Egg Quality: here is the reason that your medications matter

A reader of this blog recently requested that I explain why I utilize certain medications for my IVF/fertility patients and caution against the use of others. It all comes down to their effect upon egg quality. Although there is still much to be learned, most fertility specialists agree that what is going on hormonally in a woman’s body will impact the success of her cycle. That’s why I feel that it’s so important to optimize their hormone balance and individualize the protocol to suit each woman’s unique situation. Here’s what we know.

Prior to the month that an egg is going to have its opportunity to ovulate, the DNA within it remains inactive. It has been in this state of rest since birth. Whether or not egg develops in an environment that is balanced more toward estrogen or testosterone is the key factor which will determine whether it will mature normally. Eggs that are “estrogenized” are more likely to mature earlier, fertilize normally and develop into healthy embryos. “Androgenized” eggs are more likely to become atrophic, fertilize abnormally or become a first trimester miscarriage.

Typically, a woman’s fertility begins to drop dramatically about 13 years before she’s going to enter menopause; typically their mid to late thirties. This drop is associated with a shift toward a higher level of testosterone within the ovary and not surprisingly a drop in egg quality. What triggers this hormone shift within the ovary is that as women age they produce a more potent form of the hormone LH as well as develop a tendency to have greater sensitivity to this hormone. Therefore, when designing a protocol for a fertility treatment cycle, I feel it is important that we shift the balance toward a higher level of FSH relative to LH in order create a more favorable setting for egg maturation. Creating such protocols has been among the great accomplishments of my friends and colleagues Drs. Geoffrey Sher and Jeff Fisch when they demonstrated in their landmark paper that pregnancy rates can be substantially improved in women with a history of previous fertility treatment failure. The trick is to stimulate the ovaries with an FSH dominant signal early in their development and then add in a low level of LH late in maturation to optimize the quality of as many eggs as possible. From a practical standpoint, that means being able to control FSH and LH levels independently.

Many centers use simplified preparations of FSH and LH for their ease or lower cost. But I describe this as being similar to mixing your salt and pepper together in the same shaker. It may work in some situations but most patients need varying degrees of adjustment get “more salt” or “less pepper.” What makes this approach even more problematic is that these mixed preparations—called urinary derived gonadotropins—are made from the urine of the least fertile population, women in menopause. In effect, that “makes the pepper even spicier” as these women produce a far more potent form of LH. All too often, this results in a disappointing outcome. It is true that the lower cost, pre-combined products work well enough when given to the most fertile patients. I believe that’s what keeps the market for them alive. In addition to their impact upon egg quality however, I am also concerned about the impurities that they contain.

A recent analysis of both the standard and more highly purified urinary preparations found them to be 95 to 99% free of contamination. These contaminating proteins can not only impact the how a woman’s ovaries respond to them, they can also initiate an allergic reaction. Even more problematic, they carry a very low but real risk of transmitting infection which recently resulted in their use being banned in England and the rest of the United Kingdom.

In summary, the use of the latest technology has made it possible for companies to manufacture untainted FSH and LH in separate preparations so that their dosing can be uniquely adjusted to each patient’s individual needs. Better still, these are BioIdentical products that are exact replicas of the hormones produced by fertile women. Additionally, they are 100% pure and therefore free from the risk of allergic reaction or infection. For all of these reasons, I believe that these products are most suited toward meeting the needs of the patients that I see in my practice.

136 thoughts on “Egg Quality: here is the reason that your medications matter

  1. Hi Dr Greene,
    I have a previous condition called Idiopathic Intracranial Hypertension. I live in Australia and want to do PGD/IVF for family balancing. Is there a problem with me doing a cycle of IVF with this previous condition? I cannot find any help here in Aust. I had my 3rd boy in Feb 08 by c/section with no complications. Thank You. Sheree

  2. hello,

    this blog entry caught my eye. i am of advanced maternal age and was wondering if you treat older women with high fsh or can recommend someone in my area? i eat organic/natural, am of normal weight and health and have ingested loads of supplements including all that you mentioned in your latest article. i appreciate your low key natural approach. most doctors are out of my price range or they won’t see me as i am older and any failures would adversely affect their success rates. i don’t necessarily wish to do ivf but i think correcting hormonal imbalances would help, what do you think? thanks.

    1. Dear Diane,
      I understand fully what you describe as a reluctance of some providers to see patients that aren’t going to help them advertise their success rates. I’m not sure if you’ve read my blog post on that phenomena but I find it offensive and reassure you that is not how we operate at our center. I would be more than happy to review your records with you and discuss your treatment options. I do find that some women with diminished ovarian reserve do seem to respond better to low dose protocols. Therefore, this would be one of the options that I’d be happy to discuss with you. If you click on the link for setting up a free consultation, you can initiate that process if you like.

      Best thoughts,
      ~Robert

  3. hi again, thanks for your reply. i didn’t think you had seen my note because i didn’t see it immediately after posting.

    i am seeing a new doctor in my area and we are doing low stim iui with femara and vivelle patches. i produced 2 good sized defined edged follicles, now i am in the 2ww.

    but my question is pertaining to testosterone.
    i have suffered from low libido since i got off the testosterone based birth control pill in my thirties and it really plummeted later in that decade. i have been tested for testosterone and am on the low/normal side. i took some creme and it really helped me with libido when i was 40. i finally found another doctor who prescribed it for me and i have been taking a portion of the little packet of androgel up to ovulation and then no more until my next cycle.

    you indicate that the ovaries contain testosterone and more so in mid age? wouldn’t that show up on a hormone level test? i don’t understand and am reluctant to give it up because i am never in the mood without it. what would you suggest instead(please don’t say ‘a glass of wine’)

    thanks for your time.

    1. Hello Diane,
      I’m hoping that your current cycle works out. The reality is that when it comes to changes in libido and testosterone levels, there is not a simple relationship. In fact, new studies have provided tremendous insights into how the neurotransimitters (brain chemicals produced by nerves) may be the real key to improving/restoring libido. Additionally, the ratio of amount of testosterone in relation to the estrogen levels is more important than the simple testosterone level alone. The bottom line is that I would not over analyze lab tests nor would I recommend that deviate from your doctor’s instructions. Too much testosterone can reduce your chance of becoming pregnant so please proceed with caution when it comes to utilizing anything to boost your libido. Additionally, you may wish to check out some of the other recommendations that I describe in my book PERFECT BALANCE (chapter 8) because there are some nonhormonal solutions that you may find useful while you’re going through fertility treatment.

      Best thoughts,
      ~Robert

  4. Hello Dr Grene,
    A question for you. I am 41 years old, have an almost 2-year old son, and am currently on my fourth injectibles cycle. The last cycle I was on 225 of Gonal-F for 8 days and ended up with 8 large follicles (over 18), estradiol at 890, lining at 8, and no pregnancy. This time on 300 Gonal-F for 8 days I had 8 follicles at 10-16, and an estradiol of 150. At that point they added Manopur (75) for two days, and today there are now 6 follicles over 18 and 2 at 14 – and estradiol is still below 200. The answer I am being given is “empty follicles” or “bad eggs”. And no suggestion as to what to do differently. For the record, currently my fsh is under 7, my AMH is ok, and the other labs look good. When I conceived my son I had 16 follicles, estrdiol was 1600, and lining was 10.
    Any thoughts or suggestions?
    Thanks for you help.
    Jennifer

    1. Dear Jennifer,
      Sounds like what you’re seeking is a second opinion. I’d be more than happy to oblige but I would need additional information including a copy of your medical records and your specific AMH result. Have you considered contacting my office for a free consultation?

      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG
      Medical Director
      SIRM–Northern California

  5. I should go on to point out that I am actually finished with the cycle since the cycle was considered unproductive and we’ve cancelled the IUI. What I’m trying to do now is to gather information about what is going on so I can have a productive conversation with my RE about what approach to take in the next cycle.
    Incidentally, is there any evidence that it is a good idea to wait between stim cycles because ovaries get “tired”? (Something else that the office suggested, so I thought I’d ask.
    Thanks,
    Jennifer

    1. Hi Jennifer,
      I don’t know nearly enough about your medical history and response to guide you. If you’re looking for information to empower you to pursue this further with your doctor, I’d encourage you to check out my book PERFECT HORMONE BALANCE FOR FERTILITY at your local library, bookstore or http://www.amazon.com. Hope this helps.

      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG
      Medical Director
      SIRM–Northern California

  6. great i will check out your book. btw, all RE docs refused to prescribe testosterone and this doc wanted me to take 3 packets a day, so i am just doing the best i can with it. don’t know about brain receptors but i can honestly say that i have greater desire when i am on it and zilch when i am not.

    thanks for your reply, i really do appreciate it.

  7. Hi! I hope you can give me some advice!

    I conceived my son at age 32yrs, 1st attempt at unmedicated IUI using a sperm donor. My Day 2 FSH was 6 & my E2 160. At age 34/35 I tried for 2nd baby. My Day 2 FSH was 6 but my E2 was 250. I had two failed unmedicated IUIs. Was found to be having premature LH surges. Third try Dr used buserelin & 100iu puregon. My daughter was conceived this cycle at age 35.
    Have been trying for baby#3 since April ’09. Day 2 FSH came back at 8.5 & E2 68. First IUI using buserelin & 100IU I grew too many follies, & cycle was cancelled. Next two IUI cycles failed even though I stimmed fine with good sized follies. Dec ’09, Day 2 FSH was 10 & AMH .71. I tried 1st IVF Jan ’10. Used long prot, buserelin & puregon 300iu. Triggered at E2 of over 5000. Got 6 eggs, 4 fertilised. Two had fragmentation, ET done day 3 of one ‘perfect’ 8-cell. Other embryos developed fast & arrested before Day 5. Second IVF converted to IUI in May. Antagonist protocol only grew three good sized follicles. Another negative! Tested FSH immediately after cycle, Day 2 was 14, E2 180. Next month, Day 2 FSH was 6.2, E2 a high 220! Finished 2nd failed IVF in June, using micro-dose flare. Retrieved 8 eggs, 6 fertilised. Triggered at E2 of 12,774. Again 50% of embryos had fragmentation. ET done on Day 3 of one good 8-cell & one good 12-cell. Others arrested before Day 5.
    Saw RE yesterday, going to try 3rd IVF. He will use micro-dose flare again. I wanted to try Estrogen Priming & also try using DHEA, but he said neither of these would help me. Do you agree? I’m worried I only have bad eggs left, even though I conceived pretty easily before. Can you add anything to the mix?
    Thanks so much!!

