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.
Hi Dr Sher,
Would welcome your advice.
We’re a couple undergoing lengthy battle with IVF. Began IVF 6/2017. M and F both now 35 and 2 months. F: AMH 1.2, FSH and estrogen WNL. Subclinical hypothyroidism (negative for antibodies) currently controlled w/ 25 mcg levothyroxine; Raynauds; BMI approx. 18.8. M: high sperm count, motility and morphology WNL, but 70% DFI.
4 IVF cycles:
Cycle 1: Poor response to meds, 11 mature follicles retrieved, 4 fertilized, no ICSI, no blastocyst at day 5 but transferred 2 embryos. Spotting through meds prior to HCG test at 14 days post transfer. HCG = 0.
Cycle 2: Microdose Lupron protocol. Responded well. 12 mature follicles retrieved. ICSI. 7 fertilized. 7 continued to divide normally at day 3. 2 AB blastocysts at day 5 and 6 (1 PGS normal). FET. HCG = 0 at 14 days post transfer.
Cycle 3: Microdose Lupron protocol. Responded well. 14 mature follicles retrieved. ICSI. 7 fertilized. 7 continued to divide normally at day 3. 1 AB blastocyst at day 6 (1 PGS normal). FET with additional 12 hours of progesterone. HCG >1,000 at day 14. Day 16 HCG doubled. Day 17 spotting. Day 18, HCG rose but did not double. Day 19 HCG continued to rise and sac seen on ultrasound. 6w2d blighted ovum on ultrasound.
Cycle 4: Microdose Lupron protocol. Right ovary did not respond well to medication. 6 mature follicles. TESE used for surgical extraction of sperm because of high DFI. ICSI. 4 fertilized. 4 continued to normally divide at day 3. 1 AA blastocyst at day 6 (PGS normal).
ERA conducted after stim cycle 4 before FET. ERA showed female receptive at 123 hours +/- 3 hours. AA blastocyst from stim cycle 4 transferred at 124.5 hours of progesterone initiation. Spotting began 11 days post FET. HCG on day 14 post transfer = 27. HCG on day 16 post transfer = 12.
All transfer cycles were assisted with estrogen 2mg 5x day (3x orally and 2x vaginally) and 1mL intramuscular progesterone nightly. Uterine lining was thick enough at all transfers.
Karyotype testing done on both female and male. Everything normal.
Neither endometrial biopsy nor hysterscopy have not been performed.
Also of note, prior to IVF cycles, period would arrive 6 days after ovulation, could this be indicative of a Luteal phase defect?
Ideas as to what may be causing repeated failures and where to go next? Possible immunological factors getting in the way of implantation? Natural Killer Cell testing? High DFI? Gestational carrier?
Would much appreciate your thoughts based on this history. Thank you.
Sorry i forgot to add i had done karyotype testing after my first miscarriage and turned out i have genetic issue(45Xx(3),46xx(27) out of 30 cells being examined)
Regard
Maria
Sounds like you might have a mosaic karyotype. However, if the embryo being transfered is euploid, this should not present a problem!
Good luck!
Geoff Sher
hi dr Sher
I had miscarriage two years ago at 8 weeks( heartbeat & sac shown, and suddenly bleeding bright red the next day after ultrasound check and spontaneous miscarriage afterwards), then last year i had chemical pregnancy( hcg number very low). This year March i tried ivf with icsi and pgs. Got 2 blastocysts grade BB5B and BB5D. Went to pgs test and one embryo is normal while the other embryo is monosomy chromosome 7(30%). I did hysteroscopy end of june. Dr found myoma ,removed it and mild infection on the endometrium( dr gave antibiotics).
Next month i will do frozen embryo transfer on my normal PGS tested embryo. My question is
1. I only have one normal embryo based on PGS. What is the chance of implantation this time with PGS normal embryo? Prognosis to viable pregnancy and healthy childbirth?
2. I’ve been pregnant naturally two years ago eventhough it ends with miscarriage and i had chemical pregnancy last year, do i have tendency of having NK cells activation or blood clot or thyroid disorders those autoimmune diseases based on your observation?
Regards,
Maria
1. I only have one normal embryo based on PGS. What is the chance of implantation this time with PGS normal embryo? Prognosis to viable pregnancy and healthy childbirth?
