10 Responses to “Ovarian Stimulation in IVF: Why It Is Important to Down-Regulate LH”

1. Kris says:

   October 25, 2012 at 7:12 am

   I am 37 years old and have had three failed IVF cycles with the same clinic. All three cycles were 10-21 days of birth control pills followed directly by simulation medications (150 of menopur and varying amnts of follistim) with Ganirelix added the last three days. We retrieved a 15-20 mature eggs with each cycle but had low fertilization and only 2 blasts on day 5 and 1 blast on day 6. We transferred a total of 3 blasts and 3 morulas. My RE concluded that I have a higher than expected number of eggs with chromosome abnormalities and recommended donor eggs. I am with a new clinic now that recommends a natural start Lupron protocol beginning on day 21 of my cycle. Is there a reason to believe this would be more successful?

   Reply
   • Geoffrey Sher says:

     October 25, 2012 at 2:35 pm

     I cannot comment above saying that the protocol used for ovarian stimulation is a very important factor in determining egg/embryo quality and hence IVF outcome. Please to the home page on this site, find a “search bar” in the upper right hand column and type in the following subjects into the bar and it will take you to all the relevant articles I posted there.
      “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
      “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
      “Agonist/Antagonist Conversion Protocol”
      “Embryo Implantation………” (Part-1 and Part- 2—-Posted August 2012)
      “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
      “A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
      “IVF success: Factors that influence outcome”
      “Staggered IVF”

     Since you reside in the NY area, consider calling 646-792-7476 (SIRM-New York) and arrange to have a consultation with Dr Tortoriello).

     Geoff Sher

     Reply
2. Kris says:

   October 25, 2012 at 7:14 am

   I should also mention – my e2 was always in the upper 3,000s and I was triggered when my lead follicle was 17 but many others were around 14-15.

   Reply
   • Geoffrey Sher says:

     October 25, 2012 at 2:31 pm

     I personally trigger when at least 2 follicles are greater than 18 mm and at least half are above 15mm.

     Geoff Sher

     Reply
3. Gretchen says:

   March 27, 2013 at 6:13 pm

   I’m just wondering — you talk about how stepwise increases in LH are bad for egg quality, but how high is too high for LH? The protocol I am on currently uses femara, and clomid along with follistim — which after a fair bit of reading of your website, I can see you don’t recommend because they both increase LH. My initial day 2 LH was 3, FSH was 5. A week later, 5 days after starting the femara, and 3 days after starting the follistim 75u, my estrogen was 140, P 0.8, LH was 10, and FSH was 9. I know that during the LH surge, it should spike to like 70 — but how high do you think it needs to be before it is detrimental to egg quality? If it stays sort of low – like under 20 – is that safe enough, or do I need to be worried that even those levels are negatively impacting my chances of success?

   It is too late for me to change anything in this cycle I think, since the only thing I could do now would be to add in a GnrH antagonist to block LH production – and I’m not sure that’s advisable. Is that advisable? Should I be asking for that right now before LH increases and has a chance to do any damage? Or is it too late and I just have to go with it, watch my numbers and then see what happens? Naturally, I want to do everything possible to make this cycle a success, and not have to start over. Any thoughts?

   Gretchen

   Reply
   • Geoffrey Sher says:

     March 27, 2013 at 7:36 pm

     An LH of 10MIU/ml in the peripheral blood is high but what really matters is the local ovarian androgen level, which is not readily reflected by peripheral blood levels because of a dilution effect……..The local ovarian concentration of androgens is several times higher than diluted peripheral blood levels. Femara and Letrozole are good drugs when given to women with normal ovarian reserve. They both induce ovulation through causing a generalized increase in hypothalamic GnRH, intended to increase pituitary FSH so as to promote folliculogenesis. However, GnRH also elicits concurrent pituitary LH release, which is not very prejudicial in women with normal ovarian reserve, however, in my opinion, because women with DOR have increased ovarian stroma (theca) which produces androgens (mainly testosterone) in response to LH, even modest elevations in LH can cause in their ovaries a considerable and disproportionate excess in stromal (thecal)production of androgens.This, I believe in women with DOR could be harmful to egg development (ovogenesis),ultimately leading to an increase in meiotic aneuploidy with dire consequences.

     It is almost certainly too late for you to change course in the midst of a cycle. There is no point in adding an antagonist midway through stimulation. I would see this cycle through as planned.

     I hope that this does not apply in your case and that you will be successful.

     Good luck!

     Geoff Sher

     Reply
4. alma says:

   April 16, 2013 at 1:15 pm

   Hi,
   Do you think that a dose of 75 Luveris (together with Gonal ) could be good during stimulation for DOR and over 40 years old?

   Thank you

   Reply
   • Geoffrey Sher says:

     April 16, 2013 at 1:56 pm

     It depends on your specifics!

     Geoff Sher

     Reply
5. Michelle says:

   April 22, 2013 at 11:46 pm

   I am 35. I have a low AMH of 2.5pmol/L. I just completed one failed IVF. I took no drugs in the previous cycle and started Puregon 200 on day 3 of the IVF cycle. I had a scan on cycle day 8 which showed 6 follicles all at different sizes. By retrieval day, I had 4 follicles 22mm, 20mm, 14mm & 10mm. They only took one egg out and the genetic material in it started disintegrating at day 2 so it could not be transferred. Could I get your opinion as to how you would proceed with my next IVF taking into account my low AMH and that I would like to have more eggs to work with next round (ie. more follicles growing at the same rate).

   Reply
   • Geoffrey Sher says:

     April 23, 2013 at 10:16 am

     HiMichelle,

     From reading this blog you must know that I do not use the type of protocol you allude to …especially in women with diminished ovarian reserve. Please read articles; 1,2& 3 below and then perhaps also the ones on Staggered IVF and Embryo Banking, below.

     Please go to the home page of this blog, http://www.IVFauthority.com. When you get there, look for a “search bar” in the upper right hand corner. Type the following subjects into the bar, click on it and it will take you to all the relevant articles posted there.

     1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)

     2. “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”

     3. “Agonist/Antagonist Conversion Protocol”

     4. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)

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

     6. “IVF success: Factors that influence outcome”

     7. “Staggered IVF”

     8.“Embryo Banking”

     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