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.
Dr. Sher:
What do you think about tamoxifen for poor responders and low amh? I have 0.8pmol amh and not responding well to stimming. Would this medicine help?
I think it is a poor option…especially for women with DOR.
We should talk. Please call Julie Dahan and set up a Skype consultation with me to discuss your case in detail.
Geoff Sher
We have done three IUIs and three IVFS, none resulted in pregnancy despite high ratings with the embryos. We then became pregnant in our own which ended at 6 weeks. We switched to donor eggs and became pregnant with the first transfer. We saw the heartbeat at 6 weeks but lost the heartbeat st 7 weeks and 3 days. I had a D&C and sent the pregnancy tissue for testing which was normal. I have a history of hypothyroidism. What testing or recommendations do you suggest?
Thank you,
Jackie
This sounds like an implantation dysfunction to me.
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 .
*The 4th edition of 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
Hi Dr. Sher,
My wife and I recently finished our first round of reciprocal IVF and one failed single embryo transfer (her eggs, my uterus). IVF was purely elective in the sense that we had no known fertility issues; I am 33, my wife is 34, and neither of us has DOR or other known problems. We have one remaining 5-day blast (4AB, no PGS performed) but its (oo)genesis is quite unusual and we’d like your expert opinion on the advisability of transferring it before moving on to a second round of IVF. 15 eggs were retrieved but to everyone’s surprise 11 were GVs; 4 M2s; no M1s (to the extent you can weigh in on possible causes for the high number of GVs please do…we have yet to receive any explanations and are greatly frustrated!). My wife’s hormone levels and follicle sizes leading up to the retrieval were “textbook” according to our RE. After retrieval, the embryologist left all fifteen denuded eggs in culture until the time of ICSI. When she went to perform ICSI, exactly five hours after the retrieval, she noted that three GVs had matured to M1s. She believes this is the first time this has happened in her 30 years at the lab. It is the lab’s policy to inject morphologically normal M1s when a patient has <6 M2s so they injected the three. The next day, two of the injected M1s were 2PN. One of those survived to day 5 and is now our remaining frozen blast (the failed FET was from one of the 4 M2s). The embryologist says she's certain this is the first time in 30 years a retrieved GV has resulted in a 5-day blast.
Do you have any hope for this embryo? Are the chances so low as to not warrant an FET? Have you ever heard of a GV resulting in an M1 capable of proper fertilization by the time of ICSI? Does the very high proportion of GVs tell you anything about the potential competence of this embryo? We are desperate for your expert advise!
Thank you very much.
Shayla
In my opinion, this sounds like a stimulation issue. The protocol used needs to be carefully reviewed. In the meanwhile, I definitely would transfer the 1 blastocyst first.
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 .
*The 4th edition of 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
Hey Dr, Sher, hoping to pick your brain with a couple questions:
1) Do you think there’s credence to the research suggesting that HCG levels (the absolute number) in early pregnancy might be a predictor for full-term pregnancy (and for miscarriage?). I’ve read some studies looking at hcg levels at 16dpo and suggesting a threshold for where if the number is over (I think it’s like 200 or 300?) you have a 95% confidence of a viable pregnancy. Would love to hear your thoughts on whether high early hcg suggests strong pregnancy. (I’ve read your article on the subject, just interested in your thoughts on this research).
2) If a miscarriage occurs after a heartbeat is heard and after say 7-8 weeks, is it more likely to be due to structural abnormalities or inadequate hormonal levels rather than chromosomal factors? Or do both still apply?
1) Do you think there’s credence to the research suggesting that HCG levels (the absolute number) in early pregnancy might be a predictor for full-term pregnancy (and for miscarriage?). I’ve read some studies looking at hcg levels at 16dpo and suggesting a threshold for where if the number is over (I think it’s like 200 or 300?) you have a 95% confidence of a viable pregnancy. Would love to hear your thoughts on whether high early hcg suggests strong pregnancy. (I’ve read your article on the subject, just interested in your thoughts on this research).
A: No I do not. However, the rate of rise in early hCG levels is a predictor of likely healthy implantation
2) If a miscarriage occurs after a heartbeat is heard and after say 7-8 weeks, is it more likely to be due to structural abnormalities or inadequate hormonal levels rather than chromosomal factors? Or do both still apply?
A: Most miscarriages are due to abnormal embryos (usually chromosomal aneuploidies) however an implantation dysfunction (often immunologic) can also result in miscarriage.
Good luck!
Geoff Sher
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please dr what is the meaning of , progesterone concentration suggests that ovulation occurred at a point in index cycle.
The presence of elevated progesterone suggests the likelihood that ovulation has occurred at a certain point.
Geoff Sher