Ask Our Doctors – Archive
Our Medical Directors are outstanding physicians that you will find to be very personable and compassionate, who take care to ensure that you have the most cutting-edge fertility treatments at your disposal. This is your outlet to ask your questions to the doctors.
Could a parents medication use cause offsprings infertility?
I doubt it!
Geoff Sher
Dear doctor.,
we already had 7 IVF / ICSI procedures. The number of egg cells was always 10-12, but the embryos were only one, two or 0. The embryos were inserted on Day 3. Rcently I discovered an inherited hemochromatossis (accumulation of iron). Could this affect the quality of egg cells and embryonic embryos? All before the 8th ivf, I made 5 venipunctions and now the value of iron in the blood is normal. Is it possible that this is the cause of infertility and poor quality of cells? Can I expect a better result due to venipunctions?
Very humbling to answer.
Tanja
I doubt that the hemochromatosis is a likely factor here!
Whenever a patient fails to achieve a viable pregnancy following embryo transfer (ET), the first question asked is why! Was it simply due to, bad luck?, How likely is the failure to recur in future attempts and what can be done differently, to avoid it happening next time?.
It is an indisputable fact that any IVF procedure is at least as likely to fail as it is to succeed. Thus when it comes to outcome, luck is an undeniable factor. Notwithstanding, it is incumbent upon the treating physician to carefully consider and address the causes of IVF failure before proceeding to another attempt:
1.Age: The chance of a woman under 35Y of age having a baby per embryo transfer is about 35-40%. From there it declines progressively to under 5% by the time she reaches her mid-forties. This is largely due to declining chromosomal integrity of the eggs with advancing age…”a wear and tear effect” on eggs that are in the ovaries from birth.
2.Embryo Quality/”competency (capable of propagating a viable pregnancy)”. As stated, the woman’s age plays a big role in determining egg/embryo quality/”competency”. This having been said, aside from age the protocol used for controlled ovarian stimulation (COS) is the next most important factor. It is especially important when it comes to older women, and women with diminished ovarian reserve (DOR) where it becomes essential to be aggressive, and to customize and individualize the ovarian stimulation protocol.
We used to believe that the uterine environment is more beneficial to embryo development than is the incubator/petri dish and that accordingly, the earlier on in development that embryos are transferred to the uterus, the better. To achieve this goal, we used to select embryos for transfer based upon their day two or microscopic appearance (“grade”). But we have since learned that the further an embryo has advanced in its development, the more likely it is to be “competent” and that embryos failing to reach the expanded blastocyst stage within 5-6 days of being fertilized are almost invariably “incompetent” and are unworthy of being transferred. Moreover, the introduction into clinical practice about a decade ago, (by Levent Keskintepe PhD and myself) of Preimplantation Genetic Sampling (PGS), which assesses for the presence of all the embryos chromosomes (complete chromosomal karyotyping), provides another tool by which to select the most “competent” embryos for transfer. This methodology has selective benefit when it comes to older women, women with DOR, cases of unexplained repeated IVF failure and women who experience recurrent pregnancy loss (RPL).
3.The number of the embryos transferred: Most patients believe that the more embryos transferred the greater the chance of success. To some extent this might be true, but if the problem lies with the use of a suboptimal COS protocol, transferring more embryos at a time won’t improve the chance of success. Nor will the transfer of a greater number of embryos solve an underlying embryo implantation dysfunction (anatomical molecular or immunologic).Moreover, the transfer of multiple embryos, should they implant, can and all too often does result in triplets or greater (high order multiples) which increases the incidence of maternal pregnancy-induced complications and of premature delivery with its serious risks to the newborn. It is for this reason that I rarely recommend the transfer of more than 2 embryos at a time and am moving in the direction of advising single embryo transfers …especially when it comes to transferring embryos derived through the fertilization of eggs from young women.
4.Implantation Dysfunction (ID): Implantation dysfunction is a very common (often overlooked) cause of “unexplained” IVF failure. This is especially the case in young ovulating women who have normal ovarian reserve and have fertile partners. Failure to identify, typify, and address such issues is, in my opinion, an unfortunate and relatively common cause of repeated IVF failure in such women. Common sense dictates that if ultrasound guided embryo transfer is performed competently and yet repeated IVF attempts fail to propagate a viable pregnancy, implantation dysfunction must be seriously considered. Yet ID is probably the most overlooked factor. The most common causes of implantation dysfunction are:
a.A“ thin uterine lining”
b.A uterus with surface lesions in the cavity (polyps, fibroids, scar tissue)
c.Immunologic implantation dysfunction (IID)
d.Endocrine/molecular endometrial receptivity issues
Certain causes of infertility are repetitive and thus cannot readily be reversed. Examples include advanced age of the woman; severe male infertility; immunologic infertility associated with alloimmune implantation dysfunction (especially if it is a “complete DQ alpha genetic match between partners plus uterine natural killer cell activation (NKa).