    1. Dear Marietta,
      The advice that I’d give you would be that you’d benefit from a second opinion. There is simply too much to cover here in this format and not information from you on how to begin the discussion. You clearly have a complicated situation that unfortunately has not yet resulted in a pregnancy. Having been through treatment with my own wife, I understand that frustration. But even though you have not created a baby, you have generated a lot of data. Now it is worthwhile to have someone analyze the existing information with a fresh pair of eyes to see if they have any advice for you. If they reaffirm what your current doctor has suggested, then you can feel empowered to move forward with confidence. If they offer you a different path, you can decide what makes the most sense for you and your partner. Since you may need to redirect your treatment, I recommend that the second opinion should be with someone that you’d actually go to for treatment if you like their advice–this will minimize further frustration. If you live near northern California, or are willing to travel here for treatment, I’d be more than happy to offer you such a consultation. What I can share is that rarely does a 32 year old simply have “bad eggs” without some explanation. I do hope that you find this to be empowering.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG
      Medical Director
      SIRM–Northern California

  8. Hi Dr. Greene!
    Your advice sounds wonderful.
    I have a question re: Bravelle. Is that what you would consider a “better” FSH-LH medication to treat unexplained infertility with IUI? (or would you opt for other brands? My clinic opts for this one because, as you mention in your post, it is cheaper than other brands).

    1. Dear Annie,
      Personally, I don’t often prescribe Bravelle. It is less expensive. But since it comes from a biological source–the urine of menopausal women–it has the potential for unplanned effects. For this reason, I choose not to use it for most of my patients. In fact, my experience has been that since patients often need an extra day or two of medication on Bravelle, it ends up costing about the same.

      Best thoughts,
      ~Robert

      1. thank you for your response! I took Bravelle and the HcG shot and did IUI, and started spotting the night of the IUI, and it never stopped until my period almost two weeks later. This happened two months in a row (with the same protocol), so we’re starting to suspect that my body may be reacting to the LH in Bravelle perhaps… not sure. I am going in tomorrow to talk to my RE and I’m hoping that he will be more open to trying other more pure FSH-LH meds… (there’s only one clinic in the state unfortunately… so we can’t go anywhere else..)

  9. Are you able to share the names of the medications that you use? (you explain using FSH and LH independently to have greater control rather than having a high level of LH–thus decreasing chances for pregnancy) or is that not something you do in this blog?

  10. This is very helpful information. Are you able to share which medications you find to be more in the “salt and pepper combo” style and best to avoid?

    I have “undetectable” level of AMH and have been on Femara+Bravelle for 1 cycle and Femara+Menapur for 1 cycle. Ovulation on day 9 both cycles, which seems very early. I am wondering if there are better meds to improve egg quality?

    1. Dear Laura,
      Please understand that this blog represents my opinion based upon my interpretation of the research as well as my clinical experience treating women with diminished ovarian reserve. You should therefore discuss your concerns with your doctor and remain open to their opinion as well. That said, I would not recommend the use of Menopure in woman with your history nor would I encourage the use of Bravelle. Instead, I would consider Either Follistim or Gonal-F along with a very low dose of Luveris.
      Best thoughts,
      ~Robert

  11. Hello Doctor
    I’m 35 years old and currently reside in Arizona.. I have undergone 6 miscarriages
    (1 abortion (D&C), year-1999
    3 miscarriages(1 @19th weeks(yr- 2004)(D&C) , 1@ 12 weeks(D&C)(yr-2007), 1@ 12 weeks)(D&C)(yr- 2009),
    1 miscarriage (no heart -beat found @ 10 weeks)(D&C) (year- 2006)
    1 @ 6 weeks started regular period)(year – 2008))

    i started seeing Reproductive endocrinologist in 2007 and they took my case as unexplained miscarriages.. i had difficulty in conceiving as well. with superovulation started iui’s
    3rd cycle iui , i conceived and miscarried at 12 weeks in 2009 then in 2010 i did 6more cycles of iui and it failed.. now they are reffering ivf with ICSI..

    please advise me.
    my recent blood report shows some concern about low ovarian reserve, low protin S level.
    Blood work on DAY3
    FSH-8.0
    AMH-0.61
    protin S -43
    prolactin – 26.5

    Day 14: FSH/E2 11.7/151

    please advise me with the diagnosis and treatment plan ..

    1. I am so sorry that you have been through so much and have not yet achieved a successful pregnancy. Unfortunately, this is not the proper forum for giving accurate medical advice. I would need to learn so much more about your history, your treatment, your partner’s testing as well as your goals and concerns before I could possibly begin formulating a plan. If you’d like to set up a consultation, I’d be more than happy to create a plan for you. In the meantime, please continue to pursue your dream and learn as much as you can so that you can be the most effective advocate for yourself as possible.

      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG

      California IVF Fertility Center

  12. Dear Dr Greene,

    I had two IVF ICSI done.

    First cycle (35YO) long down reg 225IU gonal F upped 300IU, more than 10 follicles, 5 eggs, 4 day 3 embryos, No pregnancy.

    Second cycle (37YO) long down reg 450IU, 11 eggs, 6 embryos, 2 compacting & expanded blasts, No pregnancy.

    Husband sperm count 5mil, poor motility, poor morphology, lots immature sperm, used HA-binding for second cycle to select mature sperm. Took one whole hour getting 11 sperm.

    Myself AMH 6.1mo/L, recent FSH 17IU/L. Vit D a bit low.

    I dont want to sound like I am seeking second opinion here, actually it would be third (i have seen 2 REs at two fertility clinics). Would you have me try the antagonist next round? My 2nd RE is recommending that, with 450IU gonal F again and oragultran injections on Day 5 or 6. He does not want to try A/ACP even when I mentioned to him. He is very conventional. I am unfortunately not living in USA. They dont practise that protocol here.

    Would you throw in Luveris if you were my RE? I am thinking my egg quality could have been bad though my response wasnt bad. Sperm have been ICSI and HA selected, so I am guessing the MFI issue is overcome.

    My Day 3 FSH recent blood test is so high, how agressive should treatment be according to you? Do you think I should go on 450IU or should I go on a lower dose 300 or ?

    My RE said if I go on the antagonist, I wont need birth control pills. But wouldnt that be good for my high FSH? Would BCPs suppress my response too much?

    What is your opinion regarding this? My E2 for my second cycle peaked at 5328 but it was not a concern to my RE at all. Is it not good? I thought the higher the better?

    I really hope you wont perceive me as seeking a second opinion from you and help me with my questions. If you need more info I will be happy to provide. I think I have sought enough opinions from two other REs and I cannot go around the whole town RE shopping and changing REs. Thank you for your time.

    1. Dear mum2oneds,
      Unfortunately, current guidelines as well as best practice guidelines, do not me to make specific comments about a patient’s treatment. Truly, I believe that’s in your best interest. There are so very many factors that must be considered in creating a treatment protocol for a specific couple that I could not possibly know how to best serve you and your partner. I would imagine that the RE’s that you’ve seen have given you specific recommendations that they have tailored to your situation. If you’re not convinced of that, it is worth considering another formal consultation. There is a unique relationship formed between a patient and a fertility provider. A plan should be based upon them suggesting a range of options that they are comfortable with and then explaining the advantages, disadvantages and anticipated outcome of each one. Then you should be able to question these options in order to select the one that you’re most comfortable with. If that has not happened; don’t stop until it does.
      Best thoughts,

      ~Robert
      Robert Greene, MD, FACOg

  13. Thank you DR Greene, I understand. The problem with my first RE was the distance to travel to the fertility clinic, about 1.5hours to the city. The problem with my current RE/OB is though he is very nice, but he does not have time for us and it is always rushed during consultations and we wait a long time (up to 7 weeks) in between appointments. I think by waiting, I can feel my ovarian reserve is going kaput already and I am not young anymore to do this sort of waiting anymore. There is no time to discuss more and he likes to shut me up. I think he hopes I would not read so much or ask so much. Isnt good to have patients led by the nose? That would make a doctor’s work so easy. That is why we are going to see another new RE. I hate changing REs but I have not got a choice so far. Thank you once again.

  14. Very interesting… I have been through 2 IVF cycles:
    1 – 300 iu Follistim 300 iu Menopur added Ganirelex. 7 eggs/5 fert/2 tran
    + preg. Ended up being ectopic
    2- 2 weeks of Lupron 300 iu Follistim 300 iu Menopur (stop Lupron) added nothing. 4 eggs/2 fert/1 tran + preg in uterus. Ended up blightened ovum no hb.

    Reading your book and researching on my own I am wondering if my high dosage of Menopur is contributing to my cycle? I have researched, Microdose Flare, Estr prim, Long Lupron etc to find out what my next step should be & may be switching RE. I have gotten several other opinions…all different of course! My current RE is recommending DHEA, but another opion say no being it is androgen and that is bad for the eggs! So confusing!!

    I am 32 yr. Borderline FSH at 11.37 and HIgh prolactin at 34 (unmedicated) have been on Bromocriptin for that.

    Thanks!

  15. I forgot to mention that my second time I had more follicles than the first…and was suprised to only retrieve 4 eggs..I got an opinion that maybe I starting ovulating some on my own since I was only on Foll/Meno.

    1. Dear Melissa,
      There is still so much for us to learn. That is why there is no universal agreement on these issues. In fact, the variation from one patient to another adds another layer of complexity as well. Unfortunately, I cannot comment on your specific treatment because I do not know enough about your history to render my opinion. As I have mentioned however, I do feel that the hormonal and nutritional environment in your body during egg development/maturation does impact the quality of the embryos created. Studies published this week at the large fertility meeting in Europe have provided new evidence supporting this opinion. So keep on seeking answers until you find a regimen that you are comfortable with and a provider that you feel is sympathetic to your opinions.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG

      1. Thanks for the reply. Just curious what else would you need to know about my history to give an opinion?

        Thanks!

