19,771 Comments

1. April on May 2, 2018 at 4:09 pm

   Hi Dr S! So my RE wanted me on Predinisone but is now putting me on 0.75mg Dex for my FET after I showed him your blog and nagged him :). He however says he will switch me over to Prednisone after BFP as Dex crosses the placenta. My questions are:

   1. Is it ok to switch from Dex to Prednisone (5mg 2x a day)
   2. Can i just switch over, like do Dex today, and then do Prednisone tomorrow? Or do i need to first taper off dex and then start Prednisone?

   Thank you!

   • Dr. Geoffrey Sher on May 2, 2018 at 4:22 pm

     1. Is it ok to switch from Dex to Prednisone (5mg 2x a day)
     A: Yes
     2. Can i just switch over, like do Dex today, and then do Prednisone tomorrow? Or do i need to first taper off dex and then start Prednisone
     A: In my opinion you could just switch.

     By the way, both dexamethasone and Prednisone cross the placenta.

     Geoff Sher

2. Sharon on May 2, 2018 at 3:17 pm

   Hi Dr Sher
   Thank you for sharing your expertise on this open forum. It is an amazing resource for those of us who are struggling for answers as to why we are unable to conceive.

   I am 38 and my husband is 46. We have one little girl who was conceived naturally and who just turned 5. Four years ago, we began trying for another baby, we had 2 miscarriages in the first year of trying, and after another 6 months of trying unsuccessfully we began fertility investigations and treatment.

   My AMH was 1.87ng/ml in 2015, 1.47 in 2016, 2.1 in 2017 and 2.18 in 2018. There were male morphology issues initially but they have been rectified, samples have been in the normal range since 2016. DNA fragmentation test in 2018 was 11%. Karyotype tests in 2017 showed no chromosomal abnormalities in either of us. Immunological blood test tests in early 2018 excluded any significant immunopathological issues but flagged evidence of shift of immunity system and activation of Th1 part of my immunity system (elevation of IFN gamma, TNF alfa …). My TSH levels have been increasing from 1.91 mIU/L in 2015 to 3.12 mIU/L in 2018.

   Since April 2016, we have 5 rounds of IVF (all ICSI), all of which have been unsuccessful. The long protocol was used for the first cycle and the short protocol was used for each of the next 4 cycles. Increasing doses of gonadotropins have been used in each cycle – some using just one (150 Gonal F in first cycle, 375 Menopur in fifth cycle) and some using a combination of Gonal F and Menopur. We have had 3 fresh transfers (1 x top grade day 5 blastocyst, 1 x very early day 4 blastocyst, 2 x day 4 morula) but have never achieved implantation.

   In our last cycle, I took 5mg Prednisolon for 4 weeks prior to egg retrieval, 375 Menopur for 10 days and 3 sniffs per day of Suprecur per day from the first day of stimulation until the day of the trigger which was 250 Ovitrelle. While 9 follicles were aspirated, which all measured between 15 and 22mm in pre-trigger scan, only 3 eggs were retrieved, all of which fertilised but resulted in 2 poor quality day 5 blastocysts and 1 embryo that stalled after day 3.

   I know there is a lot of information here but I would be really grateful for your advice in relation to the following:
   Do I first need to address the rising TSH levels before considering a 6th cycle?
   Can you please suggest a protocol which might better preserve egg quality?
   How we can ensure that we can retrieve eggs from as many as the follicles as possible – perhaps increase the dose of the trigger?

   Thank you in advance.

   • Dr. Geoffrey Sher on May 2, 2018 at 4:25 pm

     Your elevated uterine TNf-alpha suggests uterine natural killer cell activation (an immunologic implantation dysfunction: See below:

     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

3. Caroline on May 2, 2018 at 3:52 am

   Hello Dr Sher
   We are an Australian couple planning to do pre implantation genetic testing for a recessive, single gene disorder. We have detailed genetic results from a genetic doctor including the location of the variations on the gene. Our fertility specialist here has just confirmed that we need to wait 4.5 months for the probe or workup to be completed before they start creating embryos. I had heard that this process takes around 1 month in the US. Can you please let me know if it is possible for us to arrange this workup through you in the US, and have our treatment here in Australia?
   Thank you very much

   • Dr. Geoffrey Sher on May 2, 2018 at 12:30 pm

     Caroline.

     I suggest you contact Reprogenetics in NY to determine how long it would take.

     Geoff Sher

4. jennifer on May 2, 2018 at 1:11 am

   Good evening! I am 8 weeks 2 days pregnant. My beats have been riding appropriately throughout this pregnancy as has development of baby and heart rate always great. However today I had ultrasound baby measured ahead and heart rate 174 but my beta hcg had dropped slightly. Last week it was 63000 today (a week later) 57000. My re said they are not concerned as the numbers can plateau and drop at this time. And baby looks great. (Checked weekly)
   Should I prepare for the worst or can all still be well?
   Thankyou.

   • Dr. Geoffrey Sher on May 2, 2018 at 12:29 pm

     I would not be very concerned either. There are fluctuations at this high level.

     Geoff Sher

5. Danie on May 1, 2018 at 10:50 pm

   Hi. I am currently going through my 4th miscarriage. I’ve had a miscarriage workup (blood clotting, chromosomes, hormones, thyroid, etc) including and HSG and everything came back normal. My husband had seman analysis and chromosomes as well that were normal. All losses seem to be around 5-6weeks. I’ve tried baby aspirin and progesterone but had no luck. Is this most likely due to chromosomes? Would IVF with genetically testing embryos help?

   Thank you