I strongly recommend that you visit http://www.DrGeoffreySherIVF.com. Then go to my Blog and access the “search bar”. Type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.
•The IVF Journey: The importance of “Planning the Trip” Before Taking the Ride”
•Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation (COS)
•The Fundamental Requirements for Achieving Optimal IVF Success
•Use of GnRH Antagonists (Ganirelix/Cetrotide/Orgalutron) in IVF-Ovarian Stimulation Protocols.
•Ovarian Stimulation in Women Who have Diminished Ovarian Reserve (DOR): Introducing the Agonist/Antagonist Conversion protocol
•Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
•Human Growth Hormone Administration in IVF: Does it Enhances Egg/Embryo Quality and Outcome?
•The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
•Blastocyst Embryo Transfers should be the Standard of Care in IVF
•IVF: How Many Attempts should be considered before Stopping?
•“Unexplained” Infertility: Often a matter of the Diagnosis Being Overlooked!
•IVF Failure and Implantation Dysfunction:
•The Role of Immunologic Implantation Dysfunction (IID) & Infertility (IID): PART 1-Background
•Immunologic Implantation Dysfunction (IID) & Infertility (IID): PART 2- Making a Diagnosis
•Immunologic Dysfunction (IID) & Infertility (IID): PART 3-Treatment
•Thyroid autoantibodies and Immunologic Implantation Dysfunction (IID)
•Immunologic Implantation Dysfunction: Importance of Meticulous Evaluation and Strategic Management 🙁 Case Report)
•Intralipid and IVIG therapy: Understanding the Basis for its use in the Treatment of Immunologic Implantation Dysfunction (IID)
•Intralipid (IL) Administration in IVF: It’s Composition; how it Works; Administration; Side-effects; Reactions and Precautions
•Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
•Endometrial Thickness, Uterine Pathology and Immunologic Factors
•Vaginally Administered Viagra is Often a Highly Effective Treatment to Help Thicken a Thin Uterine Lining
•Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
•A personalized, stepwise approach to IVF
•How Many Embryos should be transferred: A Critical Decision in IVF?
•The Role of Nutritional Supplements in Preparing for IVF
If you are interested in seeking my advice or services, I urge you to contact my concierge, Julie Dahan ASAP to set up a Skype or an in-person consultation with me. You can also contact Julie by phone or via email at 702-533-2691/ Julied@sherivf.com You can also apply online at http://www.SherIVF.com .
*FYI
The 4th edition of my newest book ,”In Vitro Fertilization, the ART of Making Babies” is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoffrey Sher MD
Hi Dr Sher
Last year (at 36 years of age) I did my 1st IVF cycle where I retrieved 8 eggs, 5 fertilised through ICSI, of which 3 embryos grew to Day 5 and were frozen. The blastocyst quality was 2 good, 1 above average. Sadly that cycle ended in failure where 1 good blastocyst was transferred and implanted but miscarried naturally at 5 weeks (slow heartbeat). The remainder 2 blastocysts were transfered together but did not implant at all. My doctor and I were disappointed. I have no problems except a 1cm polyp, and my husband has teratozoospermia.
This year (37 years of age) I just finished my 2nd IVF cycle retrieving 17 eggs, 13 fertilised through ICSI, of which 7 embryos grew to Day 5 and were frozen. The blastocyst quality was 2 good, 3 above average, and 2 average quality.
Since the frozen transfer of 2 embryos last year failed, I am concerned about implanation, but my doctor doesn’t think that’s a problem for me since one blastocyst implanted last year. My doctor also does not believe in Intralipid treatment. In my country (Singapore), genetic screening for embryos is not legal and can’t be done. So my doctor recommended to (1) remove my 1cm polyp, (2) do an endometrium scratch in April. Then do frozen embryo transfer (the 2 good quality embryos) in May.
I have some questions please
– are there side-effects or dangers associated with Intralipid?
– in you opinion does endometrial scratch work?
– what can I do to increase the chances of implantation this time?
– Is it possible to ‘ship’ frozen embryos abroad (say to the U.S) for genetic screening. But the embryos have to be defrosted rite, then frozen again??? What happens.
Thank you Dr Sher. I’ve been reading your forum every day and its insightful, helpful, and I somehow feel less alone after seeing all the other posts from other people also struggling with infertility. I bought your book ‘IVF the ART of Making Babies’ through Amazon Kindle too and its great, very informative and reasonably priced at USD10 only!
1. are there side-effects or dangers associated with Intralipid?
A: The risk of complications and side effects are in my opinion, minimal.
