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,
I am 43 years old and mother of 6 children, who I conceived naturally. After an extra uterine pregnancy I lost one tube. Most cycles the ovulation is one the side without a tube, so it is difficult to get pregnant again. But 2,5 years ago there was no difficulty at all and I got pregnant after three cycles.My youngest daughter is healthy and wonderful. But our wish to have a last baby is still so strong.
With my other children I got pregnant very fast. Now we try since 18 months with no success. My AMH is 6,5 I was diagnosed with PCO years ago but never had any problems with that. My other hormones are o.k. and my husband is very fertile too. There is no reason, that we can`t conceive again. My fertility doctor says it belongs to my age…. we had two ivfs in the last 4 months. one in natural cycle, one stimulated with puregon. Both times we had 100% of fertilized eggs. First time one was given back on day 2, second time one blastocyst was given back one day5. Both times A quality. But no pregnancy. My doctor says, the only thing I con do is try again and again, because it takes time in my age.
Me and my husband are boths doctors, too. We checked out all specific blood tests, to go shure I am healthy and I am.
I take melatonin 3g, Q10, Omega 3, folic acid, zinc and vitamin D3…. is there anything else I can do?
In my opinion there is something we don’t see… because I got pregnant so easily in the last years.
Thanks a lot for answering,
Elisabeth
Hi Dr Sher,
I am going to ask my Dr to change my trigger shot for my upcoming cycle from Ovidrel to HCG 10,000iu but my question is does this change effect the timing between administration of the trigger shot and egg collection? I would be requesting the combined trigger but I’m on a micro lupron flare protocol so don’t think I can use the combined trigger?
I am not a big fan of “flare protocols”. I never prescribe them. “Flare” protocols involve initiating gonadotropin therapy simultaneous with the administration of GnRH agonist (e.g. Lupron/Buserelin). The intent here is to deliberately allow Lupron to elicit an initial surge (“flare”) in pituitary FSH release in order to augment FSH administration by increased FSH production. Unfortunately, this “spring board effect” represents “a double edged sword” because while it indeed increases the release of FSH, it at the same time causes a surge in LH release. The latter can evoke excessive ovarian stromal androgen production which could potentially compromise egg quality, especially in older women and women with PCOS, whose ovaries have increased sensitivity to LH. I am of the opinion that by evoking an exaggerated ovarian androgen response, such “(micro) flare protocols” can harm egg/embryo quality and reduce IVF success rates, especially in older women, and in women with diminished ovarian reserve. Accordingly, I do not prescribe them at all.
As far as the timing of the the hCG trigger. It is done 36h prior to ER.
My final IVF cycle at SIRM-LV commences on March 19th and concludes on April 2nd. If you are interested in undergoing a fresh IVF treatment cycle with me or if you have embryos cryopreserved at SIRM-LV and wish to undergo a Frozen Embryo Transfer (FET) prior to my departure, please contact me immediately….. My March cycle is likely to be very much in demand…….So, time is of the essence!
Following my departure from SIRM in mid-April, 2019, I will continue to provide comprehensive consultations to those of you that wish to have my guidance. Upon scheduling a SKYPE consultation with me, you will promptly receive a detailed questionnaire, along with a request that you submit available medical records for my review prior to our consultation. Additional tests and records can/will be requisitioned later, as needed. Your +/- 1 hour comprehensive SKYPE consultation will be followed by a detailed written report which you can also share with your personal Fertility Physician.
I will soon be posting a list of internationally regarded Fertility Specialists whom I endorse and who will have expressed a willingness to implement my suggested approaches, at their discretion. It is to one of these doctors that I would selectively refer you…upon request.
CONTACT INFORMATION:
•Online: Go to sherivf.com and Schedule a Skype Consultation. Upon doing so, you will be able to download a free copy of my new eBook ” Recurrent Pregnancy Loss (RPL) and Unexplained IVF Failure: The Immunologic Link”
•Phone
oIf you live in the USA or Canada: Please call 1-800-780-7437 or 702-533-2691
oIf you reside elsewhere Abroad: Please call 702-533-2691
oEmail: concierge@SherIVF.com
Please monitor this website for future announcements on further developments.
