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
After a brutal 12 years of infertility treatment, I have a surrogate carrying my baby after an FET. My RE said that she should stay on progesterone (suppositories and endometrin pills) and Estrase (2x2mg pills 3x daily) until week 12. However on Monday she was complaining of severe vaginal irritation and itching from the suppositories and the RE reluctantly said she could stop her meds. On Monday, she was 11 weeks 3 days. Should I be concerned about this potentially causing a MC? Is it relevant that the baby was measuring 2 days ahead at the 7 week ultrasound? There has not been an ultrasound since.
#2 Is there any benefit to doing the Harmony Test on a PGS tested embryo pregnancy?
Many thanks for answering my question.
I never have my patients on progesterone beyond the 10th week.
Good luck…This sounds good to me…
Geoff Sher
Hi Dr Sher!
I moved onto IVF this year after 3 iui’s last year. I have had 3 chemical pregnancies through IUI and have the homozygous a1298c mutation. As a precautionary measure, I am on low dose aspirin as well as lovenox daily.
My egg retrieval gave me two embryos (one day 6 [4ab] and one day 7 [4bc]). PGS results are Mosaic Del(21)(pter-q21.2)[mos] and Dup(9)(q12-qter), -15[mos].
How do you feel about transferring those two?
In my oinion, day-7 blastocysts hardly ever propagate viable pregnancies. The other so called “mosaic” embryo is in my personal opinion also suspect because the presence of abnormalities involving >1 chromosome are also usually not truly “mosaic”. …see below.
Human embryo development occurs through a process that encompasses reprogramming, sequential cleavage divisions and mitotic chromosome segregation and embryonic genome activation. Chromosomal abnormalities may arise during germ cell and/or pre-implantation embryo development, and represents a major cause of early pregnancy loss. About a decade ago, I and an associate, Levent Keskintepe Ph.D were the first to introduce full embryo karyotyping (identification of all 46 chromosomes) through preimplantation genetic sampling (PGS) as a method by which to selectively transfer only euploid embryos (i.e. those that have a full component of chromosomes) to the uterus. We subsequently reported on a 2-3 fold improvement in implantation and birth rates as well as a significant reduction in early pregnancy loss, following IVF. Since then PGS has grown dramatically in popularity such that it is now widely used throughout the world.
Most IVF programs that offer PGS services, require that all participating patients consent to all their aneuploid embryos (i.e. those with an irregular quota of chromosomes) be disposed of. However, there is now growing evidence to suggest that following embryo transfer, some aneuploid embryos will in the process of ongoing development, convert to the euploid state (i.e. “autocorrection”) and then go on to develop into chromosomally normal offspring. In fact, I am personally aware of several such cases occurring within our IVF network. So clearly , summarily discarding all aneuploid embryos as a matter of routine we are sometimes destroying some embryos that might otherwise have “autocorrected” and gone on to develop into normal offspring.
Thus by discarding aneuploid embryos the possibility exists that we could be denying some women the opportunity of having a baby. This creates a major ethical and moral dilemma for those of us that provide the option of PGS to our patients. On the one hand, we strive “to avoid knowingly doing harm” (the Hippocratic Oath) and as such would prefer to avoid or minimize the risk of miscarriage and/or chromosomal birth defects and on the other hand we would not wish to deny patients with aneuploid embryos, the opportunity to have a baby.
The basis for such embryo “autocorrection” lies in the fact that some embryos found through PGS-karyotyping to harbor one or more aneuploid cells (blastomeres) will often also harbor chromosomally normal (euploid) cells (blastomeres). The coexistence of both aneuploid and euploid cells coexisting in the same embryo is referred to as “mosaicism.” As stated, some mosaic embryos will In the process of subsequent cell replication convert to the normal euploid state (i.e. autocorrect)
It is against this background, that an ever increasing number of IVF practitioners, rather than summarily discard PGS-identified aneuploid embryos are now choosing to cryobanking (freeze-store) certain of them, to leave open the possibility of ultimately transferring them to the uterus. In order to best understand the complexity of the factors involved in such decision making, it is essential to understand the causes of embryo aneuploidy of which there are two varieties:
1.Meiotic aneuploidy” results from aberrations in chromosomal numerical configuration that originate in either the egg (most commonly) and/or in sperm, during preconceptual maturational division (meiosis). Since meiosis occurs in the pre-fertilized egg or in and sperm, it follows that when aneuploidy occurs due to defective meiosis, all subsequent cells in the developing embryo/blastocyst/conceptus inevitably will be aneuploid, precluding subsequent “autocorrection”. Meiotic aneuploidy will thus invariably be perpetuated in all the cells of the embryo as they replicate. It is a permanent phenomenon and is irreversible. All embryos so affected are thus fatally damaged. Most will fail to implant and those that do implant will either be lost in early pregnancy or develop into chromosomally defective offspring (e.g. Down syndrome, Edward syndrome, Turner syndrome).
2.“Mitotic aneuploidy” occurs when following fertilization and subsequent cell replication (cleavage), some cells (blastomeres) of a meiotically euploid early embryo mutate and become aneuploid. This is referred to as mosaicism. Thereupon, with continued subsequent cell replication (mitosis) the chromosomal make-up (karyotype) of the embryo might either comprise of predominantly aneuploid cells or euploid cells. The subsequent viability or competency of the conceptus will thereupon depend on whether euploid or aneuploid cells predominate. If in such mosaic embryos aneuploid cells predominate, the embryo will be “incompetent”). If (as is frequently the case) euploid cells prevail, the mosaic embryo will be “competent” and capable of propagating a normal conceptus.
