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.
I’m hoping to get some advice on what I should do next re IVF treatment.
I have a 4.5 year old daughter conceived naturally after 3 years of
trying. During that time I suffered an ectopic and chemical
miscarriage. Non-eventful pregnancy and delivered at 42 weeks via
C-section due to lack of dilation after being induced.
After two years we started trying again but 6 months later, nothing. Aged 37 our Dr didn’t want to waste time and suggested help so we did a few cycles of clomid and IUI then tried a round of IVF in
October 2014. Husband had sperm tested as part of IUI and could single-handedly populate the world based on his results, I had low/average AMH for my age.
I didn’t respond that well to stimulation and out of 10 follicles only got three eggs. All three fertilised. They transferred two on daythree and watched the third but didn’t think it was good enough to freeze. We ended up pregnant with triplets but lost them at 20 weeks in March 2015 – the twin boys were momo and one passed away causing early labour. The babies were tested after delivery and they were
perfect just too little.
In October 2015 we did another round of IVF, I responded much better
(I also insisted on a double trigger after reading your blog) and had 9 follicles, 7 eggs, 5 fertilised and all 5 made it to blastocyst. We transferred one perfect blastocyst (after what happened last year) but it was negative. We tried again with a frozen medicated cycle the next month and ended up pregnant but the 7-week scan showed a blighted ovum the week before Christmas. We’ve just tried a perfectly timed natural cycle and they too looks like a chemical or blighted ovum.
I have two frozen blasts left – 1 good quality and the other was one day late reaching blastocyst.
I’m wondering whether 1) it’s worth getting them genetically tested before having any other transferred 2) should I do another
fresh round and have all eggs tested before freezing or 3) carry on with the two we have and hope for the best and if they don’t work do another fresh round and have them tested or don’t bother testing at my
age and previous pregnancies.
Any advice would be greatly received.
I do not think it is wise thawing the embrys to re-biopsy them for PGS, only to refreeze while waiting for PGS results and then having to re-thaw for transfer. It is in my opinion too stressful on the embryos. The question regarding whether or not to go through another fresh cycle and do PGS then is a personal one. In my opinion you should probably first do an FET with the two frozen embryos you have, ASAP and if no pregnancy, then do another fresh cycle with PGS testing. The final issue is that with a mid-trimester loss of your triplet pregnancy the possibility that you might have cervical incompetence should be considered so that when you do again conceive your cervical length can be watched ultrasonographically and a stitch (cerclage) put in place after 12 weeks should the cervix start shortening .
I strongly recommend that you visit my NEW blog on this site. When you get there, go to 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
•Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the “Conventional” Antagonist Aproach
•Ovarian Stimulation for IVF: Comparing “conventional” use of GnRH antagonists to the Agonist/Antagonist Conversion Protocol (A/ACP)
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•The “Biological Clock” and How it Should Influence the Selection and Design of Ovarian Stimulation Protocols for IVF.
•Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
•Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
•Frozen Embryo Transfer (FET): What Does it Involve?
•Hereditary Clotting Defects (Thrombophilia)
•Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
•PGS-Biopsy for the Assessment of Embryo Numerical Chromosomal integrity (Ploidy): Should it be done on Day 3 or on Day 5-6 post fertilization?
•Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
•Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
•IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
•The Role of Nutritional Supplements in Preparing for IVF
I invite you to call 702-699-7437 or 800-780-7437 and set up an one hour Skype consultation with me to discuss your case in detail.
I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoff Sher
Dear Dr. Sher, shortly about our situation. I have conceived my son (now 5) naturally after three months trying, at the age of 31 (birth at 32). Soon after we tried for a second child and have not succeeded so far. After 7 IVF cycles and 2 clinics, the third clinic finally discovered one underlying cause of the failures which is Hashimoto. Since 7 months I am treated for Hashimoto and the current TSH is 0,25. I had another retrieval in a mini stimulated cycle (Femara from day 5-9) 4 months after starting the treatment for Hashimoto. We ended up with 2 frozen blastocysts, 4BC and 4cc. After the transfer of the 4BC blastocyst I got pregnant (rising HCG levels all the way), had an ultrasound confirming normal growing foetus and visible heartbeat at 6w 5days so we were very hopeful. However, at the 8w5d scan the baby just measured 8mm and had no heartbeat. According to the doc I had a missed miscarriage and underwent D&C 1 week later. As it was my first miscarriage no tissue sample test was done. Now my question: what are our chances to succeed in the next IVF cycle (I am currently 37, husband 45)? Is the miscarriage most likely due to low egg quality or what else could be the reason? What are the chances I can experience another miscarriage? Should we transfer the remaining 4CC blastocyst or better go for a fresh cycle? What tests should be done before we try again? Day 3 Data before last transfer: FSH 11,1, E2 28, AMH 0,62. I am really devastated and wonder whether we should continue with IVF treatment as I underwent 2 long antagonist protocols in the first clinic and responded with a very low egg count of 5 and 9 eggs, nothing to freeze, therefore the natural or mini stimulation approach. many thanks for your help, Hide
Please read the article referred to below on Thyroid aautoimmune disease and immunologic implantation dysfunction (IID). You will note that about 50% of women with this condition (Hashimoto’s diseasse) have activated uterine natural killer cells which can interfere with implantation . Read the rest of the articles on IID listed below as well.