Geoff Sher
This questions is in regards to a A/ACP in a diminished ovarian reserve patient. The GnRH agonist needs to overlap with the BCP for a “few days”. Does the length of overlap have consequences on ovarian stimulation? Meaning, will a 3 day overlap affect the ovaries differently than a 5 day overlap?
It probably does not matter but in my opinion, 3 days is long enough.
Geoff Sher
1st IVF details:
Gonal F 225iu upped to 300iu nearing the end along with Lupron 5units and HCG 10000iu. On day of trigger E2: 1432, LH: 1.07, P4: 1.00, Follicles sizes on left ovary were: 21, 17, 17, 16, 16 (and multiples less than 10mm). Sizes on right ovary were: 19mm, 18mm, 17mm, 15mm, 15mm (and multiples less than 10mm). At ER they retrieved 16 eggs out of which only 8 were mature. 4 fertilized and only 1 made it to freeze. Fresh transfer was negative which was a day 3 transfer and FET (day 6) was a chemical pregnancy
2nd IVF:
Fast forward 6 months and moved to a different clinic where I did the Antagonist Cycle. Meds were BCP’s, Gonal-F (300iu), Cetrotide and Novarel 10000 for trigger. These were my results below on day of trigger: Left Ovary- 12mm,12mm,12mm, Right Ovary-14mm, 15mm, 18mm, 16mm,18mm, 16mm, 18mm, 17mm, Endo Thickness: 10.3
E2: 1658.6, Progesterone: 1.28. They triggered me a day early because of my rising progesterone and retrieved 14 eggs out of which 10 were mature and 7 got fertilized (even without ICSI). None made it to freeze though and we transferred one B grade quality embryo which resulted in a negative test
3rd IVF:
We were also planning on doing PGD and PGS along with ICSI since I was found to have the BRCA gene (if that is worth mentioning). Meds used were Gonal F (300iu), Menopur (150iu), and Cetrotide 0.25mg along with Ovidrel 500mcg for Trigger. The results are below on day of trigger: E2: 3032, LH: 1.08, P4: 1.50. Sizes on left ovary were: 19mm, 18mm, 16mm, 15mm, 14mm,
13mm, 12mm (and multiples less than 10). Right ovary sizes were: 17mm, 17mm, 14mm, 14mm,13mm, 12mm, 12mm (and multiples less than 10). On day of ER they retrieved 11 eggs out of which only 2 were mature and 1 got fertilized with ICSI. My Dr ended up canceling the PGD testing and we were going with a day 3 transfer but the transfer didn’t happen as the embryo got arrested.
I should also mention that before my first IVF we got pregnant naturally which ended in CP and in between the 2nd and 3rd cycles also we got pregnant naturally in January 2018 which ended in miscarriage at 8 weeks.
4th IVF:
My updated Day 3 labs (AFC 6R, 5L; AMH 1.55; LH 2.89; FSH 6.9), did an endo biopsy to check for endometriosis (came back negative), RPL (came back normal) karyotyping (normal), Saline Hysteroscopy (came back normal but he did find a fibroid/polyp which later I had surgery to remove)
So my next protocol was:
Estrogen Patch pre menses (after I ovulate), Gonal-F, Menopur, Dexamethasone and a double trigger- Lupron+HCG, it yielded in Left Ovary: 18mm, 17mm, 17mm, 17mm, 17mm, 16mm, 14mm and Right Ovary: 19mm, 17mm, 16mm, 15mm, 15mm, 15mm, 14mm, 14mm. E2 at time of trigger was 5500 and Progesterone was rising 2.2. I eventually triggered with HCG 10000 (but inject 0.5ml) and use Lupron trigger x 2 at 80ml due to risk of ohss. They retrieved 13 eggs, 7 mature, 4 got fertilized using ICSI. The lab was able to mature 2 eggs overnight and fertilize one of them. That 1 made it to day 5 and was a 4AA grade blastocyst which also came back pgs/pgd normal. The remaining 4 got arrested on day 4. We did a frozen transfer using this final embryo using Estrogen Patches, PIO and Endometrin Suppositories. He also put me on low dose aspirin, prednisone, Pepcid, loratadine to take 2 days before transfer. This yielded in a positive pregnancy with beta number at 276. My 2nd beta came back at 657 but 3rd came at 420. I have a 4th beta to see where things stand but preparing myself for a possible miscarriage.
