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 love your content and website thank you for being a source of support for all of us struggling with infertility.
I had a question, we have two embryos currently being cultured after our recent IVF cycycle and they are on day 4 and are at the 8 and 7 cell stage, they grew from yesterday but they are slow. They are compacting today as per the embryologist. Tomorrow would be the day 5 transfer, would you suggest waiting them out until day 6 and then freezing or transferring them tomorrow in the state they are in? They may only be in the Morula stage tomorrow. We previously did a day 3 transfer and it was unsuccessful with 2 good quality 8 cell embryos on day 3. My concern is that our clinic will not freeze poor quality blasts, so we may loose out on them if we don’t do the transfer but don’t want to put them in unless we actually have a shot. I would really appreciate your advice. We are so confused and are getting a lot of conflicting information. I’m 32 and endometriosis and an endometrioma on one ovary.
Thank you so much!
I do not believe in transferring embryos that have not reached blastocyst by day 6 post-fertilization. I agree that freezing such embryos is also of no merit. Your endometriosis and the endometrioma is however of concern to me. In my opinion, the endometrioma can compromise egg development and thus “competency in the affected ovary. It should be addressed. I am also concerned that the endometriosis could be associated with a natural killer cell -related immunologic implantation dysfunction.
When women with infertility due to endometriosis seek treatment, they are all too often advised to first try ovarian stimulation (ovulation Induction) with intrauterine insemination (IUI) ………as if to say that this would be just as likely to result in a baby as would in vitro fertilization (IVF). Nothing could be further from reality It is time to set the record straight. And hence this blog!
Bear in mind that the cost of treatment comprises both financial and emotional components and that it is the cost of having a baby rather than cost of a procedure. Then consider the fact that regardless of her age or the severity of the condition, women with infertility due to endometriosis are several fold more likely to have a baby per treatment cycle of IVF than with IUI. It follows that there is a distinct advantage in doing IVF first, rather than as a last resort.
So then, why is it that ovulation induction with or without IUI is routinely offered proposed preferentially to women with mild to moderately severe endometriosis? Could it in part be due to the fact that most practicing doctors do not provide IVF services but are indeed remunerated for ovarian stimulation and IUI services and are thus economically incentivized to offer IUI as a first line approach? Or is because of the often erroneous belief that the use of fertility drugs will in all cases induce the release (ovulation) of multiple eggs at a time and thereby increase the chance of a pregnancy. The truth however is that while normally ovulating women (the majority of women who have mild to moderately severe endometriosis) respond to ovarian stimulation with fertility drugs by forming multiple follicles, they rarely ovulate > 1 (or at most 2) egg at a time. This is because such women usually only develop a single dominant follicle which upon ovulating leaves the others intact. This is the reason why normally ovulating women who undergo ovulation induction usually will not experience improved pregnancy potential, nor will they have a marked increase in multiple pregnancies. Conversely, non-ovulating women (as well as those with dysfunctional ovulation) who undergo ovulation induction, almost always develop multiple large follicles that tend to ovulate in unison. This increases the potential to conceive along with an increased risk multiple pregnancies.
So let me take a stab at explaining why IVF is more successful than IUI or surgical correction in the treatment of endometriosis-related infertility:
1.The toxic pelvic factor: Endometriosis is a condition where the lining of the uterus (the endometrium) grows outside the uterus. While this process begins early in the reproductive life of a woman, with notable exceptions, it only becomes manifest in the 2ndhalf of her reproductive life. After some time, these deposits bleed and when the blood absorbs it leaves a visible pigment that can be identified upon surgical exposure of the pelvis. Such endometriotic deposits invariably produce and release toxins” into the pelvic secretions that coat the surface of the membrane (the peritoneum) that envelops all abdominal and pelvic organs, including the uterus, tubes and ovaries. These toxins are referred to as “the peritoneal factor”. Following ovulation, the egg(s) must pass from the ovary (ies), through these toxic secretions to reach the sperm lying in wait in the outer part the fallopian tube (s) tube(s) where, the sperm lie in waiting. In the process of going from the ovary(ies) to the Fallopian tube(s) these eggs become exposed to the “peritoneal toxins” which alter s the envelopment of the egg (i.e. zona pellucida) making it much less receptive to being fertilized by sperm. As a consequence, if they are chromosomally normal such eggs are rendered much less likely to be successfully fertilized. Since almost all women with endometriosis have this problem, it is not difficult to understand why they are far less likely to conceive following ovulation (whether natural or induced through ovulation induction). This “toxic peritoneal factor impacts on eggs that are ovulated whether spontaneously (as in natural cycles) or following the use of fertility drugs and serves to explain why the chance of pregnancy is so significantly reduced in normally ovulating women with endometriosis.