Separately,your low AMH level suggests that you have DOR and thus time is of the essence. In my opinion, you should embark upon fresh IVF using a modified, robust, long pituitary down-regulation protocol. I would use an agonist/antagonist conversion protocol with human growth hormone (HGH) augmentation and would recommend “Staggered IVF” with “embryo banking of PGS (next generation gene sequencing)-normal blastocysts, to make hay while the sun still shines (see below).
Please visit my new Blog on this very site, 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
•Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•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.
•Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
•The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
•Frozen Embryo Transfer (FET): What Does it Involve?
•Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
•Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
•Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
•IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
•Unexplained IVF Failure
•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)
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF
•The Role of Nutritional Supplements in Preparing for IVF
•IVF for Women Who Have Previously Conceived (Secondary Infertility).
I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoff Sher
I underwent an IVF in December / January. It totally failed, was
transferred to IUI. Among others, the Orgalutran was given when the
follicles were only 5, 6 and 8 mm big (I had only three, more small ones
appeared later but did not grow much). I was on BCP before, but NO
overlapping was done. Only FSH (300 units Puregon) starting day 5 after
last day of period, starting December 19 until January 1. Orgalutran was
started on December 25. Now, after I was not pregnant, I did day 3 blood
work and the FSH had increased greatly compared to the last time it was
checked (three months before). I know that it can fluctuate but this was
a big increase. Can it be that some of the FSH is still in my body and
the FSH increase is because of that?
I suffer from Hashimoto and have DOR, I believe what happened to me is what was just published in the article “Anti-Müllerian hormone as a marker of premature ovarian aging in autoimmune thyroid disease” by Saglam F , Onal ED, Ersoy R, Koca C, Ergin M, Erel O, Cakir B. in Gynecol Endocrinol. 2015 Feb;31(2):165-8. doi: 10.3109/09513590.2014.973391. Epub 2014 Oct 16. what is your view? do you see any chances for me? what protocol would you choose? could I come to your clinic in NY or Connecticut and coudl I book a skype conference (I already made a request but receivd no reply). Thank you!
When considering FSH levels it is important to realize that you always look at the highest level as indicative of ovarian reserve. BUT, it is far better to look at AMH to deterine the reserve. By the sound of things, you could well have DOR making time is of the essence. In my opinion, you should embark upon fresh IVF using a modified, robust, long pituitary down-regulation protocol. I would use an agonist/antagonist conversion protocol with human growth hormone (HGH) augmentation and would recommend “Staggered IVF” with “embryo banking of PGS (next generation gene sequencing)-normal blastocysts, to make hay while the sun still shines (see below).
Separately, please read the article referred to below on Thyroid autoimmune disease and immunologic implantation dysfunction (IID). You will note that about 50% of women with this condition (Hashimoto’s diseasse) have activated uterine natural killer cells which can interfere with implantation . Read the rest of the articles on IID listed below as well.
Please visit my new Blog on this very site, 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
• Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
• IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
• 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.
• Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
• The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
• Frozen Embryo Transfer (FET): What Does it Involve?
• Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
• Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
• Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
• IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
• Unexplained IVF Failure
• 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)
• Traveling for IVF from Out of State/Country–
• A personalized, stepwise approach to IVF
• The Role of Nutritional Supplements in Preparing for IVF
• IVF for Women Who Have Previously Conceived (Secondary Infertility).
I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoff Sher
Hi Dr. Sher,
I am 38 years and 1 month old, never been pregnant and just finished my first round of IVF after 6 years of ttc. Male factor infertility always seemed to be the issue but I recently found out that I have PCOS. I was a high responder to the Menopur and Follistim injections so my RE lowered my doses and the day before retrieval my estradiol levels were only about 4200 which was good considering the how quickly my numbers increased. My stim period was shortened by 3 days due to high estrogen levels. They retrieved 24 follicles but only 16 were mature. Of those 16, only 7 were successfully fertilized using ICSI. 6 of them made it to the blast stage and are now frozen. They originally told us that only 3 would make it to the blast stage and asked if we wanted to proceed with PGS but we decided against it since there were so few of them. But now that we have 6 we are regretting that decision and its too late to change it.