Since some mitotically aneuploid (“mosaic”) embryos can, and indeed do “autocorrect’ while meiotically aneuploid embryos cannot, it follows that an ability to differentiate between these two varieties of aneuploidy would be of considerable clinical value. And would provide a strong argument in favor of preserving certain aneuploid embryos for future dispensation.
Aneuploidy, involves the addition (trisomy) or subtraction (monosomy) of one chromosome in a given pair. As previously stated, some aneuploidies are meiotic in origin while others are mitotic “mosaics”. Certain aneuploidies involve only a single, chromosome pair (simple aneuploidy) while others involve more than a single pair (i.e. complex aneuploidy). Aside from monosomy involving absence of the y-sex chromosome (i.e. XO) which can resulting in a live birth (Turner syndrome) all monosomies involving autosomes (non-sex chromosomes) are lethal and will not result in viable offspring). Some autosomal meiotic aneuploidies, especially trisomies 13, 18, 21, can progress to viable, but severely chromosomally defective babies. All other meiotic autosomal trisomies will almost invariably, either not attach to the uterine lining or upon attachment, will soon be rejected. All forms of meiotic aneuploidy are irreversible while mitotic aneuploidy (“mosaicism) often autocorrects in the uterus. Most complex aneuploidies are meiotic in origin and will almost invariably fail to propagate viable pregnancies.
There is presently no microscopic or genetic test that can reliable differentiate between meiotic and mitotic aneuploidy. Notwithstanding this, the fact that some “mosaic” embryos can autocorrect in the uterus, makes a strong argument in favor of transferring aneuploid of embryos in the hope that the one(s) transferred might be “mosaic” and might propagate viable healthy pregnancies. On the other hand, it is the fear that embryo aneuploidy might result in a chromosomally abnormal baby that has led many IVF physicians to strongly oppose the transfer of any aneuploid embryos to the uterus.
While certain meiotic aneuploid trisomies (e.g. trisomies 13, 18, & 21) can and sometimes do result in chromosomally defective babies, no other meiotic autosomal trisomies can do so. Thus the transfer of trisomic embryos in the hope that one or more might be mosaic, should exclude the use of embryos with trisomies 13, 18 or 21. Conversely, no autosomal monosomic embryos are believed to be capable of resulting in viable pregnancies, thereby making the transfer of autosomally monosomic embryos, in the hope that they are “mosaic”, a far less risky proposition. Needless to say, if such action is being contemplated, it is absolutely essential to make full disclosure to the patient (s) , and to insure the completion of a detailed informed consent agreement which would include a commitment by the patient (s) to undergo prenatal genetic testing aimed at excluding a chromosomal defect in the developing baby and/or a willingness to terminate the pregnancy should a serious birth defect be diagnosed.
Geoff Sher
PH: 800-780-7437
Dr sher
Last night (wednesday night) my period started. When I was going to bed, it is spotting, This morning (thursday morning) it’s flowing
So, is wesnesday CD1 and thursday CD2
or thursday is cd1??
Why is it important for me!
Because this cycle Iwill have FET. at 8 o clock I gave blood to test my estradiol and progesteron level.
and estradiol test came back 57!! doctors usually don’t want estradiol to be over 50 when doing FET. What should I do
May be it is high Because it is not cd2 or cd3 blood test, it is only CD1, And if I would take another blood test tomorrow, maybe my estradiol level would be normal range. (But I’ve already started estradiol pills and taken one in the morning( after test) and one pill in the evening.. )
Maybe cycle Day 1 or 2,3 doesn’t change the fact that my estradiol level is high!
Should I cancel the treatment or 57 estradiol is not big deal and go on and continue to take estradiol pills
What is your suggestion??
E2 57
Progestrone 0.57
TSH 0.35
T4 1.49
Last week when CD23 estradiol 117 progesterone 10.21
sometimes my estradiol goes 70 90 but usually it is 30 or 40 and last couple of months always it was 30ish. I dont know what happened this month.. This january I am going to be 43 years old. I don’t want to lose another month
can I do FET this month or should i change the treatment and do IVF and get some eggs to freze before january. Is it possible after pills i took. I am so confused. I want my frozen 4aa 4bb blast embrios back in my uterus. Please say implantation doesn’t fail because of my estradiol level. Tomorrow afternoon I’will have my first intralipid serum it is cd2 or cd3 please I need your answer to go on
You are CD 2 today!
For me I require a baseline E2 of <70pg/ml to start a cycle
Geoff Sher
My husband and I have been looking into egg donors and found one who meets most of our desired characteristics. She is 24 years old and has one previous cycle with these stats:
23 eggs
16 mature
15 fertilized
2 embryos (2BB, 1CC)
The 2BB embryo has resulted in pregnancy.
Or fertility specialist recommends we find another donor. The fertility clinic where this data comes from would not provide information about the sperm donor.
What do you recommend?
This is really a decision to be made by you and your doctor!
Good luck!
Geoff Sher
Dear doctor sher, there are lots of speculations about what to eat or do not eat before and after an embriyo transfer like pineapple avokado carrot pomegranate etc
what is your suggestions
I really don’t think it matters! I would however avoid too much caffeine, smoking and alcohol consumption.
Good luck,
Geoff Sher