  16. My husband and I have questions and need advice about egg quality and fertilization. We just finished our second round of IVF and we didn’t make it to the second part of the magic. I have a low egg count and they are fertilizing abnormally. My husbands sperm count is fine. The first time we tried my egg weren’t mature enough and my estrogen level dropped. The second time I was on a new protocol and the eggs were mature, estrogen level good and we use ISCI, but it failed again. The doctor said because I had an UAE that my eggs were affected and there is nothing the they could do and I need to look at other options. The other options are not feasible and we would like to try IVF again. We need to find another RE because they will not do another IVF cycle on me because of the UAE. They have never had success getting anyone pregnant after an UAE even through there has been studies of other women who have given birth after an UAE. I think I have other problems. The doctors didn’t find any hormone problems, but I’m 33 and still have acne and I had an abnormally large fibroid in my mid 20’s. Below are my questions.

    How do eggs fertilize abnormally?
    Could they ever fertilize nornally?
    Could a hormone imbalance produce poor egg quality?
    Is there any meds that can help egg quality?

    1. Poor egg quality is one of the most vexing problems to diagnose and to treat. I have gone to great lengths to try to explain this problem as well as latest information on what may help optimize the outcomes for couples with your sort of history in my blog and my book. Beyond that, I would need to have much more information as well as the ability to interact with you in order to provide more individualized advice. If you like, you can call CNY Fertility Center at 800-539-9870 to set up a consultation. Othersise, I regret that I am not allowed to provide medical advice in this forum as it is considered a breech of our state licensure process. The bottom line is that your questions are reasonable and you should seek out clarification.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG

  17. Hi Dr,
    I had my first failed IUI last month. I was on following hormonal injection during my IUI treatment starting from 5th day: Inj IVF-M 150 IU IM for 4 days, Inj IVFM 150 IU IM + Inj Ouvurelix 0.25 mg for 3 days, then Inj IVF-C 10,000 for 1 day and then finally on 13th day, IUI was done. 2 eggs were seen. Unfortunately IUI failed and the possible reason given was due to high LH level (11.08) on day 5. Now I have been asked to reduce LH level using Lupron Depot ijection and redo IUI. I have also been prescribed Folic acid tablets. I suffer from PCO. My husband sperm count is fine. I am wondering whether my doctor is going in right direction? Do you forsee any problems in future? if not, kindly provide some pointers so that I can speak with my doctor.Thanks.

    1. Dear Savita,
      I am so sorry to learn of your unsuccessful attempts to conceive. Unfortunately, I do not have nearly enough information here to begin to guide you on specific treatment. It would be a serious disservice to both you and your provider. It would be best that you redirect these questions to whomever you are seeing so that they can respond with their full knowledge of your case. Then if you have a specific question about what they are saying about treatment, testing or your diagnosis; you can email me back. As an alternative, you can consider having someone else review your history, completed tests and medical records and provide you with a second opinion. It is best to inquire from someone that you may wish to follow up with assuming you like their recommendations. Bottom line, don’t give up. Persistance is the key to success.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG
      CNY Fertility Center

  18. Hi Dr,
    I am 32 yr old female. I have 3.6 AMH and borderline elevated prolactin levels for which i take Bromocriptine. Husband (35) has low sperm count, low sperm motility. Have gone through 4 fresh ICSi cycles, 2 suppression with Luveris and ended up in a blighted ovum in the second attempt but in both the cycles had high e2 before retrival. Changed the clinic and the new RE did anatoginst approach. I am the only one in my RE clinic who had elevated progesterone levels before the LH surge. My RE used Ganirelix to control the remature rise of progesterone but it was still borderline 2 days before the retrival. My RE thinks that elevated progesterone levels before LH surge compromises the receptivity of the lining and thus reducing the chances of pregnancy. My question is, am I a rare case and cannot be treated? What can be done to control the premature rise of progesterone? I also want to point out that i don’t take Bromocriptine all the time, i take it only before treatment begins to minimize the effects of it. Does elevated prolactin levels effect the quality of eggs too?
    Thanks

    1. Dear Ran,
      Thank you for seeking out my input. Unfortunately, I do not feel comfortable providing specific guidance regarding your situation since I am not fully informed of your entire medical/reproductive history. I can however make some general comments on some of the principles that you dealing with that I hope you’ll find helpful:
      –Premature rise in progesterone level–although there is some data suggesting this can compromise implantation there is a comparable amount suggesting otherwise. As a result, this remains an active debate in our field. Personally, I do not feel that it is a major issue and therefore I do not alter my recommendations based upon progesterone levels during the stimulation phase of an IVF cycle. This is not an uncommon problem which is the reason it has been fairly well researched.
      –Having a “high e2” level may alter the hormonal milieu in an unfavorable way. THAT finding would sometimes prompt me to suggest a “staggered cycle” (one in which the embryos are created in one month and then vitrified (cryopreserved) for transfer during a separate cycle.
      –Borderline prolactin levels rarely require treatment (in my opinion). Prolactin is a stress hormone. It can be mildly elevated based upon what time of day it tested, when your last meal was and many other variables. Rest assured, if you are producing eggs, it will not compromise their quality or chance of implanting.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG
      CNY Fertilty Center

      1. Thanks Dr Greene. Does premature rise of progesterone effects the quality of eggs? I have had 15-20 eggs retrived in both of the of anatognist cycles and close to 12-13 fertilized. The lining always develops pretty nicely but no implantations.

  19. Hello!
    I am wondering if you could help me further understand my current infertility problem. Both my husband and I myself are 29 years old. We just completed a failed IVF cycle, and during our follow up appointment, our doctor informed us of what happened.
    All of my tests, numbers and everything in between looked great. We were told repeatedly that we were the best canadiates for the IVF procedure because my husband has low sperm count and morphology and we would be pursuing ICIS.
    At the time of retrieval, they got 17 eggs. Of those 17 eggs, they fertilized 9 on the first day. The other 8 eggs were immature, so they let them mature over night.
    First day fertilitized eggs, 1 out 9.
    Second day eggs matured, and 4 out 8 fertilized.
    Third day, they did a three day transfer. First day embroy was at 8 cells, the and the best 2 day embroys were at 2 cells and 4 cells. The other 2 embroys did not make it to freezing.
    We met with our doctor yesturday, who told us that it is egg related issues. Specifically, egg maturity and quality. My question is, does egg immaturity directly result in poor quality?
    I have read up on IVM and was wondering if that could potentially be a viable option for us, given that the maturity is done outside the body?
    Thank you!
    Kristin

    1. Dear Kristin,
      Thank you for seeking my opinion but unfortunately, I do not have enough information here to accurately guide you. I can speak however in general terms. Typically, maturation should occur prior to retrieval. In my experience, if fewer than 80% of the eggs are immature upon retrieval then there may have been some problems in timing the hCG injection with the egg retrieval. Again, it would take a more comprehensive review of your medical records to determine if this may have been the case in your situation.

      Generally, speaking In Vitro Maturation (IVM) is still considered experimental. It is more expensive and less consistent in the results that it produces. It also requires the use of stem cell cultures which can make it more controversial by some people’s standards–depending if the stem cells come from you, another person or an animal source. These issues and other unanswered questions have limited the utilization of IVM in 2012. Then again, who knows what the future holds?
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG
      CNY Fertility Center
      e-mail me at rgreene@cnyfertility.com
      Call our toll-free number at 800.539.9870 or request a consult here http://cnyfertility.com/new-appointment-form/ .

  20. Hi im Samia,i live in Pakistan and im 46 years old and i have been trying to conceive since 12 years and no success. i should be mentioning here that i have two kids from my first marriage and this is my second marriage since 12 years with no signs of a baby. i have been having regular but heavy menstrual cycles 2 years ago and the reason was a uterine fibroid. but gradually the uterine fibroid shrunk miraculously and i got rid of heavy menstrual cycles. since three months i haven’t been menstruating which made me to think that i had conceived but an ultrasound was showing a 7cm ovarian cyst which was the reason i wasnt menstruating. the cyst was causing unbearable pain and i took Wobenzym N as i heard it useful in washing away extra tissues from the body and after 6 days of taking it i had my period and the pain also disappeared. the cyst might have shrunk most probably. please suggest a good treatment for me as im medically fit to have a baby but still there is no hope. please help me out😦

    1. Dear Samia,
      I am so sorry to learn that you have had such a difficult time. Unfortunately, this forum is not set up in way that I can provide specific advice for any one specific patient. It would be in your best interest to set up a consultation in your area with a reprodutive endocrinologist. If after having such a consultation, you have any specific questions please let me know. I will do all that I can to guide you but some treatments–like Wobenzym N–are not available in our area so I have no real insight that I can offer. Take heart, there are many different treatment options. The challenge is simply finding the one that is best suited to your specific needs/preferences.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG
      CNY Fertility Center

  21. Hi Dr. Greene- I found this blog because I’m looking for a reason that our injection cycle/IUI worked (x3) but then we lost two of the babies by 9 weeks. The 3rd is still going strong (10.2weeks) and we are praying s/he continues to do well. I used generic Menopur from Europe (HMG/Lepori), from what I’m reading here, could this have been the cause of our fertilization but unsuccessful continuation for the 2 babies. I’m curious because we will attempt another pregnancy when this baby is around 1 and I’m wondering if I should start saving now for the higher end medication. . . I don’t want to keep sacrificing babies in order to get a healthy one. I conceived right before my 35th birthday and have three previous children (from clomid at ages 22-26) so I have a hard time swallowing that my eggs may be old, especially since my mom passed away at 52 without starting menopause. My RE is pretty awesome and recommended we go with generics because I should have been pregnant and money was a definite issue for us. . .

    1. I am sorry that there are no easy answers to the complex problems related to reproduction. There is no correlation between a woman’s health and her egg quality. I am pleased to learn that your pregnancy is continuing…that is the most important test of egg quality. Related to the rest of the details, I wouldn’t worry too much about them and focus on the healthy outcome of the pregnancy. Regarding specific issues related to your cycle, I wish I could be more helpful but it is best to redirect those questions to your doctor.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG
      CNY Fertility Cenyter

  22. Hello Dr. Greene, so nice to find this blog!
    I am a 42-year-old woman who has had 3 failed, non-medicated IUIs (just one procedure at a time–not two), 2 failed fresh IVF cycles, and one failed frozen ET. My AMH level is good and during a day 2 sonogram the doctor said he visualized good ovarian reserve. My FSH is 6. I do have a few minimal fibroids that are asymptomatic and that my fertility specialist doesn’t seem worried about. I have had most tests done (although I’ll now request a natural killer cell test). I’m not willing to give-up and go the donor egg route–not yet anyway, so I’m looking to rule-out any non-age-related causes and take steps to help. I have used Menopur, gonal-F and ganirelix in both stim cycles. As per your thoughts above, I will ask my doctor about switching from Menopur to Luveris, but I’m wondering what your thoughts about ganirelix are?