Considering my age how many embryos would you recommend transferring? Is it unreasonable to request 3 at a time? Does the fact that only 7 of 16 eggs fertilized indicate poor egg quality? Would the fact that I have PCOS lead to even poorer quality embryos than would be expected due to my age?
Thanks so much for your help! I am so glad to have stumbled upon your website!
With PCOS, there is often a tendency to cut the cycle short, to trigger with a lower dosage of hCG or to use Lupron for the trigger…… so as to avoid OHSS. This often leaves you with immature eggs and a lower yield of blatocysts. Besides, women with PCOS do have a greater yield of poorer quality eggs by nature of the condition. Thus PGS is not a bad idea in such cases.
I would not transfer >2 blastocysts at a time for fear of triplets or greater.
My approach is consistently to use a long pituitary DR protocol with an agonist, coming off 1-2 months on the BCP. The latter is intended to lower LH and thereby reduce stromal activation (hyperthecosis) in the hope of controlling ovarian androgen release. I then stimulate with low dosage FSHr to which I add a smidgeon of LH/hCG (Luveris/Menopur) from the 3rd day and watch for the # of follicles and [E2] starting on the 7th day of COS. If there are > 25 follicles, I keep stimulating (regardless of the [E2] until 50% of all follicles reach 14mm. Then, provided the [E2] is >2500pg/ml, I stop the agonist and the gonadotropin stimulation and follow the E2 (only) daily, without doing further US examinations. The [E2] will almost invariably climb and I watch it go up (regardless of how high the concentration of E2reaches) and track it coming down again. As soon as the [E2] drops below 2500pg/ml (and not before then ever), I administer 10,000U hCGu or hCGf (Ovidrel/Ovitrel-500mcg) as the “trigger” and perform an egg retrieval 36h later. ICSI is a MUST because “coasted” eggs usually have no cumulus oophoris and eggs without a cumulus will not readily fertilize on their own. All fertilized eggs are cultured to blastocyst (up to 6 days). And up to two (2) are transferred transvaginally under US guidance.
The success of this approach depends on precise timing of the initiation and conclusion of “prolonged coasting”. If you start too early, follicle growth will stop and the cycle will be lost. If you start too late, you will encounter too many post-mature/cystic follicles (>22mm) that usually harbor abnormally developed eggs.
Use of the above approach avoids unnecessary cycle cancellation, severe OHSS, and optimizes egg/embryo quality. The worst you will encounter is mild to moderate OHSS and this too is uncommon.
I do not use antagonists in high responders (e.g., PCOS) because it interferes with the assay of E2 (often causing the value to be understated), a valuable index in assessing risk for the development of severe/critical OHSS. I also do not believe in the agonist trigger to prevent OHSS. The reason is that the magnitude of the induced LH surge varies and if too little LH is released, meiosis can be compromised, thereby increasing the oocyte aneuploidy index.
Please visit my new Blog on this very site, 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
•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.
•Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF
•The Role of Nutritional Supplements in Preparing for IVF
•Understanding Polycystic Ovarian Syndrome (PCOS) and the Need to Customize Ovarian Stimulation Protocols.
I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoff Sher
Hello Dr. Sher. I had 8 unsuccessful embryos’ returns, still unsuccessfully.
> i have Crohns’ disease (balanced now, CRP 1.5 (0.5 is the maximum) and have 2 children.
lately I had 2 miscarriages (natural pregnancies) in week 7. i also had night sweats
> during the seven weeks of these pregnancies and it has never occurred
> in my previous successful pregnancies. what should i check to figure
> out the reason for these sweats?
> how can i check the autoimmunity reason for unsuccessful implantation and recurrent miscarriages?
I also took clexan (henoxaparin) due to high fibrinogen, high factor 8 and positive lupus anticoagulant test. But no APLA.
> so what else can I do that I have not done? (hystroskopy is perfect, low sperm count – 2% morphology)
many thanks for your kind help. Hanni Naor
Please review the articles below.
When confronted with “unexplained” IVF failures where morphologically good embryos were transferred, the question arises as to whether the problem is due to inherent egg/embryo “incompetence” (which usually equates with an irregular chromosomal configuration [aneuploidy]) or whether it is due to an implantation dysfunction. The younger the woman and the higher the quality of available embryos (preferably blastocysts), the less likely it is that the fault lies with embryo “incompetence” and the greater is the likelihood that it is due to underlying implantation dysfunction.
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)
Implantation dysfunction (anatomical or immunologic) is a common cause of repeated “unexplained” IVF failure with good embryos. 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.
Please visit my new Blog on this very site, 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
•Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•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)
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF
•The Role of Nutritional Supplements in Preparing for IVF
I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.