• Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF. zona pellucida) making it much less receptive to being fertilized by sperm. Coming off the BCP Compromise Response? In more than 70% of cases the loss is due to embryo aneuploidy (where there are more or less than the normal quota of 46 chromosomes). • Controlled Ovarian Stimulation (COS) in Older women and Women who have Diminished Ovarian Reserve (DOR): A Rational Basis for Selecting a Stimulation Protocol Sadly a lot of embryos don't make it to blastocyst, but as others have said, I think it is just bad luck. • Early -Endometriosis-related Infertility: Ovulation Induction (with or without Intrauterine Insemination) and Reproductive Surgery Versus IVF These are less developed than Blastoscysts, but still have the possibility to develop into blasts within the uterus (although the chances are less likely). I’ve had two attempts at egg retrieval. “Click” and you will immediately be taken to those you select. Also, my book, “In Vitro Fertilization, the ART of Making Babies” is available as a down-load through http://www.Amazon.com . If you’re lucky you will have responded well to the treatment and have lots of happy little follicles growing inside of you. Short (“Flare”) GnRHa Protocol: Another GnRHa usage for COS is the so called “(micro) flare protocol”. On are ICSI cycle we fertilised 7 eggs but on day 3 we got the phone call to say none have progressed, what could be the out come of this because I know it is very uncommon, and my fertility unit are quite shocked by this, I have a follow up appointment next week, is there any questions I could ask them or tests taken so this doesn’t happen again thanks. My husband’s sperm are normal. She is very fortunate to have such a loving and supportive sister as you are! • The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). • Staggered IVF with PGS- Selection of “Competent” Embryos Greatly Enhances the Utility & Efficiency of IVF. For our 2nd retrieval, we did a more detailed test on my husband’s sperm and saw that he had a borderline issue. Worse still, but it’s a question I’m asking myself every day: is there any point in still trying? This, in my opinion could be particularly harmful when undertaken in older women and those who have DOR. The most common reason relates to the protocl used for ovarian stimulation. These androgens are then transported to the granulosa cells of the adjacent follicles in a “bucket brigade fashion”. This is especially the case in young ovulating women who have normal ovarian reserve and have fertile partners. This, in my opinion could be particularly harmful when undertaken in older women and those who have DOR. Successful pregnancy resulted in 42% of women who responded to the Viagra. Menopur) can have a negative effect on the development of the eggs of older women and those who have DOR and should be limited. This approach is often augmented with preimplantation genetic screening (PGS) of all embryos that reach the expanded blastocyst stage of development by day 5-6 post-fertilization. The positive here is you’ve given yourself a chance at pregnancy (remember, no … Ovarian androgens can also reach the uterine lining where they sometimes will compromise estrogen receptor -induced endometrial growth and development. In fact, the vast majority of cases of RPL are attributable to non-chromosomal causes such as anatomical uterine abnormalities or Immunologic Implantation Dysfunction (IID). Over-exposure of the follicle to testosterone can compromise egg development and lead to an increased likelihood of chromosomal irregularities (aneuploid) following LH/hCG-induced egg maturational division (meiosis) and compromise embryo “competency/quality. They retrieved 12 eggs, 9 were mature and 7 fertilized. Such a chromosomally numerically normal (euploid), mature (MII) eggs, upon being fertilized will (hopefully) propagate euploid embryos that have 46 chromosomes and will be “: competent” to propagate viable pregnancies. It is especially important when it comes to older women, and women with diminished ovarian reserve (DOR) where it becomes essential to be aggressive, and to customize and individualize the ovarian stimulation protocol. This is why, it is my preference to administer GnRH-antagonists, starting at the initiation of gonadotropin administration. Thanks so much for discussing this thorny issue in such lucid language! • Deficient blood flow to the uterine lining (thin uterine lining). Is there anything you would do different?. While no one can influence underlying genetics or turn back the clock on a woman’s age, any competent IVF specialist should be able to tailor the protocol for COS to meet the individual needs of the patient. This is why women who take a BCP to launch a cycle of COS need to have an overlap of the BCP with an agonist. On the one hand many factors that profoundly influence egg quality; such as the genetic recruitment of eggs for use in an upcoming cycle, the woman’s age and her ovarian reserve, are our outside of our control. • Immunologic Dysfunction (IID) & Infertility (IID): PART 3-Treatment • Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas: The agonist causes FSH to be released by the pituitary gland and if overlapped with the BCP for several days and this will (within 2-5 days) facilitate PAF to AF conversion…. This suppression needs to be countered by artificially causing blood FSH levels to rise in order to cause PAF to AF conversion prior to COS