Dr. Tortoriello at SHER for Low AMH/high FSH?

lawyer630 · March 2017

Hi ladies! I'm 41 yo, amh is .05 and highest fsh was 25 last month. No other issues. I had a consult with Dr. tortoriello at SHER in NYC last week. I don't know if I should go for a second opinion, or just trust his methods and start cycling with SHER. He recommended low stim IVF (in vitro fertilization) with banking of only healthy embryos. Unfortunate my insurance doesn't cover IVF, so whether or not a dr takes my insurance is not an issue. From what I've read up so far, SHER's pricing has changed and it's about the most expensive clinic in NYC, and since I will be doing multiple retrievals, it is going to get pricey.
With that being said, should I keep searching for another high fsh/low amh friendly dr, or should I just stick with SHER? Obviously, time is of the essence, but I don't want to jump into anything blindly and make a mistake by not going to another dr for a second opinion.
Has anyone else cycled with success at SHER with my stats?

Thanks in advance!!

natalie4oscar · March 2017

It is always good to get a few different opinions and compare their results, methods and costs.

I am currently seeing Dr T and while we didn't do cycling, I can honestly say that I am having a wonderful experience with him. He is very thorough and will alter the cycle to meet your needs. He will work with you and provide you with lots of information every step of the way. I had issues with my previous RE and began to feel like just another number and barely saw my own doctor, with him I only ever saw him apart from one time when I had to go in for monitoring on the weekend.

He responds to all of my email requests, no matter how quirky they may appear and has seriously given me back my sanity after my first two stressful cycles.

Its early days but I am now 5 weeks pregnant and have my first U/S next week with Dr T.

lawyer630 · March 2017

Congrats and thank you for responding!!! I hear only wonderful stories and experiences with him, I'm just hesitant to jump all in without getting a second opinion. I, like you, was with a different clinic, and was only a number, and after 3 failed IUIs, it was time to change the dr and method! If you don't mind me getting too personal, do you have the same issues as I? My amh is terribly low, and my fsh is terribly high...hence the egg banking...

natalie4oscar · March 2017

I have DOR - Diminished Ovarian Reserve, so not exactly the same issues, but it makes producing a good amount of eggs difficult not to mention the quality of them.

His methodology for me was to tamper with them as little as possible, he knew I wasn't going to produce a lot, so he wanted to get them as strong as possible. He had me on a mixture of vitamins before hand, I then did estrogen priming and he reduced my previous priming intake which meant it took a little longer, but hopefully got them stronger.

If we were going to do PGD testing he then suggested the egg banking, but that wasn't on the cards this cycle.

Hopeful_mom · March 2017

I have Low AMH and was thinking of mini IVF if this next cycle doesn't go well. So each ER is the same in pricing? Since they to more retrievals in a mini I thought they included that in the price. I have to say at times I haven't been in love with my RE and many told me to go for a second opinion or at least switch to one of the other drs but I do like the fact that she does always aswer my questions and tries to be very thorough, even though she is not the warmest of people. AND I did get pregnant with twins...I did MC at 10 wks BUT they appeared to be super healthy so hoping it was just the bad luck of the first pregnancy. My insurance doesn't cover IVF either so it feels like every where is super pricey. I too am 40 and you dont want to miss a cycle...if you're comfortable you should go with your gut!

Hopeful_mom · March 2017

@natalie4oscar hey lady how r u?? Hope ur feeling great when is us time

make sure to update me, so exciting!!

lawyer630 · March 2017

Good morning! From everything that I've heard and read, Dr. T is one of the best drs that deal with our issue. I have a double whammy of low amh and high fsh. So since I'm doing embryo banking, I purchased a package of two cycles. SIRM used to offer a package of three but they recently changed their pricing methods. From my limited contact with Dr. T so far, he spent over an hour with me at my consultation and has been very receptive to my emails and responds within an hour! My prior clinic on Long Island was a nightmare. An utter nightmare and it's refreshing to be able to speak to a dr almost instantaneously. For me it cuts down on the stress if I know my dr is communicative. I know we ladies need to remain as stress free as possible!

Hopeful_mom · March 2017

@lawyer630 have you started a cycle with them? Do mind sharing how much they charge?

mandasd · March 2017

@lawyer630 I am curious as well! I read through Dr Sher's blog and actually emailed him and he wants to set up a SKYPE call however I'm trepidatious going down this path because the closest clinic to me is Las Vegas (I'm in San Diego) and I'm concerned about the cost. If it ends up not working, I'm not sure how much we can take financially or emotionally. I was resolved to use donor eggs but Dr Sher said I was just given the wrong protocol, twice.

20T · March 2017

@mandasand do you mind me asking what protocol he thinks you should have received?

mandasd · March 2017

@20T Here is the response I got:

In my opinion, the protocol used for ovarian stimulation, against the backdrop of age, and ovarian reserve are the drivers of egg quality and egg quality is the most important factor affecting embryo “competency”.
Women who (regardless of age) have DOR have a reduced potential for IVF success. Much of this is due to the fact that such women tend to have increased production of LH biological activity which can result in excessive LH-induced ovarian male hormone (predominantly testosterone) production which in turn can have a deleterious effect on egg/embryo “competency”.

