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.
Dr Sher we would really like a chance to expand our family with you before you leave SIRM! We would like it if we could get a discount on a FET or payment plan or anything? If you could help us once again make our and our daughters dreams come true of adding a sibling we would be forever grateful. Thank you
If you wish for me to treat you in my last treatment cycle at SIRM-LV in March, you really need to call Tina at 800-780-7437 or 702-533-2691, no later than today or tomorrow and she will get things in motion. Ask her to se4t you up with a follow-up consultation with me immediately t make arrangements.
Thank you.
Geoff Sher
Hi Dr. Sher, I did an immunity test and the CD19 and CD5+ cell count was 65% where normal was 5-10. In addition, my Intracelleluar cytokine ratio was also slightly elevated. We have done IVF now about 5 times with no success and only did the immunity testing before this last time. The clinic mentioned that the results were only borderline and the regimen of pred and clexane was enough. What is your opinion on these elevated results? Do you think intralipid is needed?Noone discussed the relevance of CD19 and CD5 cells in pregnancy and I am a bit at a loss as to what to do.
If your TH-1 levels are even slightly elevated, it strongly suggests that you might have activation of NK cells and require intralipid/steroid therapy. In my opinion the testing should be expanded.
Unless tests for immunologic implantation dysfunction (IID) are performed correctly and conducted by a one of the few reliable reproductive immunology reference laboratory in the United States, treatment will likely be unsuccessful. . In this regard it is most important that the right tests be ordered and that these be performed by a competent laboratory. There are in my opinion only a handful of reliable Reproductive Immunology Laboratories in the world and most are in the U.S.A. Also, it is my opinion that far too often, testing is inappropriate with the many redundant and incorrect tests being requested from and conducted by suboptimal laboratories. Finally for treatment to have the best chance of being successful, it is vital that the underlying type of IID (autoimmune IID versus alloimmune) be identified correctly and that the type, dosage, concentration and timing of treatments be carefully devised and implemented.
Who Should Undergo IID testing?
When it comes to who should be evaluated, the following conditions should in always raise a suspicion of an underlying IID, and trigger prompt testing:
•A diagnosis of endometriosis or the existence of symptoms suggestive of endometriosis (heavy/painful menstruation and pain with ovulation or with deep penetration during intercourse) I would however emphasize that a definitive diagnosis of endometriosis requires visualization of the lesions at laparoscopy or laparotomy)
•A personal or family history of autoimmune disease such as hyper/hypothyroidism (as those with elevated or depressed TSH blood levels, regardless of thyroid hormonal dysfunction), Lupus erythematosus, Rheumatoid arthritis, dermatomyositis, scleroderma etc.)
•“Unexplained” infertility
•Recurrent pregnancy loss (RPL)
•A history of having miscarried a conceptus that, upon testing of products of conception, was found to have a normal numerical chromosomal configuration (euploid).
•Unexplained IVF failure
• “Unexplained” intrauterine growth retardation due to placental insufficiency or late pregnancy loss of a chromosomally normal baby
What Parameters should be tested?
In my opinion, too many Reproductive Immunologists unnecessarily unload a barrage of costly IID tests on unsuspecting patients. In most cases the initial test should be for NK cell activation, and only if this is positive, is it necessary to expand the testing.
The parameters that require measurement include:
oFor Autoimmune Implantation Dysfunction: Autoimmune implantation dysfunction, most commonly presents with presumed “infertility” due to such early pregnancy losses that the woman did not even know she was pregnant in the first place. Sometimes there as an early miscarriage. Tests required are: a) blood levels of all IgA, IgG and IgM-related antiphospholipid antibodies (APA’s) directed against six or seven specific phospholipids, b) both antithyroid antibodies (antithyroid and antimicrosomal antibodies), c) a comprehensive reproductive immunophenotype (RIP) and, c) most importantly, assessment of Natural Killer (NK) cell activity (rather than concentration) by measuring by their killing, using the K-562 target cell test and/or uterine cytokine measurement. As far as the ideal environment for performing such tests, it is important to recognize that currently there are only about 5 or 6, Reproductive Immunology Reference Laboratories in the U.S capable of reliably analyzing the required elements with a sufficient degree of sensitivity and specificity (in my opinion).
oFor Alloimmune implantation Dysfunction: While alloimmune Implantation usually presents with a history of unexplained (usually repeated) miscarriages or secondary infertility (where the woman conceived initially and thereupon was either unable to conceive started having repeated miscarriages it can also present as “presumed” primary infertility. Alloimmune dysfunction is diagnosed by testing the blood of both the male and female partners for matching DQ alpha genes and NK/CTL activation. It is important to note that any DQ alpha match (partial or complete) will only result in IID when there is concomitant NK/CTL activation (see elsewhere on this blog).
