “ton of eggs” at 4.1)

   This IVF cycle has been a challenge. In my u/s on Tuesday the doc counted roughly 24 follicles on one side and several more on the other. However my lining had begun to change and were instructed to do a “freeze all”. I Just completed my retrieval today in which 13 eggs were retrieved. Sort of a surprise given the number of eggs counted on Tuesday. Here’s the worse news. Embryologist says that the follicle/egg quality is just not looking good. Assuming none fertilize and/or make it to freeze the recommendation is to do another IVF cycle with modified protocol before jumping to the conclusion of overall poor egg quality. It sounds like he’d reduce stimulation drugs to a lower dose so that we get fewer follicles, but hopefully higher quality and then use the traditional Ovidrel to trigger.

   I am wondering if you could 1) comment on my situation and 2) point me to the evidence you reference in your first sentence. I’m interested in reading more about this and am more than willing to pour through journal articles. Trust me, I’m familiar with reading scholarly texts, given my previous experience with the partial molar.
   Thank you!

   Reply
   • Geoffrey Sher says:

     July 7, 2012 at 6:47 am

     Without access to the precise stimulation implemented, it is hard to comment. I do agree that the egg yield relative to follicles available was low and this could have to do with the protocol of stimulation. Also, if Ovidrel is used be sure the dosage is doubled to 500mcg. The single dosage of 250mcg lacks biopotency 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)
      “Agonist/Antagonist Conversion Protocol”
      “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)
     “
     Once this cycle is over, 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
9. laurel solis says:

   July 21, 2012 at 2:07 pm

   dr sher, hi, i need your opinion, i am presently on my ivf treatment,however my estrogen went up to 10,000, i am still being coasted . now that mybestrogen is trending down, my re gave me a choice, since my estrogen is at 5,000, they can trigger me for my retrieval, or we will wait for one more day,so my estrogen will be at safe llevel, however he informed me that the egg will significantly reduced, thelast ultrasound that i had, i have 8 eggs on right side, and 10 on the other with 18-22 in diameteron most of the follicles. im still taking lupron daily, mhowver iit was advised for me to stop gonal f since the 18, initially i was aking gonal f 225 , and menopur i vial everyday for 3 days, then itnwas tapered to 150 of gonal f to 1 menopur, for 2 days, and gonal f 75 for couple of days. now im only with lupron, and no gonal f or menopur, will my egg’s qulaity be significantlly reduced, for i am being coasted for morethan 5 days. will it means that i might have a failed ivf??? thanks. your response will be greatly appreciated.

   Reply
   • Geoffrey Sher says:

     July 23, 2012 at 5:22 pm

     Outcome will not depend on the length of the “caosting period”. Rather it will depend on when the coasting was initiated. If it was only initiated after >50% of the follicles were >16mm, the follicles will ultimately be likely to be cystic and the eggs poor. If it was initiated when the E2 was 2500-3000pg/ml and at least half of the follicles were 14-16mm, most of the eggs should be OK.

     I would not stop the coast until the E2 fell below 2500pg/ml.

     Good luck!

     Geoff Sher

     Reply
10. Annette Morris says:

    August 3, 2012 at 6:31 am

    Hello Dr Sher, I would like you’re opinion please. I will be 38yrs old in Oct. I have had 3 cycles of IVF – the first I only developed 2 follicles and one egg retrieved after long down reg with buserelin and stims of Gonal F of 225iu increasing to 450iu, ebryo transfered, negative test. 2nd cycle was short protocol, on COCP to down regulate, stims of menopur 450iu whole way through -developed 2 eggs, 1 embryo transfered after delayed fertilisation. 3rd cycle cancelled as I only developed 1 small follicle on aspirin 75mg, dexamethasone 1mg, gonal F 225iu and menopur 225iu after down reg of COCP. Was told to go for egg donation but I feel I have a chance of conceiving my own child. I have regular cycles, most recent FSH 8.9u/L, LH 4.7u/L, oestradiol 313 pmol/L, prolactin 216 mu/L on day 2, progesterone 55.3 nmol/l on day 21, TSH normal, FBC normal, cardiolipin antibodies normal.I also feel that I have an ovarian cyst on L side which goes up and down because of occassional pain which can be moderate at times. What would my options be, in your opinion. I live in London and have so many IVF clinics to choose from and don’t know where to go. Would appreciate your help.