    1. Dear Julietta,
      Unfortunately, this is not a forum where I can make specific recommendations about any one person’s protocol. In general, I do not feel that Ganirelix adds any benefit but it does have some specific situations where it can be the best option. I am sorry that I cannot be more direct in your query.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG
      CNY Fertility Center

  23. Hi,
    I am 27 years old and my husband and I have been trying to have a baby for the past 6 years. We have been seeing a fertility specialist for the past 2 years; and in that time we have completed 2 IUIs that both failed and 3 IVF Rounds. The first IVF we had 5 eggs, and resulted in a pregnancy that we lost within the first 3-4 weeks and the doctor never said if it was or wasn’t a chemical pregnancy. The second round we had only 3 eggs and the doctor canceled the round. The third round we had 5 eggs and on 5-day transfer we found out that all of the eggs had died and the doctor then preceded to tell us that we had poor egg quality and that I couldn’t conceive with my own eggs. I am not sure if I should head down the route of egg donors or if I should get a second opinion. I for the most part am really healthy, with the exception of being slightly over weight and recently finding out from my regular practitioner that I have a major vitamin D deficiency…. and same thing with my husband he is really healthy with the exception of his sperm ‘needing glasses’ as the doctor puts it. Just curious what your thoughts were on our situation. Thank you

    1. hi doctor am 33 years old and have been trying to get pregnant since one and a half years. I have a child girl 5 years old and had normal delivery. am actually on clomid and gonal f injection and no response to make my eggs become mature. and my menses have to take primolut for them to come.

  24. Hello Dr. Green,
    thank you very much for sharing your knowledge and your experience with us. Information provided on your blog is very helpful for all of us fighting IVF failures and infertility.
    I am 40 (now suffering from advanced maternal age as my doctor says). My husband is 52 with mild male factor (low count – 10 mil). I naturally conceived in 2009 which ended up as a missed abortion at 10 weeks. Since 2011 I have had 6 IVFs (4 fresh, 2 FET cycles) at two clinics, one of them very famous for their success rates. Each time in the fresh cycle the protocol was the same Menopur starting from the second day of my menstrual cycle and Cetrotide introduced five days after the commencement of Menopur plus Ovitrell as a trigger. Each time I ended up with the same number of follicles – 12, the same number of mature eggs – 8 and the same number of 8 fertilized embrios by ICSI. The last time we did PGD which showed only one embrio suitable for transfer. But it was no success. Each time after fresh IVF cycle I start bleeding before the time for beta HCG test (usually 7-9 days post transfer). Once it ended up in positive beta HCG despite the bleeding but turned out to be blighted ovum and had trisomy 18 and monosomy XO. The doctor said trisomy 18 was one of the most common m/c causes in women of my age.
    I started to believe that the stimulation medication influence my egg quality apart from advanced maternal age and asked my doctor to change or review my protocol. He said that is the best and most suitable protocol for my age. My FSH was 6,04, AMH 0,58 just before my last stimulation.
    Could you please tell me if the change in protocol may bring about any benefits to me. I would like to try at least once again before switching to donor egg.
    Thank you very much

    1. I am sorry to learn of your continued challenge and limited success. The fact that you have had positive pregnancy tests is reassuring. Unfortunately, there is no protocol that can reverse the effect that the passage of time has had upon egg quality. There are various supplements that may optimize egg quality. There is also some data that the use of Human Growth Hormone (hGH) may provide some eggs with the ability to repair themselves–but it can be quite expensive. I am sorry that I do not have anything further that I can suggest in this forum.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG
      CNY Fertility Center

  25. Hello Dr. Greene,

    Your blog is very interesting!

    I am a 32-yr old with diminished ovarian reserve (highest FSH 13.5, AMH 3.5, usual AFC about 4 total), and I’ve had 2 unsuccessful IVFs… 1 long-protocol with minimal drugs (2 eggs, 1 fertilized) and 1 short protocol using 450/day of Menopur (11 eggs, 8 fertilized, such slow developers that at Day 5 my best 2 embryos for transfer were a developing morula and the equivalent of a Day 3; all the rest arrested). Do you think that the Menopur, while it yielded lots of eggs, affected my egg quality? I’ve also had a big increase in my FSH since the last failed attempt a few months ago (from 7.4 on the month of treatment to 13.5, my worst ever by more than 3). Is this a reaction to the drugs? We’re waiting on a good FSH and AFC result to even talk about going ahead with another treatment, so I’d very much appreciate your advice!

    Thanks for any advice you can offer!

    1. Dear Gina,
      Sorry that I was not able to provide guidance to you at the time you originally posted your question. Please let update me and let me know if I can be of further assistance/guidance as I am currently revitalizing my blogging efforts.
      Best thoughts,
      ~Robert Greene, MD, FACOG
      Board Certified, Reproductive Endocrinology & Infertility

  26. Dear Dr Greene, Great blog! Im wondering, how worried should I be that my prolactin has just been measure at 39 (it was 32 2 weeks ago)? Im doing IVF starting my 4th cycle tomorrow. Have had good fertilization on my stimulated cycles so far and good embryos, except last cycle which was a natural cycle, we got the one natural egg out but it didnt fertilze even though it was apparently mature. First mature egg Ive had which didnt fertilize. Im freaking a bit as to whether it could be the high prolactin which has affected my natural egg. And really would like to get a low dose of parlodel or cabergoline. I was on 10 mg Prednisone and 20 mg for around 2 months before this. But had been off it for 4 days before my last blood test. Could it be affecting my prolactin like this? Yours Freya

    1. Dear Freya,
      Thank you for your kind words. I am just in the process of regenerating this blog for 2015 so thanks for finding it please check back–as well as share with anyone that you think would find it to be helpful.
      Regarding your question about prolactin levels; there are MANY different reasons to explain a mild elevation in prolactin levels including time of day it was checked, recent meal, sexual activity within the previous 12-15 hours, stress. Bottom line is that it is VERY unlikely that what you’ve described is clinically significant. In response to your fears related to a “natural cycle” I would also reassure you. Personally, I feel that “natural IVF” is an oxymoron. There is nothing “natural” about IVF. Given that, there is no clinical benefit from combining IVF with a “natural cycle.” Having a lot of experience with this over the years; I discourage “natural IVF” as well as “MiniIVF” as they sound great but the success rates are very low in comparison to conventional IVF. Hope you find this helpful.
      Best thoughts,
      ~Robert Greene, MD, FACOG
      Board Certified, Reproductive Endocrinology & Infertility

  27. Dear Dr Greene, thank you very much for your reply! So you don’t agree with those IVF-doctors who say that elevated prolactin can affect egg quality? – or should these levels be much higher than mine to have a negative effect?
    Have a wonderful evening! Freya

  28. Dear Freya,
    The half life of prolactin is a bit less than hour. Therefore, there are fluctuations in level throughout the day. Unless your lab’s range is very different from ours; it sounds like that may have been a blip and not representative of your average daily prolactin level. My review of the data is that prolactin levels need to be much higher to have any potential negative impact upon egg quality. I hope that this makes sense and at the very least promotes a more detailed discussion between you and your IVF provider.
    Best thoughts,
    ~Robert

    Robert Greene, MD, FACOG

    1. P.S. I have now been put on parlodel, 2.5 mg per day while on stims. Will being on hormone stimulation elevate my prolactin even more? Im on Elonva for 6 days then 150 pergoveris untill trigger.
      Have a lovely weekend!
      Yours Freya

  29. Dear Dr Greene,
    I have another question about egg quality. Had my egg retrieval today and one of the eggs looked ‘dark’ said the embryologist. She said that immature eggs often look darkish, could it still fertilise? Im on double dose antagonist (orgalutran), short protocol. Could the double dose orgalutran ‘suppress me too much even though Im getting Pergoveris with it to counteract? Thanks a lot! Yours F

    1. Dear Freya,
      Embryologists do the best that they can to gather information by looking at them but it is hardly diagnostic. Best to wait and see how they fertilize and grow. THAT’s the test that really matters. Stay positive in your thoughts.
      Best regards,
      ~Robert

      Robert Greene, MD, FACOG

  30. Thank you Dr Greene! Can I ask you something else: would you say that back-to-back ivfs can harm egg quality? I do Elonva with 150 pergoveris-stims. Yours Freya

    1. Thanks Dr Greene, this is really good to know! Im over 40 and have had top score embryos on my last transfer (biochemical), and on my transfer this week. Can over 40’s topscore embryos be as good as a younger woman’s top score embryo? Have a lovely evening! Greetings from Copenhagen in the snow. Freya

  31. Dear Freya,
    Embryo grading is simply the “best estimation” of the embryo quality without performing a biopsy or a biochemical test. The real test is whether or not the embryo implants and becomes a healthy baby. Stay hopeful (and warm).
    Best thoughts,
    ~Robert

    Robert Greene, MD, FACOG

  32. Thank you Robert! Why is so much emphasis then put on the grading by embryologists and IVF-docs? And why then are not all fertilised eggs transferred no matter fragmentation-degree? Have a lovely day! Yours, Freya

  33. Hi doctor Greene, very interesting blog! Ive had 2 biochemical pregnancies with my IVF no 3 and 4. I was on Elonva and 150 pegoveris from day 6, then double orgalutran and double pregnyl before ER. Grade A embryos transferred on day 2. Would you recommend me to change protocol? Would a stim without LH in it be an option? Thank you.