How should results be interpreted?
Central to making a diagnosis of an immunologic implantation dysfunction is the appropriate interpretation of natural killer cell activity (NKa) .In this regard, one of the commonest and most serious errors, is to regard the blood concentration of natural killer cells as being significant. Rather it is the activity (toxicity) of NK cells that matters as mentioned. Then there is the interpretation of reported results. The most important consideration is the percentage of target cells “killed” in the “native state”. In most cases a level of >10% killing should be regarded with suspicion and >12% overtly abnormal. In my opinion, trying to interpret the effect of adding IVIG or Intralipid to the sample in order assess whether and to what degree the use of these products would have a therapeutic benefit is seriously flawed and of little benefit. Clinically relevant NK cell deactivation can only be significantly effected in vivo and takes more than a week following infusion to occur. Thus what happens in the laboratory by adding these products to the sample prior to K-562 target cell testing is in my opinion likely irrelevant.
There exists a pervasive but blatant misconception on the part of many, that the addition of Intralipid (IL) /immunoglobulin-G IVIG) can have an immediate down-regulatory effect on NK cell activity. This has established a demand that Reproductive Immunology Reference Laboratories report on NK cell activity before and following exposure to IVIG and/or IL. However, the fact is that activated “functional” NK cells (NKa) cannot be deactivated in the laboratory. Effective down-regulation of activated NK cells can only be adequately accomplished if their activated “progenitor/parental” NK cells are first down-regulated. Thereupon once these down-regulated “precursor” NK cells are exposed to progesterone, they will begin spawning normal and functional NK cells, which takes about 10-14 days. It follows that to assess for a therapeutic response to IVIG/IL therapy would require that the patient first be treated (10-14 days prior to embryo transfer) and thereupon, about 2 weeks later, be retested. While at 1st glance this might seem to be a reasonable approach, in reality it would be of little clinical benefit because even if blood were to be drawn 10 -14 days after IL/IVIG treatment it would require an additional 10 days to receive results from the laboratory, by which time it would be far too late to be of practical advantage.
Neither IVIG nor IL is capable of significantly suppressing already activated “functional NK cells”. For this to happen, the IL/IVIG would have to down-regulate progenitor (parent) NK cell” activity. Thus, it should be infused 10-14 several prior to ovulation or progesterone administration so that the down-regulated “progenitor/precursor” NK cells” can propagate a sufficient number of normally regulated “functional NK cell” to be present at the implantation site 7 days later. In addition, to be effective, IL/IVIG therapy needs to be combined with steroid (dexamethasone/prednisone/prednisolone) therapy to down-regulates (often) concomitantly activated T-cells.
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.
•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!
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
Hi dr sher hope you are well. I have 2 ngs helthy embryos I have one 5aa and one 5cc dos etge grades really matter do they have the same % of implementing thanks
Probably both of equivalent quality/”competency”.
Good luck!
Geoff Sher
Sir iam tubectomised 2years back…in dec 31 2018 had one fet with 2 grade 3 embryos….on day 14 my beta hcg came 21 with negative upt
Day 16 beta hcg came49
Day 18 b hcg came 112
Day 20 b hcg came 228
Day 23 bhcg came 484
Day 27 b hcg came 710
But sir till now gestational sac is not visible any where..my ivf specialist told that it is a pregnancy of unknown location …repeated scan can also find nothing so she adviced me to stop all medicines since 4 days…now my endometial thickness came from 15mm to 9mm yesterday…after stopping all med also i got b hcg value of 710 sir…it increased but it didnt doubled…after 7weeks they could see nothing in my uterus…will i miscarry normally sir or i require methotrexate dose…? Is tubectomy the reason for my PUL or ectopic pregnancy sir? Please suggest can i go for another fresh ivf cycle…iam afraid of this ectopic prenancy as i read that in tubal infertility bacause of pressure changes it sucks back the embryo placed in uterus into the tube..please explain me about this issue sir…iam totally confused..
If there is nothing in the uterus and the beta hCG keeps rising, it is likely to be an ectopic (tubal) pregnancy and I would discuss taking MTX with your RE.
Good luck!
Geoff Sher
Geoff Sher
Although you are not continually doing cycles now. Would you be willing to do a transfer for a previous client?
Yes! But to make my last cycle in Mid March, you would need to call Tina (800-780-7437) tomorrow to book. My last cycle at SIRM is likely to be hectic.