There is an ever growing realization, recognition, and acceptance of the fact that uterine immunologic dysfunction can lead to immunologic implantation dysfunction (IID) with “unexplained” infertility, IVF failure, and recurrent pregnancy loss (RPL). Although there are many factors that contribute to such implantation dysfunction, in the final analysis it is activated, “functional” uterine natural killer cells (NKa) in association with cytotoxic-T cells (CTL), which, through the production of cytotoxic cytokines (see below), damage the “root system” (trophoblast) of the embryo, causing the pregnancy either to be immediately rejected or so compromising placentation that early pregnancy loss occurs. Both immunoglobulin-G (IVIG) and intralipid (IL) therapy given in combination with corticosteroids (e.g. dexamethasone, prednisone, and prednisolone) are used to effectively reduce/down-regulate activated NK cells.
NK cells reach the uterus from the woman’s bone marrow, early in the menstrual cycle, as so called “parental” or “progenitor” cells. There, these early NK cells proliferate under the effect of estrogen. Only upon being exposed to progesterone do they begin to propagate “functional” NK cells that release cytokines and promote implantation. The concentration of functional NK cells in the endometrium is maximal about 7 days after exposure to natural(endogenous), or synthetic (exogenous) progesterone ….i.e. corresponding to the time the time when the embryo implants into the uterine lining (endometrium).
Functional uterine natural killer (NK) cells as well as T-helper cells are immune cells that frequent the uterine lining. They produce growth factors known as cytokines that regulate orderly implantation of the embryo and facilitate placentation (development of a functional placenta, the baby’s life line).There are two varieties of uterine cytokines: a) TH-2 (humoral) cytokines that promote permeation of the uterine wall by the embryo’s trophoblast (“root system and, b) TH-1 (cellular) cytokines that oppose trophoblastic proliferation and permeation of the uterine wall by culling interstitial trophoblastic cells. Orderly implantation and formation of a functional placenta (lifeline of the baby) requires that TH-1 and TH2 activity be in equilibrium There are two categories of immunologic implantation dysfunction (IID) linked to NK cell activation (NKa).
•Autoimmune IID: Here, there is often a personal or family history of autoimmune conditions such as Rheumatoid arthritis, Lupus Erythematosus, and thyroid autoimmune activity (e.g. Hashimoto’s hypothyroidism) etc. Autoimmune IID also occurs in about one third of cases of endometriosis, regardless of severity.
•Alloimmune IID: Here uterine NK cell activation results from uterine exposure to an embryo derived through fertilization of an egg by a spermatozoon which shares certain genetic (HLA/DQ alpha)characteristics with that of the mother or embryo recipient.
In both autoimmune and alloimmune IID, the end point is an excessive NKa/CTL, TH-1 release that damages the embryos trophoblast, resulting in failed implantation or early pregnancy loss.
It is important to bear in mind that measurement of the concentration of blood NK cells has little or no relevance when it comes to assessing NK cell activation (NKa). Rather, it is the degree of NK cell activation (cytotoxicity) that matters. In fact, there are certain conditions (such as with endometriosis) in which the NK cell blood concentration is normal or well below normal and NK cell activation is markedly increased.
There are several methods by which NK cell activation (cytotoxicity) can be assessed in the laboratory. Methods such as immunohistochemical assessment of uterine NK cells and/or TH-1 and TH-2 cytokines have been used with some success. However, use of the K-562 target cell test remains the gold standard. With this test, NK cells are isolated from the woman’s blood using Flow Cytometry and are incubated in the presence of specific “target cells”. These are then incubated together. The percentage (%) of “target cells” killed through exposure to NKa/CTL-TH1 cytokines is then quantified.
Currently, there are less than a half dozen Reproductive Immunology Reference Laboratories in the U.S.A that are capable of performing the K-562 target cell test reliably. I have for 20 + years been working with Reproductive Immunology Associates (RIA) in Van Nuys, CA and preferentially recommend them to my patients.
There exists a pervasive but blatant misconception on the part of many, that the addition of IL/IVIG can have an immediate down-regulatory effect on NK cell activity. This has established a demand that Reproductive Immunology Reference Laboratories report on NK cell activity before and following exposure to IVIG and/or IL. However, the fact is that activated “functional” NK cells (NKa) cannot be deactivated in the laboratory. Effective down-regulation of activated NK cells can only be adequately accomplished if their activated “progenitor/parental” NK cells are first down-regulated. Thereupon once these down-regulated “precursor” NK cells are exposed to progesterone, they will begin spawning normal and functional NK cells, which takes about 10-14 days. It follows that to assess for a therapeutic response to IVIG/IL therapy would require that the patient first be treated (10-14 days prior to embryo transfer) and thereupon, about 2 weeks later, be retested. While at 1st glance this might seem to be a reasonable approach, in reality it would be of little clinical benefit because even if blood were to be drawn 10 -14 days after IL/IVIG treatment it would require an additional 10 days to receive results from the laboratory, by which time it would be far too late to be of practical advantage.