    1. Dear Frida,
      I am sorry that it took me so long to response; I’ve been traveling for the last two weeks. I am very encouraged to learn that you’ve had two biochemical pregnancies because it indicates that you are producing embryos that are almost healthy enough to become babies. THAT is encouraging. I agree that trying some changes to your protocol as well as your diet/lifestyle would be worth considering (see upcoming next post for some related information). However, it would also be misleading to lead you believe that your previous cycles were compromised by the protocol. Many of each egg’s inherent quality was determined years ago. The protocol can theoretically compromise an egg but that is unlikely. It is more likely that the protocol may simply alter the number of eggs recovered and since each egg is opportunity; we want as many eggs as possible. So yes I do believe that you should discuss with your provider other stimulation protocols but most importantly, keep trying. Let me know if I can be of any further assistance.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG

  34. Hi Doctor!
    I am 43 and recently had an unsuccessful go with IVF. We had 4/5 mature eggs fertilize, 3 made it to day 3, and the remainder were still alive by day 6 (not ready on day 5) but on day 6 were still not differentiated enough to biopsy for testing/transfer. My AMH is low (2.26) Prolactin, FSH all normal, all other levels normal. No male factor. We are having a follow-up because we were told that I have poor egg quality and that donor egg is our only option. I wonder if the protocol I was on has anything to do with egg quality. Menopur and Gonal F. Last year I tried Clomid and timed intercourse, and had to do an additional 5 days at double dosage to get my follicles to grow to proper size to trigger. I normally ovulate, late, at or around day 18. I feel like my eggs just don’t mature quick enough. Any ideas? Any way to improve egg quality? I have been told my Ovarian Reserve is adequate, my resting follicle count was 24. No one has indicated that I have PCOS…I am not feeling like it’s a done-deal yet, and wonder what you think?
    Regards,
    Amy

    1. Dear Amy,
      What you are describing is not an unusual scenario. Although it is likely true that the reason that your embryos did not make it to the blastocyst stage was probably due to the egg quality; that does not mean definitively that you are incapable of producing a healthy egg. Although it is true that your chance of success is substantially improved by using an egg donor; the fact that you are producing eggs means that you may be capable of producing your own genetic child. There are several supplements that may help augment egg quality like CoQ10 but I doubt that the previous protocol was the cause of your failed cycle. Some patients also benefit from Human Growth Hormone (hGH) which may also improve egg quality. So I agree that you need not abandon your efforts as long as you are moving forward with confidence and understanding.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG

  35. Dear Dr Greene,
    I was wondering if you can help me with my worry about my progesterone level: I had transfer of a perfect 8-cell yesterday on 3dpo, and asked for a bloodtest of Progesterone on the same day. The result was 166 nmol/l, – which I think corresponds to 52 ng/ml.
    And as I understand it this level is very high.

    Im only taking 3 x 100 mg of Lutinus per day nothing else, no HCG-support, no estradiol.
    My prolactin is being regulated with Parlodel, for the last 1½ months, and is down at 400 now. I really want to get it right this time.
    Have had A Grade embryos transferred for the last 3 IVFs.

    Ive read that levels above 90 nmol/l after ovulation are not normal, and might be detrimental to implantation.
    What is your take on my situation?
    Thank you.
    Yours A

    1. Dear Ada,
      I wouldn’t worry about the number too much. Hormone levels fluctuate throughout the day and there is a very wide range of normal values. Best thing to do is to remain hopeful and await your first pregnancy test. IF any questions arise at that point, please let me know and I’ll try to help you figure it out.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG

  36. Dear Dr Greene,
    Do you believe in starting the antagonist on the first day of stims to suppress LH in older women? Or are ‘older women’ as individual as everyone else? meaning some have high LH some not? Greetings! x

    1. Dear Greta,
      Thank you for seeking my input. I believe that each patient needs to be evaluated and I take great caution with ever saying “always or never” to most recommendations. That said, I have seen very limited data suggesting that beginning the antagonist early offers any benefit. I am well aware of the theory but the data seems lacking. Given the extra expense, I would encourage you to discuss it with your doctor and ask them if they have specific experience that they feel supports this recommendation as well as confirmation that it is in your best interest. Bottom line, if you’re not convinced; just say “no thanks.”
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG

  37. Dear Dr Greene, I just had my first back-to-back IVF and already had egg retrieval on day 12 where as I usually have ER on day 14-15. I have also had my prolactin regulated with parlodel for the last 2 months, so Im not sure if the shorter follicular phase is due to the much lower prolactin or the fact that we are ‘cycling’ every month. I still had a perfect embryo last cycle to transfer, so I hope there is no general rule that says that back-to back ivfs yields lower quality eggs? We are cycling again thia month, no break, so naturally Im thinking about this. Anyway Im very interested in what your experience is with shorter follicular phases and reasons for this, and also whether back-to-back IVFs can affect egg quality? Thank you so much for you time and generous spirit! x

    1. Dear Marguerite,
      I am always reluctant to comment on an on-going cycle–especially when there is more opinion than data to base my response. Let’s wait and see what happens after your pregnancy test. There is no reason to believe that your recent transfer will not result in the pregnancy that you so highly desire. So let’s focus on minimizing your stress and promoting a healthy environment for early pregnancy development. Back-to-back IVF cycles DO NOT compromise embryo quality. Sometimes, they are the very best strategy–as I’m sure that your physician felt it was for you. I look forward to learning that you’re pregnant. If not, we can provide some suggestions or insights at that time.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG

  38. Dear Dr Greene, would you say that starting Parlodel after an egg transfer could be detrimental to implantation or hormone levels in any way?
    Thanks for this forum!
    Yours

    1. Dear Storm,
      Parlodel is pregnancy Category B. That means all of the available data–and there is a substantial amount given that the drug has been around for a long time–is reassuring. So please take it if you need it. Noteworthy is that it can cause GI upset. Given that early pregnancy can also cause tummy trouble; talk to your doctor if you’re having problems.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG

  39. Thank you very much Dr Greene! This calms me. Another thing, can taking prednisone after transfer if you dont need it obstruct implantation rather than aid it? Ive had conflicting analysis of my NKcell test, one doctor says ‘yes you have elevated Nkcells but since you have very low infection you shouldnt need it’, another says that anyone who has 30% nk cells needs it no matter the lack of infection. Well, Im taking the 25 mg prednisone per day, and dont have much side effect. But is it safe to take? Yours

  40. Dear Dr. Greene!
    I’m 38 years old. diagnosed with day 3 high FSH, 20 and Low AMH, 0.6.
    My RE suggested to do 3-4 IUIs first. I took Clomide 100 for day 3-7 and Follistim 150 for day 8-11. I did ultrasound on day 12. I had 3 mature follicles. 18.5mm, 20.5mm and 27.5mm which showed I responded to Med very good. I’m in 2WW waiting time. today is day 11 but I don’t see anythinkgto make me hopeful. would it be possible to get pregnant with IUIs at all with that FSH and AMH rate. My spouse has a great semen analysis.

    what is the process for IVF? can I do IVF or my changes are still very low with IVF as well?

    Thank you

    1. Dear Springgirl1977,
      Unfortunately, this forum is not appropriate for me to offer specific options because there is far too much in your history that I do not know. In general however, in a patient any patient over 35 years of age with low ovarian reserve–which is what is suggested by your lab tests–it would typically be best to move to IVF more quickly. The fact that you responded to your IUI protocol by producing several follicles is encouraging. However, it is generally best to move on to IVF if that option is available to you. This is even more true if your goal is to have more than one pregnancy since IVF can offer you the ability to freeze extra embryos for future pregnancy attempts. The process would be highly dependent upon the center that you’re working with. You may want to redirect those questions to your local doctor or consider setting up a consultation. I’d be more than happy to discuss it with you in detail.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG

  41. Hi Doctor.
    I am 40 years old and currently I am taking injections for my 2nd IVF. I did 1st cycle of IVF Last year in November and I was on 350 IUs of Gonal F and 0.25 mg Cetrotide for 4 days on 4th day of my cycle. My eggs were harvested on 9th day. They retrieved 13 eggs and 12 of them were mature and 6 of them fertilized. After 5 days they did Genetic Screening testing for the remaining embryos and unfortunately all of the embryo were abnormal and they didn’t make their way to the transfer. I have been eating well and have been taking supplements for 3 months now and I have started 2nd round of IVF 4 days before. My new doctor gave me 225 IUs of Gonal F for 3 days and today she gave me 300 IUs of menopur to take for 3 days. My cycle usually is 28 days. After reading your post I was wondering if she has not given menopur too early? What is your opinion on this? I just don’t want to damage my eggs since I am older, and I don’t know what to do. I would really appreciate your opinion. Also, she saw my blood test results from my last cycle and she said that my hormone levels were too high and maybe this could have caused bad quality eggs. Please let you know what you think. Thank you.
    Shocy.

    1. Dear Shocy,
      I typically don’t like to respond to queries about cycles that are still going on. However in situations like this I like to make the exception. I think we give ourselves too much credit for influencing the outcome based upon the specific protocol we select. In reality however, there are many paths to success and many factors that influence the outcome. Go forward with confidence. I look forward to hearing back from you about your pregnancy. 😀
      Best thoughts,
      ~Robert
      Robert Greene, MD, FACOG
      Conceptions Reproductive Associates of Colorado

  42. Hello Dr. Greene,

    I’ve been reading your blog for years and I’d love a second opinion from you.

    I’m nearly 39, husband is 42. We have been trying to conceive for 3 years.

    He has low morphology (3%) and I have low reserve:

    TSH down from 3.6 to 2 with 75mcg Synthroid
    AMH: .76
    FSH: 6.9

    We have had 4 IVF + ICSI cycles, all using Estrace Priming and pooling embryos for CCS.

    #1: pre: DHEA, 225IU Menopur, 225IU Puregon. 3 eggs, 2 fertilized, 1 made to Day 6 blast, tested normal on CCS

    #2: pre:DHEA, 225IU Menopur, 225IU Puregon. Slow response (17 days stim). 7 eggs, 4 fertilized, none made it to blast

    #3: no DHEA. 225IU Menopur, 225IU Bravelle, 1mg Saizen up to day 9. 8 eggs, 6 fertilized, one made to blast. Monosomy 4.

    #4: no DHEA. 225IU Menopur, 225IU Bravelle,1 mg Saizen up to day 9. 10 eggs, 7 fertilized, none made it.

    Transfer FET of blast from cycle #1: BFN.