    Reply
    • Geoffrey Sher says:

      August 3, 2012 at 5:36 pm

      Your FSH is higher than represented. The reason….when the oestradiol is as high as yours on day 3, it suppresses the FSH so that you can be assured that if the oestradiol had been <200, your FSH would probably be >12. This + your blunted response points to diminishing ovarian reserve and the need to adjust your protocol. First it needs to be more aggressive, FSH dominant and you should be using a completely different approach. I think you need agonist/antagonist conversion protocol (see below). Time is a critical issue for you because ovarian reserve will continue to decline and then you might have no options other than egg donation, at all.

      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)
       “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 702-699-7437 to set up a web-based video conference or a telephone consultation with me so we might discuss your case in detail.

      Regards!

      Geoff Sher

      Reply
11. Erin says:

    November 26, 2012 at 1:59 pm

    Dr. Sher:

    I would appreciate a quick opinion on my situation. I underwent IVF in 2008 at age 29 on a standard long protocol. At the time my antral follicle count was not great, particularly for being so young (I believe it was 10) and my FSH was 8.5. My AMH wasn’t taken. I stimulated on 225 IU Follistim and I believe 75 or 100 Menopur. I only produced 7 eggs, which were all fertilized with ICSI. (My husband has severe male factor infertility – counts have been, at different times, 200,000, 1.4 million, 18.9 million, 4 million, with low motility and normal forms percentages as well). On day 3, only 2 embryos remained, and they were both grade 1 (top grade at their lab) but only 5 cells. Miraculously, the beta was positive and I now have a healthy, perfect 3 1/2 year old daughter.

    Fast forward to this year. In August 2012, a month shy of my 34th birthday, I began another IVF cycle at a different clinic. My most recent antral count was now 8, and my AMH was 1.4. I was diagnosed with slight DOR, and my husband’s count is, predictably, still very low, but his motility and normal form percentages have improved vastly. (He has lost a lot of weight since 2008, and we have wondered if that is the reason for the improvement.) I was put on a Lupron micro-flare protocol with the max dose of FSH at my clinc, 600 IU of Follistim per day. I was only on birth control for about 2 1/2 weeks prior to starting Lupron. Again, I only produced 7 eggs. By day 3, my two normally developing embryos (7 and 8 cell) were graded 3 and 4 (poor at this lab). Also, the embryologist commented that, on visual exam, my eggs were of poor quality. (At the former clinic, I never received information either way on the quality of my eggs on visual exam.) I did not get pregnant. My RE does not trust embryo grading, and does not feel it is a big worry when embryos are graded poorly. I can’t help but disagree, and feel that if it doesn’t matter, why are they being graded at all? I am not sure what to think on that.

    Do you think that a patient like me would benefit from pituitary down-regulation and estrogen priming? I am not sure if you have enough information to comment. We are considering trying one more time, and I want to know if there is a high likelihood that our embryos will once again be poor, in which case we might not go through IVF again.

    Reply
    • Geoffrey Sher says:

      November 26, 2012 at 5:51 pm

      Respectfully, I do not use “flare protocols” and especially not in women with diminished ovarian reserve (DOR). It causes the LH to increase and ovarian testosterone output to go too high as women with DOR are very vulnerable to this (see articles below). However the DOR itself should not cause you to have poor eggs. It is in my opinion more that this type of protocol in women with DOR (regardless of age) is suboptimal. Please go to the home page on this site (www.IVFauthority.com) and when you get ther 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”

      You may 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
12. natasha says:

    December 18, 2012 at 7:14 am

    Hello doc I would like your opinion on the suggested protocol for IVF 3 in Jan 2013. I have been told to have Menopur 600 iu throughout and shall be on cetrotide from Day 6. I have a dimished ovarian reserve with AMH of 1.6 and have had highest fsh level of 12.9. In terms of earlier protocols. First IVF: Menopur 600 iu for 5 days and increased to 750 iu for rest of the period. first three days on lupride 1ml and cetrotide from day 10-12. retrival on day 14. 4 eggs retrieved and 3 embryos. Second IVF: Throughtout Gonal F 450 iu, Luverus 150 iu and HCG 1250 iu. Also day 1-3 lupride and cetrotide from day 6 -9. retrival on day 11. Only 1 egg retrieved and 1 embryo. Before both IVFs i was put on BCP prior to the cycles.

    Reply
    • Geoffrey Sher says:

      December 18, 2012 at 8:30 am

      I know that if you have read the relevant articles on this blog you will know why I would not personally use either of the stimulation protocols. 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”

      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