commencing, otherwise pre-antral-to –antral follicle conversion will not take place in an orderly fashion, the duration of ovarian stimulation will be prolonged and both follicle and egg development may be compromised. During my final scan before egg collection, there were 0 follicles in my right (as expected) but 14 follicles in my left ovary albeit all different sizes. Patients can also enroll online on my website, http://www.SherIVF.com, or email Patti at concierge@SherIVF.com . We were told our chances of a pregnancy were very low and yesterday that became a reality. While it indeed increases the release of FSH, it at the same time causes a surge in LH release. • The Fundamental Requirements For Achieving Optimal IVF Success It may be due to difficulty hatching (but this is not considered a major reason), to chromosomal irregularities or to the conditions being suboptimal in the womb, for example. So you keep yourself busy for the next couple of days trying to keep the thoughts of developing embryos and embryo transfers to the back of your mind… we all know that is impossible though, right? Thus it should not be surprising to learn that it is more likely to exist in women who have a family (or personal) history of primary autoimmune diseases such as lupus erythematosus (LE), scleroderma or autoimmune hypothyroidism (Hashimoto’s disease), autoimmune hyperthyroidism (Grave’s disease), rheumatoid arthritis, etc. Day5 is 4AA , day 6 3AA , no PGS testing done . I have DOR (AMH between 1.00-1.23 and Day 3 FSH of 7.4)at the age of 30. To some extent this might be true, but if the problem lies with the use of a suboptimal COS protocol, transferring more embryos at a time won’t improve the chance of success. Gonadotropins (LH and FSH), whether produced by the pituitary gland or administered by way of fertility drugs, have different “targeted” sites of action in the ovary. The supposed reason for using the agonist, (Lupron) “trigger” is that by inducing meiosis through compelling a surge in the release of LH by the pituitary gland, the risk it reduces the risk of OHSS. . • “Unexplained” Infertility: Often a matter of the Diagnosis Being Overlooked! They are most commonly due to anatomical abnormalities of the uterus and/or cervix. Could this have compromised egg quality? • Blastocyst Embryo Transfers Should be the Standard of Care in IVF So it is that older women as well as those who (regardless of age) have DOR have a reduced potential for IVF success. Then go to my Blog and access the “search bar”. Is the couple having intercourse regularly in the periovulatory phase of the cycle? Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly. When GnRHa are administered for about 7 days prior to initiating gonadotropin stimulation (“long” pituitary down-regulation”), the LH depletion that will exist when COS is initiated, will usually be protective of subsequent egg development. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly. Could it in part be due to the fact that most practicing doctors do not provide IVF services but are indeed remunerated for ovarian stimulation and IUI services and are thus economically incentivized to offer IUI as a first line approach? There are several issues to be considered here: 2.THE EFFECT OF THE PROTOCOL USED FOR OVARIAN STIMULATION ON EGG/EMBRYO QUALITY. This is why women who take a BCP to launch a cycle of COS need to have an overlap of the BCP with an agonist. While this process begins early in the reproductive life of a woman, with notable exceptions, it only becomes manifest in the 2ndhalf of her reproductive life. Such women either over-produce LH and/or the LH produced is far more biologically active. While the effect of species on the potential of eggs to be euploid at ovulation is genetically preordained and nothing we do can alter this equation, there is, unfortunately, a lot we can (often unwittingly) do to worsen the situation by selecting a suboptimal protocol of controlled ovarian stimulation (COS). • Human Growth Hormone Administration in IVF: Does it Enhances Egg/Embryo Quality and Outcome? • Controlled Ovarian Stimulation (COS) in Older women and Women who have Diminished Ovarian Reserve (DOR): A Rational Basis for Selecting a Stimulation Protocol I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. The acquisition of FSH receptor responsivity requires that the pre-antral follicles be exposed to FSH, for a number of days (5-7) during which time they attain “FSH-responsivity” and are now known as antral follicles (AF). Pre-antral follicles (PAF) do not have such primed FSH receptors and thus cannot respond properly to FSH stimulation with gonadotropins. This results in LH levels falling to low concentrations, within 4-7 days, thereby establishing a relatively “LH-free environment”. For more information, go to the press release on my website, http://www.sherIVF.com . A major cause of RPL. Initiating ovarian stimulation in women taking a BCP, without doing this is suboptimal. Dear Dr. Sher, Johanna, Autoimmune IID: Here an immunologic reaction is produced by the individual to his/her body’s own cellular components. “Click” and you will immediately be taken to those you select. Diagnostic tests useful in identifying individuals at greater risk for a problem within the pregnancy itself include: Karyotyping (chromosome analysis) both prospective parents FSH targets cells that line the inner wall of the follicle (granulosa cells) and also form the cumulus cells that bind the egg