A: All other things being normal…about a 50:50 chance!
2. I’ve been pregnant naturally two years ago eventhough it ends with miscarriage and i had chemical pregnancy last year, do i have tendency of having NK cells activation or blood clot or thyroid disorders those autoimmune diseases based on your observation?
A: That is what I am referring to when I say “all other things being normal”! You need a detailed evaluation for implantation dysfunction (both anatomical and immunologic.
Geoff Sher
Dr Sher, how many eggs would you ideally like to retrieve at egg collection of a 39 year old women? What is considered an appropriate or successful number?
About 8-15!
Geoff Sher
Hello,
I have been diagnosed with ureaplasma recently and both me and my partner had a treatment of antibiotic (Azithromycin) for it. Since NHS in UK does not fund the treatment we have to retest again in a private clinic. I have 3 questions about:
– How long should we wait before we test again?
– How accurate and reliable are home test kits?
– My ureaplasma was discovered by a vaginal swab – would the urine test detect the same bacteria?
Thank you so much!
Sylvia
You should be tested a few weeks after treatment of both partners. And., a cervical and semen swab should be tested…see below:
Ureaplasma urealyticum is a bacteria that belongs to the mycoplasma family. It can be detected in the reproductive tract of as many as 40% of individuals (male and female). Ureaplasma probably does not prevent normal conception in the majority of cases, because the uterine cavity remains sterile even in women whose cervical mucous cultures positive for the organism. However, when present in the woman’s cervical secretions, the organism can be unintentionally dragged into the uterine cavity through introduction of a catheter into the uterus at the time of embryo transfer (ET) or intrauterine insemination (IUI). Molecular biologists have shown that contamination of rapidly growing cell cultures, by this organism and its close “relative”, mycoplasma hominis rapidly destroys such cells. The implanting embryo is indeed an example of an organism that comprises rapidly growing cells in a biological culture medium (the uterine lining), and as such, the cells of the trophoblast that form the “root system” of the embryo are vulnerable to intrauterine infection with Ureaplasma. However, even if the uterine cavity were to become infected, the infection willl be purged with the shedding of the infected lining at the time of the next menstruation.
While infection with Ureaplasma rarely produces symptoms in the woman, it sometimes causes symptomatic prostatitis or epydidimitis in men. Although ureaplasma can be transmitted from one partner to the other by sexual intercourse, it may also be acquired by other means, since a large percentage of couples in monogamous relationships will culture positive for the organism. It is very difficult for the organism to grow in the laboratory. Accordingly, the reproductive secretions of both partners should be evaluated (sperm and cervical mucus) individually. Successful culturing of ureaplasma requires a specialized media in which the specimens can be transported safely from the physician’s office to the microbiology laboratory.
If both partners culture negative, we can assume that there is no infection present. However, if one partner cultures positive and the other negative, we would err on the side of caution, by assuming that the negative result was caused by the difficulty in culturing the organism. When ureaplasma is detected in the reproductive secretions of either partner, both should be treated concurrently with the appropriate antibiotic (doxycycline, zithromax, erythromycin, ciprofloxin, or metronidazole; cleomycin).
Unfortunately, in approximately 30-40% of couples infected ureaplasma urealyticum, the bacteria will have built resistance to mainstay traditional antibiotics such as tetracyclines (e.g. doxycycline) and erythromycin (e.g. Zythromax) derivatives. In such cases, ciprofloxin or metronidazole (Flagyl) therapy might be needed. This is the reason that we prefer to document cure by reculturing each partner prior to beginning ovarian stimulation for an IVF cycle.
Several authors have shown a difference in pregnancy rates among patients with ureaplasma infection who were treated with antibiotics and those who were not. Other reports have not been able to identify an effect on outcome from ureaplasma infection. Thus, until the final verdict is in regarding the roll of ureaplasma with regard to its effect on IVF implantation, we prefer to err on the side of caution and ensure that this organism is absent in cervical secretions and semen before transferring embryos. To this end, my patients all receive prophylactic antibiotic therapy around the time of embryo transfer. This is administered as oral ciprofloxin. A day or two prior to embryo transfer, vaginal cleomycin suppositories are added.
Geoff Sher