While it is presently not possible by any means, to reverse the effect of DOR, certain ovarian stimulation regimes, by promoting excessive LH production (e.g. short agonist/Lupron- “flare” protocols, clomiphene and Letrozole), can in my opinion, make matters worse. Similarly, the amount/dosage of certain fertility drugs that contain LH/hCG (e.g. Menopur) can have a negative effect on the development of the eggs of older women and those who have DOR and should be limited.I try to avoid using such protocols/regimes (especially) in women with DOR, favoring instead the use of the agonist/antagonist conversion protocol (A/ACP), a modified, long pituitary down-regulation regime, augmented by adding supplementary human growth hormone (HGH). I further recommend that such women be offered access to embryo banking of PGS (next generation gene sequencing/NGS)-selected normal blastocysts, the subsequent selective transfer of which by allowing them to capitalize on whatever residual ovarian reserve and egg quality might still exist and thereby “make hay while the sun still shines” could significantly enhance the opportunity to achieve a viable pregnancy

artemis618 · March 2017

Thanks for sharing @mandasand! I'm sorry about your last cycle. It's also crossed my mind to make trips to Vegas (from LA) if it made sense. I've been wondering who else uses the agonist/antagonist conversion thing - I've really only heard about it on Sher web sites (and a strange copy cat-looking one...). I'm hoping this next down reg cycle (2nd of two insurance-covered ones) goes better for me than my disastrous first antagonist one if LH--> excess testosterone is a thing for me (and at least I'll have tried something different), though my RE has me on Androgel again :-/

Sorry if I missed it somewhere, what protocols were your previous cycles, and what were your stim dosages (although I think you're younger?).

mandasd · March 2017

@artemis618 My 1st protocol was microdose lupron flare. At baseline I had AFC of 8. After 6 days of stims with lupron, menopur (2 vials) & gonal-f (300), I only had one follicle grow! Cancelled and converted to IUI. After begging, the military allowed me to try IVF again in January. I attempted to start mid-January with a week of estrogen priming. At baseline I had 12 follies! Then I started estrogen patches, 2x. A week later, I developed a cysts, still had 12 follies. They asked me to wait a week to see if the cyst cleared. The next week, cyst was gone but I had one follicle larger and they didn't want me to start stims and have the same thing happen. So, we triggered ovulation and I increased estrogen patches to 3. Got period 2 weeks later, immediately had baseline (2/24). Protocol was antagonist - 2 vials menopur in the morning, 300-u gonal f in evening. I added Ganerlix after day 6. Everything was going really good. I had 6 follicles all in the mature or almost mature range. After 11 days of stims, my E2 was 1000. By Saturday, it dropped to 410. My ER was scheduled for Monday. I still had all my follies when they went to do ER but they were empty. My doctor was baffled and said this has never happened to him. So, I researched and discovered it's called "Empty Follicle Syndrome." According to Dr Sher's website, this happens with increased LH activity and are thus more likely to produce excessive ovarian testosterone. It follows that sustained, premature elevations in LH or premature luteinization (often referred to as a “premature LH surge”) will prejudice egg development. Such compromised eggs are much more likely to end up being complex aneuploid following the administration of the hCG trigger, leading to fruitless attempts at retrieval and the so called “empty follicle syndrome.”

All this being said, I guess I had the wrong protocol. In my opinion, it is too risky to attempt a 3rd round of IVF at a clinic that I would need to travel to, and the cost would be astronomical. My treatment through the military is a fraction of the cost of IVF. If I switch to my insurance at work, it covers no IVF (employer did not elect it). So, the safest and most rational option for me is donor egg. I will ask my husband if he is OK with me spending $45k on additional procedures and see what he says (I'm being sarcastic!).

Hopeful_mom · March 2017

@mandasand very interesting info! I agree lupron is crap as that was a bad cycle for me too. Nervous to here about the amount of meds. Funny my acupuncturist felt that too much meds for DOR isn't good BUT i'm still not sure. We tried less meds in the beginning and upt it at the end, with a similar outcome. Why i'm always a basket case through every cycle.

artemis618 · March 2017

@mandasand I'm sorry I just now realized that I never thanked you for your detailed recap! I hate how hard this is for all of us. My baseline u/s is tomorrow morning, and if all looks well I guess I'll start stimming when/shortly after AF comes? We'll see shortly how much the lupron suppresses me (hoping the down reg is worth it). I was on the same gonal/menopur doses as you were last time - this time we won't add the menopur till the 5th day of stims per my request (the gonal hurts less anyway but a lot freaked out about the LH thing).

Extra bonus is that this ER (assuming I get there) will be inside of two weeks of our first one's EDD

So if this ER goes anything like the last one, it will not be an easy month.

dragonette505 · March 2017

@hopefulmom @mandasand I feel like we were all in a cycle group at some point.... Was just reading this because I've watched some of the youtube webinars from Sher... I guess like most everyone else its just a costly gamble (though I'd take out a loan if there were guarantees... for that they would get the money). I did ok as far as at least producing eggs on microdose Lupron flare. My last antagonist cycles I got 5 and 6 eggs apiece and nothing to freeze. On Lupron cycles I got 17 and 20 eggs apiece. We are still considering doing another cycle (I was so sick after this last one from ohss) but my DH doesn't want to spend any more till we at least try some frozen transfers.
I hate how much these cycles cost!!

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