I will be establishing Sher-Fertility Solutions (SFS) in April 2019. SFS will be a venue for providing fertility consultations to the ever growing number of patients from 40 different countries who, with complex fertility problems seek my input. In the past, I have not been able to connect with most of these patients, having had to confine my SKYPE consultations to those who expressed a willingness to travel to Las Vegas for treatment with me. But now with the “birth” of SFS, all this is about to change since upon leaving SIRM, I will as of April no longer be concentrating on the hands-on treatment to patients seeking my services. Instead, (with few exceptions) I will in large part be confining my activities to providing consulting services to as many patients as possible.
Patients will be able to access SFS online, by phone or by email (see http://www.sherIVF.com for details), the subsequent enrollment for a consultation, and the remittance of a $400.00 fee, I will review all forwarded medical record, and follow this with an initial +/-1 hour SKYPE consultation. Thereupon, I will request (and where needed) will help facilitate, additional medical and laboratory testing as may be required. This will be followed by additional SKYPE/phone consultations as might be required to make a comprehensive assessment. I will thereupon generate and forward to the patient, a written report which will also include a recommended plan of action which can be shared with the patient’s treating fertility physician(s) and, upon request by both patient and treating doctor, I will be will be happy to interact and confer with both.
By largely confining my activities to consultation and advice giving, rather than conducting hands-on treatment, I hope to remove any semblance of posing a “threat” to the treating physicians and patients .Instead, It both my objective and commitment to serve as a resource to patients from all over the world who have complex fertility issues and feel that they are spinning their wheels.
I hope soon to compile and post on my website, a list of quality Fertility doctors from key locations all over the United States, and perhaps even from abroad, who I endorse and to whom I would selectively refer SFS patients upon request. However, I would be willing to confer with the fertility physician of any patient subject to patient and physician request to do so.
Ultimately I hope to expand SFS services, nationally through consumer-driven workshops, seminars, Town Hall Meetings and by way of online outreach through webinars and social media. Needless to say, I will perpetuate personal blogging on http://www.SherIVF.com / http://www.Sherfertilitysolutions.com and through my current weekly video live feeds on Face Book (Dr Geoffrey Sher).
For me this is a very exciting venture. Please become part of the SFS family and help spread the word!
Geoff Sher
Yes! I will likely be continuing doing w cycles after I leave SIRM on a limited basis. BUT it would be at a location other than SIRM-Las Vegas since my tenure is up after the March cycle. The location that I might be performing cycles at will soon be determined. I am weighing up the options at present. As for doing an FET for you ..I would indeed be able to accommodate you in March but to get in to that cycle, you should call Tina tomorrow at 800-780-7437 and schedule both an urgent follow-up consultation with me and put your name down for the March 19th cycle.
I will be establishing Sher-Fertility Solutions (SFS) in April 2019. SFS will be a venue for providing fertility consultations to the ever growing number of patients from 40 different countries who, with complex fertility problems seek my input. In the past, I have not been able to connect with most of these patients, having had to confine my SKYPE consultations to those who expressed a willingness to travel to Las Vegas for treatment with me. But now with the “birth” of SFS, all this is about to change since upon leaving SIRM, I will as of April no longer be concentrating on the hands-on treatment to patients seeking my services. Instead, (with few exceptions) I will in large part be confining my activities to providing consulting services to as many patients as possible.
Patients will be able to access SFS online, by phone or by email (see http://www.sherIVF.com for details), the subsequent enrollment for a consultation, and the remittance of a $400.00 fee, I will review all forwarded medical record, and follow this with an initial +/-1 hour SKYPE consultation. Thereupon, I will request (and where needed) will help facilitate, additional medical and laboratory testing as may be required. This will be followed by additional SKYPE/phone consultations as might be required to make a comprehensive assessment. I will thereupon generate and forward to the patient, a written report which will also include a recommended plan of action which can be shared with the patient’s treating fertility physician(s) and, upon request by both patient and treating doctor, I will be will be happy to interact and confer with both.
By largely confining my activities to consultation and advice giving, rather than conducting hands-on treatment, I hope to remove any semblance of posing a “threat” to the treating physicians and patients .Instead, It both my objective and commitment to serve as a resource to patients from all over the world who have complex fertility issues and feel that they are spinning their wheels.
I hope soon to compile and post on my website, a list of quality Fertility doctors from key locations all over the United States, and perhaps even from abroad, who I endorse and to whom I would selectively refer SFS patients upon request. However, I would be willing to confer with the fertility physician of any patient subject to patient and physician request to do so.
Ultimately I hope to expand SFS services, nationally through consumer-driven workshops, seminars, Town Hall Meetings and by way of online outreach through webinars and social media. Needless to say, I will perpetuate personal blogging on http://www.SherIVF.com / http://www.Sherfertilitysolutions.com and through my current weekly video live feeds on Face Book (Dr Geoffrey Sher).
For me this is a very exciting venture. Please become part of the SFS family and help spread the word!
Geoff Sher