    Do you have recommendations on a different protocol? Perhaps we shouldn’t use Menopur?

    What are your thoughts on mini-IVF for us?

    Is donor eggs my best option?

    Thank you so much!

    Juvarya

    1. Dear Juvarya,
      Please let me apologize for my delayed response but it has been a most hectic week. Thank you for your kind words and I am so pleased to learn that the information that I supply has been helpful to you. I am sorry that your quest has not yet been successful and regret even more that I am not able to provide specific recommendations in this forum. The information is simply too individualized for me to tailor my recommendations to your unique situation. Even though you have provided great details in your post, I have many questions and would want to adjust my answer according to the information that I would learn including your preferences. Consider setting up a consultation for us to speak to one another (by phone or Skype) if you think that would be helpful and you are too far to come to one of our offices in Denver, Colorado. That said, let me provide some guidance by addressing your questions in the order that they appear:
      Protocol–there are many possible variations to the protocols that you have presented. Most notably you may wish to consider a priming protocol with either estradiol or testosterone if your provider feels that would be appropriate. It might also be worthwhile to consider hGH (human growth hormone). I have some information on the blog on both of these topics you wish to read more about them.
      Mini-IVF–This is an option but not one that I would recommend enthusiastically. There is no evidence that it improves egg quality and in most women it reduces the number of eggs (opportunities for success) that they acquire.
      Donor eggs–I would not use the term “best” option for that is for you and your husband to decide. It is the option with the highest success rate. But the BEST option is the one that works. You still have options with your own eggs–based upon the information that you’ve provided–if you wish to pursue them.
      I hope that this is helpful to you. Please let me know if I can be of any further assistance.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG
      Conceptions Reproductive Associates of Colorado

      1. Thank you Dr. Greene – I will contact your office.

        We did have Saizen (the HGH you recommend), as well as Estrogen priming and in 2 of the 4 cycles I was on DHEA.

        One last question – do you think we should be doing any addition screening to rule out issues with the sperm?

        Thank you!

        Juvarya

      2. Dear Juvarya,
        With the limited information that I have, I would not recommend any additional sperm screening. I hope you find that reassuring.
        Best thoughts,
        ~Robert

        Robert Greene, MD, FACOG

  43. Dear Dr Greene, I was your patient last year in Syracuse and following your suggestions today I have my baby girl and I am the happiest woman in the world.
    Today I am looking for you to plan for a second treatment … where are you located? I trust you so much!
    I am not sure if this message is appropriate for this blog but this is the only way I was able to find you. Please erase if inappropriate but please let me know your fertility centre.
    For ever thankful
    Maria

    1. Dear Maria,
      Thank you for your kind comment and for seeking me out. I apologize for not being more easily accessible during my transition. It was required by the terms of my departure that I use discretion. I am pleased to say that I am now past the necessary time period and able to openly encourage follow up. I am working out the details to also begin having consultations by Skype as well. Please feel free to either email me directly at robertg@conceptionsrepro.com or through the “Request a Consultation” link that was just added. Either way, I look forward to hearing from you soon!
      Very best thoughts,
      ~Robert

      Robert Greene, MD, FACOG
      Conceptions Reproductive Associates of Colorado

  44. Dear Dr Greene,
    I have hypothyroidism with antibodies, albeit a very low amount of antibodies – between 60-85. ATA I guess you call it. I hope you might give me some much needed advice on what to change in my treatment!
    Here is my story so far:
    Ive had 4 consecutive early bios for the last 4 cycles, 2 stimulated and 2 unstimulated IUIs. Im being given 10 mg Prednisone both in follicular and lutheal phase. Clexane for the 7 first days of stimming, and clexane from day after IUI. I also had intralipids on the day of the IUI. These bios have happend around normal period day after 3-4 days of very clear positives. I have high progesterone and always a very thick lining. I fell pregnant extremely easily with my boyfriend 3 years ago, completely naturally and the first time we tried. I am now using donor sperm, have used the same donor for the last 3 cycles. Have high NK cells but very low ‘infection’ – if any at all. (Im doing IUIs now, but have done 6 IVFs before this with transfer of topgrade embryo or embryos every time, this resulted in 1 bio and 5 negatives.) What would you advise me to change?? Thank you so much! x

    1. Dear Coco,
      Thank you for seeking my opinion. Clearly you have been through an awful lot of treatment and testing. Therefore, the last thing that I would want was to marginalize your situation by providing an overly simple answer or suggestion that had already been investigated. I can tell you that of all the aspects of your care that you’ve mentioned the one that is most important are the 6-IVF cycles. Each IVF cycle is not only an excellent opportunity for a pregnancy but also a very important test. By reviewing the details of your cycles; an experienced fertility specialist should be able to learn a lot about your fertility challenge. Then clarifying the timing/information from your other tests would help reduce the risk of further misadventure and expense. Are you able to get a second opinion from someone near where you live? If not, are you interested in considering a long-distance consultation and a possible trip? These are the key questions that I would encourage you to consider. I believe that the best advice that I can offer is that you have someone review everything with a fresh set of eyes. If you would like for me to do that, I would be more than happy.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG
      Conceptions Reproductive Associates of Colorado

  45. Thank you very much Dr Greene, I would like to hear your opinion on this, and if you have any idea how we can adjust my immune therapy Id be super grateful! Im afraid I cant afford a trip to the USA at this moment. x

  46. Dear Coco,
    Thank you for requesting clarification. My impression is that without first confirming that you are producing genetically healthy embryos; one should not assume that your immune system needs any sort of therapy whatsoever. Most of the current studies into potential immunologic issues today are starting with genetically screened embryos because the immune problems are far less common then the genetic ones. Please let me know if I can be of further guidance/assistance to you.
    Best thoughts,
    ~Robert

    Robert Greene, MD, FACOG
    Conceptions Reproductive Associates of Colorado

  47. Dear Dr Greene,
    My progesterone has been fine when it has been tested in other cycles. This cycle we tested on 4 dpo already, instead of 6-7 dpo and it was only 28 nmol/l. Its an unmedicated cycle, one egg only, no pregnyl either.
    (Had 167 nmol/l last cycle on day 6 dpo after stimulated iui on 3 mature eggs.) Does low progesterone indicate low egg quality? – If I retest it tomorrow 7dpo should I expect it to have risen?
    Good evening!

    1. Dear Pica,
      I regret that I cannot give you specific advice regarding your situation but I simply don’t have enough information to do accurately. Most centers are set up so that you should not need to manage the fine details of your cycle. I would encourage you to speak with your doctor if you are not getting the answers that you’re seeking. Otherwise, the stress that you are experiencing from worrying about such matters might be more detrimental than the levels that you’re tracking. Please let me know if you have any general questions that I can answer for you that may put your mind at ease.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG
      Conceptions Reproductive Associates of Colorado

  48. Hello. I am about to start an IVF egg sharing programme and have been instructed to take my first 100mg injection of Elonva. I am a healthy 39 year old with no fertility problems but have read that someone of my age should typically be administered a 150mgs dose. Do you think my egg production will suffer will suffer with a lower dosage?
    Many thanks,
    Natasha

    1. Dear Natasha,
      Regretfully, I am not able to provide specific advice in this forum–especially since I do not know more about your unique medical/reproductive history. That said, I can reassure you that we typically individualize our protocols based upon a combination of findings including a patient’s age. My assumption would be that your clinic does the same. IF you are not confident of that and believe that an error was made, I would encourage you to contact them and discuss your protocol prior to proceeding. My hope is that you will get the reassurance that you deserve.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG
      Conceptions Reproductive Associates of Colorado

  49. Dear Dr. Greene,

    thank you very much for your valuable information.

    I had my first IVF cycle last month, and it ended with a CP. I am 35 years old, diagnosed with SLE since I was 7.
    During the cycle, I was put on fostimon 600 IU for 11 days, which I found later that this dose is considered very high. I had 5 follicles, 3 of them between 20 and 18. 4 fertilized and one only was developing, I had 2nd day transfer with Grade B embryo.

    My main concern is my body response, is these 5 follicles indicates that I have low ovarian reserve, noting that all of my hormonal levels are normal. in addition, could this high dose effect the quality of the eggs and do I have to go again with high does to get eggs, or could low dose be more effective?

    Many thanks,
    Hadeel .

    1. Dear Hadeel,
      Thank you for your kind comments and your support of this blog. It is always helpful to learn that the information that I post is of use. Unfortunately, I am not able to provide you with specific advice–and don’t have nearly enough information to do so. That said, I can speak in general terms about some of the information that you supplied.

      Women that have any auto-immune issue–including SLE–are at higher risk of diminished ovarian reserve. Given that each egg is somewhat unique from every other; it makes them particularly susceptible to attach by the immune cells. In fact, many specialists that treat auto-immune patients advocate that they freeze eggs at an earlier age than the recommended 32 to 38 range typically used for women that don’t have these health challenges. So unfortunately, you are at risk.

      The response that you describe is suggestive of diminished ovarian reserve. The AMH blood test (see blog post on this subject) is a very good test to assess this and typically not expensive. Rest assured that even with a low ovarian reserve, you can still produce very good quality eggs. In fact, given the right protocol you might produce both more and healthier eggs. So remain encouraged that you are producing eggs. Consider discussing these questions with your doctor and see if they feel that you would be a good candidate for a protocol change or consider a second opinion. I hope that you find this encouraging.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG
      Conceptions Reproductive Associates

      1. Thank you very much Dr. I will do my best. I am sure that knowing the problem will help in reducing its negative impact.

  50. Dear Doctor –

    Can natural IVF (without stimulation) can help me produce a better quality egg which will not be affected by hormones? I was pregnant with IUI (stopped at 10.5weeks); then molar preg; Then did 6 IVFs the past 2 years with 2 chem preg (i just turned 43). Reg period; DOR; AMH 0.5. FSH 8-15. Produced btw 3-9 eggs; 3-4 embryos. Running out of time and out of choices. THought that natural IVF may select a stronger egg, even if 1? Any advice, Doctor?

    1. I have hypothyroidism (antibodies) and was treated with Levothyroxine 50mcg; as well as intralipid, prednisone, estrogen; aspirin before/after last 3 transfers. I am being told that i have poor egg quality.