Neither IVIG nor IL is capable of significantly suppressing already activated “functional NK cells”. For this to happen, the IL/IVIG would have to down-regulate progenitor (parent) NK cell” activity. Thus, it should be infused several days prior to ovulation or progesterone administration so that the down-regulated “progenitor/precursor” NK cells” can propagate a sufficient number of normally regulated “functional NK cell” to be present at the implantation site 7 days later.
It is very regrettable that so many patients are being denied the ability to go from “infertility to family” simply because (for whatever reason) so many reproductive specialists refuse to embrace the role of immunologic factors in the genesis of intractable reproductive dysfunction. Hopefully this will change, and the sooner the better.
It is in my opinion highly arrogant to discount treatments such as IL/steroids for NK cell activation (by the K-562 target cell test or uterine biopsy for TH-1 cytokines) that have helped thousands have babies when all else has failed. Perhaps you should ask your RE to explain the basis of immunologic implantation dysfunction and how IL/steroid therapy workss…I’d bet that he/she cannot!.
2. in you opinion does endometrial scratch work?
A: Unlikely to benefit.
2.what can I do to increase the chances of implantation this time?
A: Get tested for IID and have the polyp removed…then only if an IID can be confirmed go elsewhere (if need be abroad) and get the appropriate immunotherapy and consider having PGS done as well.
4. Is it possible to ‘ship’ frozen embryos abroad (say to the U.S) for genetic screening.
A: Yes. The biopsies are done at home and frozen while the DNA sent abroad for PGS testing. However while pregnancies can occur, it is in my opinion very traumatic on the embryos to thaw frozen embryos only to thaw them for biopsy, and then re-freeze them while you await results , only to have to thaw them again for FET.
TREATMENT AFAR:
There is an ever growing realization, recognition, and acceptance of the fact that uterine immunologic dysfunction can lead to immunologic implantation dysfunction (IID) with “unexplained” infertility, IVF failure, and recurrent pregnancy loss (RPL). Although there are many factors that contribute to such implantation dysfunction, in the final analysis it is activated, “functional” uterine natural killer cells (NKa) in association with cytotoxic-T cells (CTL), which, through the production of cytotoxic cytokines (see below), damage the “root system” (trophoblast) of the embryo, causing the pregnancy either to be immediately rejected or so compromising placentation that early pregnancy loss occurs. Both immunoglobulin-G (IVIG) and intralipid (IL) therapy given in combination with corticosteroids (e.g. dexamethasone, prednisone, and prednisolone) are used to effectively reduce/down-regulate activated NK cells.
NK cells reach the uterus from the woman’s bone marrow, early in the menstrual cycle, as so called “parental” or “progenitor” cells. There, these early NK cells proliferate under the effect of estrogen. Only upon being exposed to progesterone do they begin to propagate “functional” NK cells that release cytokines and promote implantation. The concentration of functional NK cells in the endometrium is maximal about 7 days after exposure to natural(endogenous), or synthetic (exogenous) progesterone ….i.e. corresponding to the time the time when the embryo implants into the uterine lining (endometrium).
Functional uterine natural killer (NK) cells as well as T-helper cells are immune cells that frequent the uterine lining. They produce growth factors known as cytokines that regulate orderly implantation of the embryo and facilitate placentation (development of a functional placenta, the baby’s life line).There are two varieties of uterine cytokines: a) TH-2 (humoral) cytokines that promote permeation of the uterine wall by the embryo’s trophoblast (“root system and, b) TH-1 (cellular) cytokines that oppose trophoblastic proliferation and permeation of the uterine wall by culling interstitial trophoblastic cells. Orderly implantation and formation of a functional placenta (lifeline of the baby) requires that TH-1 and TH2 activity be in equilibrium
There are two categories of immunologic implantation dysfunction (IID) linked to NK cell activation (NKa).
•Autoimmune IID. Here, there is often a personal or family history of autoimmune conditions such as Rheumatoid arthritis, Lupus Erythematosus, and thyroid autoimmune activity (e.g. Hashimoto’s hypothyroidism) etc. Autoimmune IID also occurs in about one third of cases of endometriosis, regardless of severity.
•Alloimmune IID. Here uterine NK cell activation results from uterine exposure to an embryo derived through fertilization of an egg by a spermatozoon which shares certain genetic (HLA/DQ alpha)characteristics with that of the mother or embryo recipient.
In both autoimmune and alloimmune IID, the end point is an excessive NKa/CTL, TH-1 release that damages the embryos trophoblast, resulting in failed implantation or early pregnancy loss.
