Infertility/Fertility/Starting IVF


Hello dr. Ramirez

I am writing from New Jersey. I will be starting IVF in March after my doctor removes a dermoid cyst from my right ovary. I have had four failed IUIs. Two with injectables and two with femera. My injectables ones were cancelled because I overstimmed and had too many follicles (8-10) even on low doses of Follistim . My dr. has said my main problem is my LH surges too early in my cycles which could be damaging to the eggs. So for my IVF cycle he will be adding lupron in to keep my LH from surging. And will trigger with a half dose of HCG. However, I do have PCOS and I'm terrified of getting OHSS and I know hcg can trigger it. He doesn't seem to concerned about OHSS but we already know I respond real well to the meds. How does his plan sound to you? I would like to get a second opinion on his plan. Thanks for taking the time to read this.

Hello Smita from the U.S. (New Jersey),

I do not make specific comments regarding protocols because there are so many variations out there and no "gold standards".  Most Physicians will use the protocols that they were trained with.  Suffice it to say, that after 21 years of doing IVF, and many many PCO patients, I have had only 3 cases of OHSS, all of whom were mild cases.  For many years now, I have used the "antagonist protocol" with Lupron trigger, as will as carefully choosing timing of the trigger, in order to prevent OHSS.  Many studies have looked at this protocol and tout it as an effective treatment to prevent OHSS.  It is not the standard but becoming more and more commonly used.  Considering how sensitive your ovaries are to stimulation, you will require a low stim protocol, and I would use the antagonist.  But, keep in mind that this recommendation is based on my experience.  Not all docs would accept this recommendation.

You've chosen this doctor to care for you and entrusted him with this care.  You need to decide if you trust him for this.  If you trust him, then you need to trust that he will treat you appropriately, safely and to the best of his ability.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program

Monterey, California, U.S.A.

for additional information check out my blog at check me out on twitter with me at @montereybayivf and facebook @montereybayivf.  Skype and internet comprehensive consultations now available via my website for those who want a more extensive evaluation that this site can accommodate.  I also now provide an Email Concierge Advisory Service with a 1 year subscription for patients that want easy access to me to answer questions along their journey (women's health, infertility, pregnancy).  Contact me at if you are interested in continuous access to me.  


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Edward Joseph Ramirez, MD, FACOG


I am a specialist in infertility and advanced gynecological care. I can answer questions about infertility, gynecology related ills, menopause...virtually anything that affects women's health. PLEASE tell me where you are writing from as I am always interested.


I have been practicing as an Ob/Gyn and Infertility Specialist for over 23 years. Gynecology, advanced laparoscopic surgery, basic infertility, IUI's, IVF, reproductive surgery, and ovulation induction are all areas of my expertise. I am Board Certified. I have been doing In Vitro Fertilization in my clinic for 19 years.

American College of OB/GYN, American Board of Obstetrics and Gynecology, American Society of Reproductive Medicine, California Medical Association, American Association of Gynecologic Laparoscopists, Fellow of The American College of Obstetricians & Gynecologists

American Journal of Obstetrics and Gynecology, Wall Street Journal, Monterey Herald, SERMO, Women's Health and Fertility Blog

Medical Degree from Stanford University, Residency at Tripler Army Medical Center, Reproductive Training at Pacific Fertility Center, San Francisco

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