      1. Ella,
        This additional information further reinforces my recommendations that you consider IVF with CCS. We see/treat many such similar histories and have an excellent success rate that validates this advice. Stay optimistic and don’t give up.
        Best regards,
        ~Robert

        Robert Greene, MD, FACOG
        Conceptions Reproductive Associates of Colorado

    2. Dear Ella,
      The concept of IVF without ovarian stimulation is an appealing one. It could save money and reduce a patient’s burden. Some have theorized that it could improve egg quality and marketed the concept under the term “natural IVF” but there is nothing natural about IVF. Unfortunately, all of the data show that with the lower cost of “minimal stim IVF” comes a proportionately lower success rate. So the good news is that it can work. But looking at all of the data–as well as experiences that I have seen in patients–it is a promise that is typically unfulfilled. I would encourage you to consider IVF with CCS (comprehensive chromosomal screening) of the embryos. Not only is it associated with the highest attainable success rates per cycle; it also provides more information about why some embryos fail. That information can be vital to decide the next step. I hope that this is helpful and that you can find this treatment locally. If not, consider setting up a consultation with a center withing traveling distance. The inconvenience may be well worth it.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG
      Conceptions Reproductive Associates of Colorado.

  51. Doctor – I did chromosomal testing on 4 embryos. 3 were abnormal. 1 failed to test. Should I transfer the last one that failed to test? ALso, if my lining is good, should I do unmet
    dicated transfer? Thank you, Doctor.

  52. Dear Ella,
    There are several different methods for performing genetic testing. Each one has separate reasons for a “failed test.” The implications of this result are unique for each as well. Therefore, i’m afraid that I can’t provide you with any guidance on this without having access to your full medical history. What did your doctor suggest? Maybe I could provide some insight based upon that information.
    Best always,
    ~Robert

    Robert Greene, MD, FACOG
    Conceptions Reproductive Associates of Colorado

    1. Dear Mona,
      I’m not sure how to interpret that test which is why I would not order it. If you on “day 7 of ovarian stimulation” then you are likely injecting FSH–in some form or another. So your result would be dependent upon which form you are using and when you took your last dose. I’m sorry that I can’t be more helpful on this. Was your doctor reassured?
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG
      Conceptions Reproductive Associates of Colorado

      1. Thank you Dr so much for your kind, I started my ivf last month with Estradiol 2MG twice daily and testosterone 12.5 M before ivf treatment and when I got my period,I went to the clinic to start the treatment but after ultrasound doctor give me birth control pills for 15 days because he found I have cyst length 3.72 and height 2.95, I didn’t have that before then he gave lupron 20 units for couple of days then 10 units of lupron + 300 follistim + 150 menopur and day after decrease lupron to 5 units, my response was very poor only 2 follicles on thr right , day 7 he check my FSH found it was 43.3 so he canceled my ivf, I checked my FSH two months ago it was 10.6 and LH 3.61 and TSH 3.30. I really need your advice. Very appreciated

      2. Good day Dr, hope you are doing well, forgot to tell you that I am 38 years old and my amh is 0.15 , do you think I still can be pregnant??.. Please advise me. Thank you!!!

  53. Dear Mona,
    I think you’d be well served by considering a “free Skype Chat.” Our office is offering a 15 minute appointment–during which I think I could provide much better guidance in a far more timely fashion. In fact, feel free to share this offer with anyone else that you know or with anyone else that is reading this post. Here is a link to anyone interested in this offer: http://www.conceptionsrepro.com/schedule-consultation.html
    Hope to Skype with you soon!
    Best thoughts,
    ~Robert

    Robert Greene, MD, FACOG
    Conceptions Reproductive Associates

  54. hi doctor am 33 since one and a half years trying to get pregnant I have a 5 years old child n had normal delivery. I have take n clomid and had done 6 gonal f injection 75 mg still no response. what do you suggest me to make my eggs become mature . and my menses have to take primolut for them to come
    .

  55. Hello Dr. I started my first ivf cycle and am on day 7 of lupron 10, reducing it to 5 and adding 450 follistim when my period starts. I’m really nervous about the stimulation period, since I have a prothrombin gene mutation, heterozygous. However no history of clots in the past. I have seen several hemotologists and have conflicting opinions about safety and risk. I will be on loveox during pregnancy but worry that the 7-10days of stims might be risky. I have a 6 year old through natural conception and no issues during pregnancy. Thank you in advance.

    1. Dear Sevannah,
      I so sorry that I was not able to respond to you sooner. Please discuss this with your doctor as there are many individual variables. However, one thing that I can assure you is that pregnancy and postpartum create a far greater risk of developing a blood clot than ovarian stimulation for IVF. Given that they’ve already identified your specific risk and are addressing; you should be very confident. The greatest concerns lie with women that are at risk and do not know it prior to starting out on their reproductive journey. Although a bit late, I hope that this is reassuring.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG
      Conceptions Reproductive Associates of Colorado

  56. Hi, i have a question on Bravelle. How important is this medication to the success of IVF. Im 45 now and my husband 35, we attempted IVF about 2yrs ago. I have 4 adult children (nature conception ) and tied my tubes after the 4th child. My husband has no children and we wanted to try to have our own. We went through the entire process very optimistic since I have no issue getting pregnant or holding a pregnancy to term ( I natural had 4 already), my oly issue was my tubes being tied and my age of course. Needless to say IVF failed and we were devistated. Recently we received a letter from the makers of Bravelle saying they will refund us the enture cost of the medication (bravelle only ) because the batch we received wasn’t as strong as it should of been. Could this cause the failure of IVF?

    1. Dear Sarah,
      The recall that you referred to had to do with potency (strength) of the product but not it’s efficacy (quality). So rest assured that although it may have taken more medication (or more time) to get the desired response; the recall should not effect the actual outcome of your treatment. You should however discuss this with your doctor to see if they recommend anything different in moving forward. Or feel free to schedule a Skype appointment with me and I will be happy to review your entire cycle and determine if I have any suggestions in how best to move forward.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG
      Conceptions Reproductive Associates of Colorado

  57. Hi Dr Greene. You’re wise and wonderful! I am using a surrogate- not because I have failed to become pregnant (have never tried), but because of other health matters. What would you recommend I be tested for and is there any hormone protocol which you feel is better for a first timer who has no history of infertility? I was going to try the low dose hormone option but read your disapproval. I am going to start HGH to help with some of my chronic issues and to help me heal from the surgeries ahead. I have taken it once before. I believe HGH is what healed two persistant joint “injuries” (Frozen shoulder and bursitis of the hip) to the point where they were not limiting my life. The cost is high, but without it I am disabled. I have found a dr that provides HGH for about $550/month. With the improvement I expect to feel, I can go back to work it so it will be worth the expense. He wants to prescribe 1.2iu 5 days on 2 days off. Do you think that is a high enough dose to boost the vitality of my ova? I would love some tips for a first timer. I will be getting my HGH here in the US . the doctor is out of state and does a phone consult after I get an exam with my primary care and have labs sent to him. The fertility hormones will come from the clinic in mexico and that is where egg retrieval will occur (couldn’t afford US rates). The HGH they offer is about the same price so I am just going to get it here because I need a US doctor’s Rx to import it anyway and not many doctors will prescribe it off-label.

    BTW, the women in my family are well known for having healthy children late in life. My mom was 44 when I was born and she was trying not to get pregnant. Her mom was about 46 when she had her youngest. My sister is in her early 50’s and never has had a pregnancy but still has a decent reserve of eggs. My cousin had her only child, a surprise baby at nearly 50. Most of my friends/cousins in my age range are having babies right now, so I feel very positive about this. Only one of my friends struggles. She did the mini IVF and her husband’s sperm has chromosomal issues. I may refer her to you, if you might have a solution for her.

    If you have any tips for a newbie, please share or point me to other things you have written or read. I appreciate it very, very much and will like to consult with you once I get information from the surrogacy/IVF clinic. No doctor likes to be told what to do, but if you disagree with anything in their protocol, I would find a gentle way to convince them to try it another way. what is your consultation fee and how do we get in touch with you when we are ready?

    Smiles,
    Nikki

    1. Dear Nikki,
      First off…you are far too kind. I do appreciate your compliments and hope that the information that I provide is a helpful guide. I began putting this out expressly for the reason’s you suggested, many of my colleagues don’t like taking advice or guidance from their peers. However, they are more compelled to listen to the concerns raised by their patients–as long as they are evidence based and within reasonable guidelines. Toward that end, I hope that this blog empowers you. It does sound like your situation is far too complicated for me to possibly provide any specific tailored advice or guidance to your situation. I don’t know nearly enough about your history and I haven’t a clue as to what the proposed treatment is that you’re pursuing. If you have any specific question(s), please let me know. I’d love to provide you with the confidence that you’re seeking as you move forward.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG
      Conceptions Reproductive Associates of Colorado

  58. Hi, i ran across this and thought you may be able to answer my question. I am about to do a medicated cycle with HMG. I have 9 amps of generic HMG-lepori and 19 vials of Menopur. If i have a day that I have to take both on the same day, how do i achieve this? Would I give myself 2 different shots and not mix them in the same?

    1. Dear Trinette,
      I regret that we are not legally allowed to provide specific medical advice to a patient through this forum. Please contact your clinic and speak with your provider. They should be able to clarify this for you rather quickly.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG
      Conceptions Reproductive Associates

  59. Dear Dr. Greene,

    Thank you so much for the article. I find it so much helpful through the IVF cycle.

    I have a question. My doctor changed the treatment from Menopur to Luveris, and I have some doubts. We have to do IVF not because I have fertility problems but because my husband had done vasectomy. I’m 27 years old and I have never had any health issues. My ovaries are perfect and so is my uterus. During my first cycle they retrieved 12 eggs which resulted in 3 blasts. My first cycle ended in miscarriage in the first trimester. And for my second cycle the doctor replaced Menupor with Luveris. I would like to know your opinion about this. If you think it is better to start again with Menopur or Luveris.