It is important to bear in mind that measurement of the concentration of blood NK cells has little or no relevance when it comes to assessing NK cell activation (NKa). Rather, it is the degree of NK cell activation (cytotoxicity) that matters. In fact, there are certain conditions (such as with endometriosis) in which the NK cell blood concentration is normal or well below normal and NK cell activation is markedly increased.
There are several methods by which NK cell activation (cytotoxicity) can be assessed in the laboratory. Methods such as immunohistochemical assessment of uterine NK cells and/or TH-1 and TH-2 cytokines have been used with some success. However, use of the K-562 target cell test remains the gold standard. With this test, NK cells are isolated from the woman’s blood using Flow Cytometry and are incubated in the presence of specific “target cells”. These are then incubated together. The percentage (%) of “target cells” killed through exposure to NKa/CTL-TH1 cytokines is then quantified.
Currently, there are less than a half dozen Reproductive Immunology Reference Laboratories in the U.S.A that are capable of performing the K-562 target cell test reliably. I have for 20 + years been working with Reproductive Immunology Associates (RIA) in Van Nuys, CA and preferentially recommend them to my patients.
There exists a pervasive but blatant misconception on the part of many, that the addition of IL/IVIG can have an immediate down-regulatory effect on NK cell activity. This has established a demand that Reproductive Immunology Reference Laboratories report on NK cell activity before and following exposure to IVIG and/or IL. However, the fact is that activated “functional” NK cells (NKa) cannot be deactivated in the laboratory. Effective down-regulation of activated NK cells can only be adequately accomplished if their activated “progenitor/parental” NK cells are first down-regulated. Thereupon once these down-regulated “precursor” NK cells are exposed to progesterone, they will begin spawning normal and functional NK cells, which takes about 10-14 days. It follows that to assess for a therapeutic response to IVIG/IL therapy would require that the patient first be treated (10-14 days prior to embryo transfer) and thereupon, about 2 weeks later, be retested. While at 1st glance this might seem to be a reasonable approach, in reality it would be of little clinical benefit because even if blood were to be drawn 10 -14 days after IL/IVIG treatment it would require an additional 10 days to receive results from the laboratory, by which time it would be far too late to be of practical advantage.
Neither IVIG nor IL is capable of significantly suppressing already activated “functional NK cells”. For this to happen, the IL/IVIG would have to down-regulate progenitor (parent) NK cell” activity. Thus, it should be infused several days prior to ovulation or progesterone administration so that the down-regulated “progenitor/precursor” NK cells” can propagate a sufficient number of normally regulated “functional NK cell” to be present at the implantation site 7 days later.
It is very regrettable that so many patients are being denied the ability to go from “infertility to family” simply because (for whatever reason) so many reproductive specialists refuse to embrace the role of immunologic factors in the genesis of intractable reproductive dysfunction. Hopefully this will change, and the sooner the better.
I strongly recommend that you visit http://www.DrGeoffreySherIVF.com. Then go to my Blog and access the “search bar”. Type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.
•The IVF Journey: The importance of “Planning the Trip” Before Taking the Ride”
•Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•The Fundamental Requirements For Achieving Optimal IVF Success
•Use of GnRH Antagonists (Ganirelix/Cetrotide/Orgalutron) in IVF-Ovarian Stimulation Protocols.
•Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
•Frozen Embryo Transfer (FET): A Rational Approach to Hormonal Preparation and How new Methodology is Impacting IVF.
•Staggered IVF
•Preimplantation Genetic Testing (PGS) in IVF: It should be Used Selectively and NOT be Routine.
•IVF: Selecting the Best Quality Embryos to Transfer
•Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
•PGS in IVF: Are Some Chromosomally abnormal Embryos Capable of Resulting in Normal Babies and Being Wrongly Discarded?
•PGS and Assessment of Egg/Embryo “competency”: How Method, Timing and Methodology Could Affect Reliability
•IVF: The first Choice for Infertile Women 40 to 43 Years of Age!
•IVF Failure and Implantation Dysfunction:
•The Role of Immunologic Implantation Dysfunction (IID) & Infertility (IID):PART 1-Background
•Immunologic Implantation Dysfunction (IID) & Infertility (IID):PART 2- Making a Diagnosis
•Immunologic Dysfunction (IID) & Infertility (IID):PART 3-Treatment
•Thyroid autoantibodies and Immunologic Implantation Dysfunction (IID)
•Immunologic Implantation Dysfunction: Importance of Meticulous Evaluation and Strategic Management:(Case Report
•Intralipid and IVIG therapy: Understanding the Basis for its use in the Treatment of Immunologic Implantation Dysfunction (IID)
•Intralipid (IL) Administration in IVF: It’s Composition; How it Works; Administration; Side-effects; Reactions and Precautions
•Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
•Endometrial Thickness, Uterine Pathology and Immunologic Factors
•Vaginally Administered Viagra is Often a Highly Effective Treatment to Help Thicken a Thin Uterine Lining
•A Thin Uterine Lining: Vaginal Viagra is Often the Answer (update)
•Cervical Ureaplasma Urealyticum Infection: How can it Affect IUI/IVF Outcome?
•Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas
•Should IVF Treatment Cycles be provided uninterrupted or be Conducted in 7-12 Pre-scheduled “Batches” per Year
•A personalized, stepwise approach to IVF
•The Role of Nutritional Supplements in Preparing for IVF
•Why did my IVF fail?
If you are interested in my advice or medical services, I urge you to contact my concierge, Julie Dahan ASAP to set up a Skype or an in-person consultation with me. You can also contact Julie by phone or via email at 702-533-2691/ Julied@sherivf.com. You can also apply online at http://www.SherIVF.com.
Also, my book, “In Vitro Fertilization, the ART of Making Babies” is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoffrey Sher MD
Dr. Sher, My wife & I have just gone through 1 unsuccessful IVF cycle. We consulted with a reproductive specialist and he suggested a sperm SDFI test. The result came back showing a DNA fragmentation of 41% and higher than normal oxidation stress level (here I need to tell you that my unwashed sperm was frozen before I had a radical prostatectomy in 2015). This reproductive specialist also sent me see a urologist for a possible TESE procedure. I did go to see him, and he prescribed a Clomid therapy for 1 month; he also tentatively scheduled a TESE surgery for April 23, 2018. My question is: how does all of this sound to you? How effective is the Clomid treatment in improving the DNA fragmentation in sperm? Is 1 month worth of Clomid treatment enough?
Thank you much for your response
Hi Leonid,
Very respectfully, In my opinion, TESE-ICSI is only needed if you are not ejaculating any sperm and if you have a normal FSH/LH, clomiphene is in my opinion also highly unlikely to enhance sperm “competency” or improve the DFI. The more likely explanation for embryo quality deficit lies in egg “competency”/quality issues that are probably linked to the protocol used for ovarian stimulation
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”.
I would favor 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 you get consider Staggered IVF (see below) with preimplantation Genetic Screening/PGS (next generation gene sequencing/NGS)-to obtain “chromosomally competent” blastocysts for subsequent selective transfer. In my opinion, such an approach could significantly enhance the opportunity for you to achieve a viable pregnancy
Please visit my new Blog on this very site, https://www.drgeoffreysherivf.com, find the “search bar” and type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.
• Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
• IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
• The Fundamental Requirements For Achieving Optimal IVF Success
• Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the “Conventional” Antagonist Approach
• Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
• The “Biological Clock” and how it should Influence the Selection and Design of Ovarian Stimulation Protocols for IVF.
• A Rational Basis for selecting Controlled Ovarian Stimulation (COS) protocols in women with Diminished Ovarian Reserve (DOR)
• Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
• Controlled Ovarian Stimulation (COS) in Older women and Women who have Diminished Ovarian Reserve (DOR): A Rational Basis for Selecting a Stimulation Protocol
• Human Growth Hormone Administration in IVF: Does it Enhances Egg/Embryo Quality and Outcome?
• The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
• Blastocyst Embryo Transfers should be the Standard of Care in IVF
• Frozen Embryo Transfer (FET) versus “Fresh” ET: How to Make the Decision
• Frozen Embryo Transfer (FET): A Rational Approach to Hormonal Preparation and How new Methodology is Impacting IVF.
• Staggered IVF
• Preimplantation Genetic Testing (PGS) in IVF: It should be Used Selectively and NOT be Routine.
• Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
• PGS in IVF: Are Some Chromosomally Abnormal Embryos Capable of Resulting in Normal Babies and Being Wrongly Discarded?
• PGS and Assessment of Egg/Embryo “competency”: How Method, Timing and Methodology Could Affect Reliability
• Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
• Traveling for IVF from Out of State/Country–
• A personalized, stepwise approach to IVF
• How Many Embryos should be transferred: A Critical Decision in IVF.
• The Role of Nutritional Supplements in Preparing for IVF
• Premature Luteinization (“the premature LH surge): Why it happens and how it can be prevented.
If you are interested in seeking my advice or services, I urge you to contact my concierge, Julie Dahan ASAP to set up a Skype or an in-person consultation with me. You can also contact Julie by phone or via email at 702-533-2691/ Julied@sherivf.com You can also apply online at http://www.SherIVF.com .