As you can see, both of our results come back normal everytime and we are unexplained. We also did the ERA test which showed Pre Receptive and that I needed an extra day of progesterone before transfer. I have no problems getting pregnant, it’s the staying pregnant part that is the issue here now. I really need another opinion to see what can be done here.
Hi,
I am a 40yr old woman. Amh 5.2, healthy uterus, lining measurements always good. EDS type 3, related minor platlet function disorder and treated hypothyroidism. Past extensive cone biopsy means I have challenging transfers, that have to be sedated.
Severe male factor infertility had led to icsi. No success yet. Cycle 1 – 14 eggs, 6 mature, 1 blastocyst, fresh transfer.
Cycle 2 (new protocol) – 11 eggs, 9 mature, 3 blastocysts, 1 fresh and 1 frozen transfer, 1 lost in defrost.
Not sure whether to continue trying or to try something new?
Concerned I’m only producing abnormal embryos or there is an implantation issue or the forceful transfers are lowering my implantation chances?
Do my results so far indicate its worth another cycle?
Thanks
The two issues to explore are 1. the protocol used for ovarian stimulation and 2.A possible immunologic implantation dysfunction .Bear in mind that hypothyroidism is often autoimmune in women and connected to NK cell activation.
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
e.Ureaplasma Urealyticum (UU) Infection of cervical mucous and the endometrial lining of the uterus, can sometimes present as unexplained early pregnancy loss or unexplained failure following intrauterine insemination or IVF. The infection can also occur in the man, (prostatitis) and thus can go back and forth between partners, with sexual intercourse. This is the reason why both partners must be tested and if positive, should be treated contemporaneously.
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
My final IVF cycle at SIRM-LV commences on March 19th and concludes on April 2nd. If you are interested in undergoing a fresh IVF treatment cycle with me or if you have embryos cryopreserved at SIRM-LV and wish to undergo a Frozen Embryo Transfer (FET) prior to my departure, please contact me immediately….. My March cycle is likely to be very much in demand…….So, time is of the essence!
Following my departure from SIRM in mid-April, 2019, I will continue to provide comprehensive consultations to those of you that wish to have my guidance. Upon scheduling a SKYPE consultation with me, you will promptly receive a detailed questionnaire, along with a request that you submit available medical records for my review prior to our consultation. Additional tests and records can/will be requisitioned later, as needed. Your +/- 1 hour comprehensive SKYPE consultation will be followed by a detailed written report which you can also share with your personal Fertility Physician.
I will soon be posting a list of internationally regarded Fertility Specialists whom I endorse and who will have expressed a willingness to implement my suggested approaches, at their discretion. It is to one of these doctors that I would selectively refer you…upon request.
CONTACT INFORMATION:
•Online: Go to sherivf.com and Schedule a Skype Consultation. Upon doing so, you will be able to download a free copy of my new eBook ” Recurrent Pregnancy Loss (RPL) and Unexplained IVF Failure: The Immunologic Link”
•Phone
oIf you live in the USA or Canada: Please call 1-800-780-7437 or 702-533-2691
oIf you reside elsewhere Abroad: Please call 702-533-2691
oEmail: concierge@SherIVF.com
Please monitor this website for future announcements on further developments.
Geoff Sher