    Thank you so much.
    Lily

    1. Dear Lily,
      Thank you for taking the time to read my blog and for valuing my opinion. Unfortunately, I am limited in my ability to provide specific advice–especially in this case as I am not fully aware of your history. I do believe that there are situations where Luveris may have benefits over Menopure. Unfortunately, we no longer have Luveris available to prescribe here in the USA. Despite its absence, I have learned to adapt. To my surprise (and delight) it has not compromised the success rates. In fact, we achieve higher success rates today then when Luveris was an option for us. Admittedly, the advance in pregnancy rates is due to other factors. That said, it has reassured me that the choice of which medications are used during the ovarian stimulation are likely not as important as we previously believed. I hope that you find this reassuring as that is how it is intended.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG
      Conceptions Reproductive Associates of Colorado

  60. Dear Dr. Greene,
    I stumbled upon your blog today and it was so wonderful to read through all your responses. I understand that you may not be able to get into specifics here but I am hoping you would be able to provide some insight into this issue which is kind of a generic widespread problem and not just specific to me – During my last several IVF retrieval cycles(in an attempt to bank some blasts), I have consistently had premature LH surge(11-18) as early as Day 5 of stims accompanied by a rise in P4(>2) as well. It does come down with cetrotide but since all my frozen embies never made to blast, I am suspecting if the surge has played a role? All of the banking cycles were EPP/antagonistic(cetrotide). Do you have an opinion on this? Why is it that while this is discussed all over the internet as a possible cause of failed cycles, yet my RE downplays it everytime? Do you take this into consideration at your clinic? Is there a protocol out there which addresses this problem? Or this really is not a problem as I am imagining. I have seen this consistently ever since started IVF at age 31. I am now 40! My RE tried starting cetritide early around day 4-5 but it stalled the follicle growth and we end up with one dominant follicle each time!! If the response to high stims give you just one follicle(despite an AFC of 7-9), is it not justifiable to consider Natural Cycle IVF? I know you are not a proponent.

    Thanks in advance for any input

    1. Dear Gayle,
      Thank you for your kind words. I so appreciate learning that the information that I put out there is of help.

      Regarding the situation that you describe, we often see a premature LH surge. My experience–as well as my interpretation of the published research–is that it can have a negative effect upon the endometrial lining but not on the oocyte. I typically continue cycle stim and push past surges just like it sounds that your doctor did. In our center, MOST of our patients have us freeze their embryos because even without a surge, the hormone levels post ovarian stimulation are not ideal for preparing the lining of the uterus for pregnancy. I do not recommend Natural Cycle IVF because lowering the number of eggs recovered, reduces success rates by more than the improvement of the uterine lining. Worse still, it is does not save patients money since they often have more tries. If it would be helpful for discuss this further, please do not hesitate to set up a SKYPE consultation. In the meantime, stay positive and please keep reading!
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG

  61. Dear Dr. Green,

    I’m 39 years old. My husband was diagnosed with oligoasthenoteratozoospermia and AZF c deletion Y chromosome. We have 2 failed IVF cycles. During my first cycle the Dr. retrieved 8 eggs which resulted in 3 embryos but just one had good quality (ET in day 3) . My first cycle ended in miscarriage at 7 weeks ( aneuploidy).
    During my second IFV ( with the same protocol :micro flare protocol : menopur + Gonal) the doctor retrieved just 2 eggs, one embryos with low quality and no pregnancy. My AMH is 1.38.
    We prepare for un another IVF cycle (with donor sperm) and my gynecologist recommend me antagonist protocol (menopur and orgalutran).
    I would know your opinion about this protocol. If you thing it is better for me and for my age to start with this medications.
    Thank you so much!
    Anna

    1. Dear Anna,
      Thank you for seeking my input. This is a very common question. Unfortunately, I cannot provide specific advice to you regarding you and your husband. That said, I can reassure you that I believe that a carefully selected protocol may optimize both the number of eggs recovered and may impact their quality to a lesser degree. However, it will rarely determine the outcome of the cycle. Your first cycle that ended in aneuploidy is a very strong clue as the greatest hurdle that you are encountering–producing a genetically healthy embryo. Maybe using the sperm donor will move you closer to this direction. At the same time, it could be worthwhile to consider genetic testing on the embryos prior to transfer. That is the technique that so many of our patients seek with tremendous results. I hope you find your success one way or the other.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG

  62. Hi Dr Greene,

    I really enjoyed your book, Perfect Hormone Balance, and found it very inspiring. Medical science too often push us to take a more aggressive approach and its refreshing to read about a doctor suggesting you take a step back and re-evaluate your lifestyle and diet.

    I’m 32 and just competed my first IVF cycle. Even though my doctors had kept me on a very low dose of gonal F throughout the cycle which was great, I was extremely disheartened to learn that of the 6 oocyte retrieved only 1 embryo (which was transferred) made it to a 8 cell on day 3. I’m now in the dreaded 2 week wait.

    Whatever the outcome, your book has given me renewed inspiration to edit my life and maybe try again naturally. My husband and I have been diagnosed with mild male factor infertility which the doctors have advised is not that severe. And your book has given me the inspiration to not always just dive straight into the most aggressive approach!

  63. Hello I am 36 years old, In my second ICSI IVF I used 75IU puregon and 75IU menopur short protocol. I have good reserve of eggs. I felt that having 75IU menopur affected the quality of my eggs, because in my first IVF i did the long protocol just with puregon, i got 14 eggs and 8 were fertilized, but in my second IVF I got 18 eggs 13 mature, but just 6 were fertilized and just 2 survived 3 days. In both protocol my levels E2 were rapidly getting high, I will try my third IVF what would you advise me? I dont smoke, normal weight, overall healthy. I dont know if the cause can be sperm even when we are using ICSI. My husband got retrograde ejaculation after testicular cancer operation. He is 41.

    1. Dear Lili,
      There are so very many facets that impact the success of an IVF cycle that it is nearly impossible for me to guid you with the limited information that I have available. Some factors relate your biology and that of your partner. Some may also relate to the center where you are cycling. The best way to get a fresh perspective is to consider getting a second opinion. Sometimes you can do this with another local center; other times it may require your willingness to travel. The bottom line is that you’ve posed some important questions that should be addressed. Rebuilding your confidence should be a key priority in planning your third attempt.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG
      Conceptions Reproductive Associates
      Denver, Colorado

  64. Dear Dr Greene,

    I had one IVF ICSI in January (decapeptyl + 12X300IU Menopur + pregnyl 5000) – 4 follicles, 2 eggs, 1 embryo D and no pregnancy. Due to DOR (AMH 0,77 and FSH 8) and age (40) we were banned from the public Portuguese Hospital. They don’t think investment is worth and legally the state can only help women under 40.

    My husband sperm had low cout, poor motility and poor morphology.

    We decided to change our lifestyle. I’ve tried to lose weight (lost 8kg since February) and he diminished Tabaco and alcohol. We both started on vitamin D (I was tested and had really insufficiency), magnesium and omega 3 suplements.

    This September we started another cycle in a private clinic (almost 5000€) with a short protocol (Elonva 150 + 9X225IU Menopur +orgulutran + pregnyl 5000) – 6 follicles, 2 eggs not fit to fertilize (1 imature and 1 broken?).

    Curiously my husband’s sperm is a lot better (60millions/ml and 66% mobility) but we know that men tent to respond better and quickly to life changes.

    Our doctor proposes us egg donation but we think is too early to even consider that option.

    I’ve been reading a lot about DHEA supplement and CQ10. Our doctor says that nothing can make my ovaries younger …

    Do you think I should try DHEA 75gr per day? Do you recommend a brand? It is not possible to buy it on Portugal so I’ve to order it online.

    Do you think I should try Vitex Agnus Castus? I’m realy afraid that can mess with other IVF stimulations.

    Do you think Menopur was once again a bad choice for me?
    I heard other friends done Gonal and Puregon, but never heard about Luveris …

    It would be great to have our opinion. Portuguese doctors are so concentrated in protocols they know and are not used to be questioned!

    Thank you for your time.
    Cristina

    1. Dear Christina,
      Thank you for seeking my input. I am so sorry to learn of your predicament. Unfortunately, this is not a forum where I can provide any accurate or personalized recommendations. Without knowing a lot more about you and your husband’s medical history and goals, it would be inappropriate. That said, at our center we do tailor our protocols to our patients’ unique physiology and history. Our results support the the theory that this optimizes pregnancy rates. Supplements as well as diet and lifestyle can help but each one has a unique intended purpose so please consult with your provider before starting a regimen. If you have have any general questions, please let me know and I will do my best to guide you.
      Fertile thoughts,
      ~Robert

      Robert Greene, MD, FACOG
      Conceptions Reproductive Associates of Colorado, USA

      1. Thank you. I understand that you can not give me a real solution. But do you think starting DHEA on my own risk can have a negative side effect?

        Thank you for your time
        Cristina

  65. Dear Christina,
    Unfortunately, DHEA can have a negative effect. It depends upon your baseline hormonal status. Although it is true that many women have a low testosterone level and can benefit from DHEA–it is possible to over-supplement and achieve high levels that can damage eggs. Also, for women with PCOS, they often have elevated basal levels to begin with. So please consider discussing this with your doctor.
    Best thoughts,
    ~Robert
    Robert Greene, MD, FACOG
    Conceptions Reproductive Associates of Colorado

  66. Dear Dr Green,

    I’ve been put on a antagonist protocol for my IVF. First day 450 iu Gonal F, second day and third day 375 iu Gonal-f, thereafter 300 menopur. I’ve never heard of anyone being scheduled for a similar protocol. Between 2nd and 3rd (cd 9) ultrasound my follicles seemed to have stopped growing. Im having a 3rd ultrasound tomorrow. Do you think the swap between Gonal-f and Menopur was harmful for my eggs? Also stepping down from 450 to 300 within a few days, does that seem like a wise approach? Is Gonal F and menopur equally potent? I mean is 300 menopur equal to 300 Gonal-F?
    Best regards
    Malin

    1. Dear Malin, Thank you for reaching out and I regret that you are under such stress. Unfortunately, I cannot answer your question as this is a very unusual protocol–one that I have not seen used. That does not mean that it isn’t an appropriate choice for you during this cycle. Given that this is causing you significant anxiety, I would encourage you to check with our treating physician as to the reasoning behind this choice of medication and the step-down protocol. If you need help with understanding their explanation, please let me know and I will do what I can to help.
      Best thoughts,
      ~Robert

      Robert Greene, MD, FACOG
      Conceptions Reproductive Associates of Colorado

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