*FYI
The 4th edition of my newest book ,”In Vitro Fertilization, the ART of Making Babies” is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoffrey Sher MD
I had twice unexplained IVF unsuccess last year. I am interested in your block about autoimmune effecting implantation, if it is relating to my situation. I am thinking to seek your help with the diagnose and treatment. Since I live in DC and you are in NV, what’s choice I have? Do you have any suggestion, if you have any center around D.C. Area or any other center that can perform the same treatment? Or any other suggestion to my limit knowledge. Thanks
For more than three decades, about 70% of the patients that I have performed IVF on, have journeyed to see me from out state or out of country. Over the years, I have been repeatedly asked how, given the distance separates us from our patients, we are able to provide optimal, efficient, and congenial services. This blog represents an attempt to describe how we accomplish this. It will outline the processes involved, and explain how the system we have put in place allows us to fully prepare and triage our patients at a distance, receive them in Las Vegas, monitor and treat them here, discharge them back to their home environments and then follow up with them through the diagnosis of pregnancy and post-IVF treatment (often with the welcomed and invited participation of their local primary physicians). It will also spell out how we are able to provide full and ready access to me and my team constantly, and finally, it will emphasize that the core of our success is routed in a commitment to being as accessible and affable as possible, at all times. In truth treating patients from afar is really not more complicated than is treating local patients. I am quite confident that if you were to ask those that have gone through the process, most, if not all, would tell you that we are well organized, seasoned in what we do and that the entire process is comfortable, easy and seamless.
Arranging for a Skype Consultation with me: Patients largely hear of Sher-IVF through word of mouth coming from the many thousands of women I have assisted in having babies over the years. Others reach Sher-IVF through Physician referrals, access to books and articles I have written on IVF and related topics, media and internet exposure or through personal online research by way of search engines. They then contact my wonderful “patient concierge”, Julie Dahan to set up a Skype consultation, either directly by calling 702-533-2691 or by email at julied@sherivf.com. Others access us by going to the Sher-IVF website at http://www.sherivf.com and making an online appointment for a Skype consultation with me that way. Regardless of how we are contacted, be assured that Julie (or her designee) will respond promptly to any such requests.
The Initial Consultation and the Report: During the initial consultation we discuss the medical and reproductive history in detail and I recommend additional testing necessary to identify the exact cause of the infertility and define an optimal approach to solving the problem. I thereupon promptly dispatch a comprehensive report by email along with a list of recommended reading of relevant articles to be found on my blog (to be found on http://www.sherivf.com).
Follow-up Administrative consultation: One or two working days later, patients receive a call from us to set up a date for a 1 hour phone consultation with our Practice Administrator, Sharon Jochman on the relevant logistical and financial considerations relating to IVF treatment with me. Thereupon, she will forward email information on such issues to patients for their review. At this point, no financial commitment to undergo treatment with me is requested or required. However, Sharon will place the patient (s) name on a tentative list for treatment in an upcoming IVF cycle batch (see below) and as that cycle draws near, she will contact the patient/couple to determine whether they wish to proceed with treatment, defer or cancel. This process protects the patient/couple from losing a chosen spot in the upcoming IVF cycle.This is because, unless in spite of best effort to contact them they are unreachable, or they expressly indicate a change of heart and wish to defer to a later cycle batch or opt out of the program, they will not lose their spot in their selected cycle of treatment. Then, subject to an expressed interest to proceed, the patient/couple would, for the 1st time, be required to make a financial commitment.
Consultation with a Nurse Coordinator: The nurse coordinator prepares patients for a cycle of treatment with me. She will discuss all the recommended testing and medical visits necessary.
Follow-up Consultation with me: Once the initial Clinical Coordinator consultation is completed and the requested tests and preparatory investigations have been done, the patient/couple has a wrap-up Skype or telephone consultation with me patients to discuss results advise and to finalize the protocol necessary for ovarian stimulation and fine tune the complete strategy for treatment.
The Nurse Coordinator Develops a Color-coded Calendar for the Upcoming IVF Cycle: At this point, the Nurse Coordinator generates an individualized and detailed color-coded electronic calendar that lays out the precise protocol that will be implemented. It starts with the use of a birth control pill, to be overlapped (for a few days) with a GnRH agonist (Lupron/Buserelin/Superfact), followed by all necessary medications involved in the process of preparation. She will go over the entire process and answer questions. A standard consent form will be forwarded to the patient/couple for their review and they will be invited to ask any questions on issues that are unclear. Thereupon consent form must be signed before we can proceed to treatment.
Access to us Throughout the Process: I provide all my patients with my cell phone number and encourage them to contact me with any medical issues at any time. They are informed that if they call and I am not immediately available, to leave their name and phone number on my voice mail and I will respond. Patients are also provided with Julie’s cell phone number and are invited to call her on any non-medical issue. Julie does an outstanding job of assisting patients with scheduling appointments with our staff and for testing, both locally and afar. She will also gladly assist and advise on travel/accommodation/and transportation to and from our office. I am told that rapidly Julie creeps into the hearts of my patients who rapidly bond with her and feel comfortable reaching out to her for advice and comforting.