to the inner surface of the follicle. ADDENDUM: PLEASE READ!! 7 – Average number of fertilised eggs that will form embryos (98%) 7 – Average number of embryos on Day 3 of culture 3.5 – Average number of blastocycts on Day 5/6 (50% of good quality day 3 embryos make it to blastocyst) It was not clear if this was their clinic’s statistics or where the source of this data came from. I also commonly recommend blastocyst banking to many such patients. • “Unexplained” Infertility: Often a matter of the Diagnosis Being Overlooked! Also, is it possible that my AMH is only on the low side due to having one functioning ovary and not because I have DOR? 1. Much of this is due to the fact that such women tend to have increased production, and/or biological activity, of LH. • Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF. • Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice. The probability that we select the three or five that would have gone to day 5 or 6 is not very high. She received a call yesterday that 5 of those 7 were doing great (they are watching the 6th to see if it catches up). I'm in 35 and in a position where I desperately need to make up my mind for 1vs 2 embryos . Short protocol with no down reg and 225iu Bemfola. (A/ACP) With the “Conventional” Antagonist Approach Day 4 – Letrozole Sandoz (Femara) (introduced to reduce estrogen due to past breast cancer) ). There are two broad categories: It is not so much dosage as it is composition and timing…i.e. Antisperm antibodies in the man or woman. Yet ID is probably the most overlooked factor. I’m using a sperm donor – so I suppose the issue is with my eggs – and the ICSI method. Hi Jennifer Still have a year or so before I occupy a rocking chair. However, the emphasis is on a “normal” amount of testosterone. • The “Biological Clock” and how it should Influence the Selection and Design of Ovarian Stimulation Protocols for IVF. 800-780-7437. That is why, the likelihood of failure to conceive, miscarrying and of giving birth to a chromosomally defective child (e.g. The Use of IVF in the Treatment of RPL My husband has poor sperm (low count/concentration but decent motility with poor DNA frag). This can result in excessive ovarian male hormone (predominantly testosterone) production. I have just had egg retrieval and we got 8 eggs although I got a call today to say that only 2 fertilised. We attempted a medicated cycle with our best embryo in March and it didn't take. This results in an initial rise in FSH and LH , which is rapidly followed by a precipitous fall to near zero. • The “Biological Clock” and how it should Influence the Selection and Design of Ovarian Stimulation Protocols for IVF. 18 eggs retrieved, only 6 fertilised! Whenever a patient fails to achieve a viable pregnancy following embryo transfer (ET), the first question asked is why! I suggest you call my assistant, Patti Converse at 702-533-2691 and set up a Skype/FaceTime consultation with me to discuss. It is true that since many aneuploid embryos are lost during development and that those failing to survive to the blastocyst stage are far more likely to be competent than are earlier (cleaved) embryos. Because of how highly complex the development to the blastocyst stage is, many embryos might never develop into blastocysts. Mild Male Factor • Intralipid and IVIG therapy: Understanding the Basis for its use in the Treatment of Immunologic Implantation Dysfunction (IID) In contrast, when the GnRHa administration commences along with the initiation of gonadotropin therapy, there will be a resultant immediate surge in the release of pituitary LH with the potential to increase ovarian testosterone to egg-compromising levels , from the outset of COS. GnRH antagonists are traditionally given, starting after 5th -7th day of gonadotropin stimulation. This may be true, but it comes at the expense of egg quality because the extent of the induced LH surge varies and if too little LH is released, meiosis can be compromised, thereby increasing the likelihood of aneuploid and immature (MI) eggs. For Example: Does it mean a fertilized D0 egg can develop into a healthy baby? • Blastocyst Embryo Transfers should be the Standard of Care in IVF GnRH agonists cause an immediate surge in release of FSH by the pituitary gland thus causing conversion from PAF to SAF. This is especially the case when it comes to older women and those with DOR, who in my opinion should preferably be stimulated using FSH-dominant products such as Follistim, Puregon, Fostimon and Gonal-F. • Human Growth Hormone Administration in IVF: Does it Enhances Egg/Embryo Quality and Outcome? Upon menstruation and confirmation by ultrasound and measurement of blood estradiol levels that adequate ovarian suppression has been achieved, The patient is given twice-weekly injections of estradiol valerate (Delestrogen) for a period of 7-8 days whereupon COS is initiated using a relatively high dosage FSH-(Follistim, Fostimon, Puregon or Gonal F), which is continued along with daily administration of GnRH antagonist until the “hCG “trigger.” This approach is often augmented with HGH administration throughout the process of COS and by preimplantation genetic screening (PGS) of all embryos that reach the expanded blastocyst stage of development by day 5-6 post-fertilization. Doing so will avoid a great deal of unnecessary heartache for many patients. • Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice. Type in the titles of any/all of the articles listed below, one by one. In your opinion, what would you do differently (if anything) to stimulate more follicle growth without comprising egg quality. Pre-antral follicles (PAF) do not have such primed FSH receptors and thus cannot respond properly to FSH stimulation with gonadotropins. You can also contact Julie by phone or via email at 702-533-2691/ Julied@sherivf.com You can also apply online at http://www.SherIVF.com . We start with estrogen skin patches applied every 2nd day (or with the BCP) for 10 days or longer, overlap it for 3 days with a GnRHa whereupon the estrogen priming is stopped. Accordingly, I do not prescribe such protocols to my IVF patients. IMMUNOLOGIC IMPLANTATION DYSFUNCTION This is also one of the most difficult questions to answer. Triggering egg Maturation prior to egg Retrieval: hCG versus GnRHa Pre-antral follicles (PAF) do not have such primed FSH receptors and thus cannot respond properly to FSH stimulation with gonadotropins. • Cervical Ureaplasma Urealyticum Infection: How can it Affect IUI/IVF Outcome? In my opinion, the over-administration of LH-containing menotropins such as Menopur, [which is comprised of roughly equal amount of FSH and hCG ,which acts similar to LH)], to older women, women with DOR and those who have PCOS can also lead to reduced egg/embryo competency . Menopur) can have a negative effect on the development of the eggs of older women and those who have DOR and should be limited. They act by causing an initial outpouring followed by a depletion of pituitary gonadotropins. • The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). • Frozen Embryo Transfer (FET) versus “Fresh” ET: How to Make the Decision Dear Dr. Sher, • Hormonal imbalances (progesterone deficiency or luteal phase defects). • Human Growth Hormone Administration in IVF: Does it Enhances Egg/Embryo Quality and Outcome? You want to call the clinic every day and check on your ‘babies’, but you don’t want to annoy the specialists or come across as one of those highly strung, over-anxious patients. • Intrauterine Insemination (IUI): Who Needs it & who Does Not: Pro’s & Con’s!IUI-Reflecting upon its Use and Misuse: Time for a Serious “Reality Check It is followed by a withdrawal bleed (menstruation), whereupon gonadotropin treatment should commence, while daily Lupron injections continue, to ensure a “low LH” environment. Estrogen Priming has succeeded in significantly enhancing ovarian response to gonadotropins in many of otherwise very poor responders. We start with estrogen skin patches applied every 2nd day (or with the BCP) for 10 days or longer, overlap it for 3 days with a GnRHa whereupon the estrogen priming is stopped. GnRH-antagonists such as Ganirelix, Cetrotide and Orgalutron, on the other hand, act very rapidly (within hours) to block pituitary LH release. Menopur) can have a negative effect on the development of the eggs of older women and those who have DOR and should be limited. • Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy! During the normal, ovulation cycle, ovarian hormonal changes are regulated to avoid irregularities in production and interaction that could adversely influence follicle development and egg quality. Day 5 – Orgalutran (250ml) introduced FSH targets cells that line the inner wall of the follicle (granulosa cells) and also form the cumulus cells that bind the egg to the inner surface of the follicle. Thus I strongly recommend that such testing be done in most cases of miscarriage. • Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice. The infection can also occur in the man, (prostatitis) and thus can go back and forth between partners, with sexual intercourse. Is the post coital (Huhner) test (periovulatory examination of cervical mucous, done 6-18 hours after intercourse) normal? • Optimizing Response to Ovarian Stimulation in Women with Compromised Ovarian Response to Ovarian Stimulation: A Personal Approach. Coming off the BCP Compromise Response? 4. • Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol There’s a chance they could grow and present better tomorrow on Day 7, but I wanted to ask you, does this seem unusual? Now is the time to remain focussed on your objective. In contrast, the LH-lowering effect of GnRH agonists develops over a number of days. However, in my opinion, in the absence of severe male factor infertility and severely diminished ovarian reserve, it is the protocol for ovarian stimulation which in my opinion is most important. I kept it under my coat until they got it. • Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas Blastocyst stage occurs about 5 or 6 days after fertilization. A significant percentage of older women and those who have diminished ovarian reserve (DOR) have increased LH activity is increased. In contrast, the LH-lowering effect of GnRH agonists develops over a number of days. The process involves; needle aspiration of the “chocolate colored liquid content of the endometriotic cyst, followed by the injection of 5% tetracycline hydrochloride into the cyst cavity. However, one of the central issues affecting egg/embryo competency is the protocol used for ovarian stimulation. I would like to ask you something. By overlapping the BCP with an agonist for a few days prior to menstruation the early recruited follicles are able to complete their developmental drive to the AF stage and as such, be ready to respond appropriately to optimal ovarian stimulation.
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