How long will Patients Need to Spend in Las Vegas for Treatment? For fresh IVF cycles with embryo transfer the female partner needs to plan on being in las Vegas for up to 2 weeks here. While male partners are encouraged to spend as much time with their partners in Las Vegas as possible, they are really only required to be here on the day of egg retrieval (and we can provide them with a 3-4-day advance notification of that day). Actually, if the man is perfectly fertile, he does not even need to come to Las Vegas at all. Instead we could arrange for a specimen of his frozen sperm to be delivered to the clinic. This will not prejudice IVF results in any way. In cases where we do frozen embryo transfers (FET), it is not imperative that the male be present at all. However, we do encourage the male partner to be here with his partner to provide emotional support wherever possible. In cases of embryo recipient cycles (egg donation/embryo adoption/gestational surrogacy and FET the woman is needed to be present in Las Vegas for about 7-9 days. Those times can be calendared a few months in advance. In cases involving FET, the male partner is really not needed onsite at all, although his presence is encouraged for the purpose of providing his partner with the support she needs. In cases of Staggered IVF which involves preimplantation genetic sampling (PGS) of embryos for chromosomal selection, the embryo transfer is deferred to a later cycle to allow for genetic testing to be completed. This means that the woman is only required to be present onsite with us for about 7 days. The day following the ET, both she and her partner can return home. We stay in touch with them regarding embryo development and planning for the future.
Follow-up at home: The day after embryo transfer (or following egg retrieval in cases where all eggs or embryos are frozen and no ET is contemplated in the same cycle), the woman and her partner (as applicable) can return home to be followed at a distance by us and/or locally by their own primary care physician who (under our oversite) will conduct pregnancy testing and subsequent gynecologic services and when applicable, prenatal care.
IVF Cycle Batches and how use of the Birth Control Pill Facilitates this: At Sher-IVF, we perform IVF cycles in 9-10 two, week “batches per year. This means that a number of patients arrive together at a predetermined date for treatment. These batches are prescheduled to start on set dates that are calendared for an entire year in advance. This enables patients to make travel and accommodation arrangements well in advance. In order to effect this, patients who are to be treated in a particular batch need to start their cycles (onset of menstruation) on or around the same date. To synchronize their cycles, we place each woman on a birth control pill (BCP) to lead into the cycle of stimulation. By shortening or lengthening the time on the BCP, we can ensure that menstrual bleeding starts at the required time to coincide with the start of a given cycle batch. Contrary to the erroneous belief that the BCP suppresses response to gonadotropin therapy, provided that in the last few days of using the BCP, it is overlapped with a GnRH agonist (e.g. Lupron, Superfact, Buserelin), this approach actually improves response to ovarian stimulation.
Following the launching an ovarian stimulation cycle on a BCP and the subsequent addition of a GnRH-agonist the woman will have a bleed. At this point she will be required to have a baseline ultrasound assessment and have blood drawn for measurement of estradiol (E2). If she is from out of town, this will have to be done by her primary OB/GYN. Provide that the ultrasound does not detect an ovarian cyst and her estradiol level is <70pg/ml), she will be eligible to start taking gonadotropins for ovarian stimulation under our oversight. . We will by this time have schooled her and partner in administering the shots…so this should not present a problem. Thereupon she will need to arrange to arrive in Las Vegas for me to begin monitoring her response, 7-8 days after commencing ovarian stimulation. It is unusual (and even inadvisable) for a woman undergoing controlled ovarian stimulation (COS) for IVF to be ready for triggering with hCG prior to the 8th day of stimulation so her arrival should be timely and not be too late..
The process of treating patients who journey to Sher-IVF in Las Vegas from afar, might at first glance seem somewhat complex, but it really is not. I have, over the last 3 decades, developed a system that is very easy, convenient, safe, seamless, uncomplicated and highly effective. The vast majority of the seventy percent (70%) of my IVF patients who journey from out of state and from abroad for treatment with us in Las Vegas would attest to this. In fact, many of my patients who underwent IVF in their own environments before coming to Las Vegas have commented on our availability and accessibility, in spite of the distance separating us.
If you are interested in my advice or medical services, I urge you to contact my concierge, Julie Dahan ASAP to set up a Skype or an in-person consultation with me. You can also contact Julie by phone or via email at 702-533-2691/ Julied@sherivf.com. You can also apply online at http://www.SherIVF.com.
Also, my book, “In Vitro Fertilization, the ART of Making Babies” is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoffrey Sher MD