2.The Immunologic Factor: About one third of women who have endometriosis will also have an immunologic implantation dysfunction (IID) linked to activation of uterine natural killer cells (NKa). This will require selective immunotherapy with Intralipid infusions, and/or heparinoids (e.g. Clexane/Lovenox) that is much more effectively implemented in combination with IVF.
3.Surgical treatment of mild to moderate endometriosis does not usually improve pregnancy potential:. The reason is that endometriosis can be considered to be a “work in progress”. New lesions are constantly developing. So it is that for every endometriotic seen there are usually many non-pigmented deposits that are in the process of evolving but are not yet visible to the naked eye and such evolving (non-visible) lesions can also release the same “toxins that compromise fertilization. Accordingly, even after surgical removal of all visible lesions the invisible ones continue to release “toxins” and retain the ability to compromise natural fertilization. It also explains why surgery to remove endometriotic deposits in women with mild to moderate endometriosis usually will fail to significantly improve pregnancy generating potential. In contrast, IVF, by removing eggs from the ovaries prior to ovulation, fertilizing these outside of the body and then transferring the resulting embryo(s) to the uterus, bypasses the toxic pelvic environment and is therefore is the treatment of choice in cases of endometriosis-related infertility.
4.Ovarian Endometriomas: Women, who have advanced endometriosis, often have endometriotic ovarian cysts, known as endometriomas. These cysts contain decomposed menstrual blood that looks like melted chocolate…hence the name “chocolate cysts”. These space occupying lesions can activate ovarian connective tissue (stroma or theca) resulting in an overproduction of male hormones (especially testosterone). An excess of ovarian testosterone can severely compromise follicle and egg development in the affected ovary. Thus there are two reasons for treating endometriomas. The first is to alleviate symptoms and the second is to optimize egg and embryo quality. Conventional treatment of endometriomas involves surgical drainage of the cyst contents with subsequent removal of the cyst wall (usually by laparoscopy), increasing the risk of surgical complications. We recently reported on a new, effective and safe outpatient approach to treating endometriomas in women planning to undergo IVF. We termed the treatment ovarian Sclerotherapy. The process involves; needle aspiration of the “chocolate colored liquid content of the endometriotic cyst, followed by the injection of 5% tetracycline hydrochloride into the cyst cavity. Such treatment will, more than 75% of the time result in disappearance of the lesion within 6-8 weeks. Ovarian sclerotherapy can be performed under local anesthesia or under conscious sedation. It is a safe and effective alternative to surgery for definitive treatment of recurrent ovarian endometriomas in a select group of patients planning to undergo IVF
I am not suggesting that all women with infertility-related endometriosis should automatically resort to IVF. Quite to the contrary…. In spite of having reduced fertility potential, many women with mild to moderate endometriosis can and do go on to conceive on their own (without treatment). It is just that the chance of this happening is so is much lower than normal.
IN SUMMARY: For young ovulating women (< 35 years of age ) with endometriosis, who have normal reproductive anatomy and have fertile male partners, expectant treatment is often preferable to IUI or IVF. However, for older women, women who (regardless of their age) have any additional factor (e.g. pelvic adhesions, ovarian endometriomas, male infertility, IID or diminished ovarian reserve-DOR) IVF should be the primary treatment of choice. 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.
•Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF:
•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!
•Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas
•Should IVF Treatment Cycles be provided uninterrupted or be Conducted in 7-12 Pre-scheduled “Batches” per Year
•A personalized, stepwise approach to IVF
•How Many Embryos should be transferred: A Critical Decision in IVF?
•Endometriosis and Immunologic Implantation Dysfunction (IID) and IVF
•Endometriosis and Infertility: Why IVF Rather than IUI or Surgery Should be the Treatment of Choice.
•Endometriosis and Infertility: The Influence of Age and Severity on Treatment Options
•Early -Endometriosis-related Infertility: Ovulation Induction (with or without Intrauterine Insemination) and Reproductive Surgery Versus IVF
•Treating Ovarian Endometriomas with Sclerotherapy.
•Effect of Advanced Endometriosis with Endometriotic cysts (Endometriomas) on IVF Outcome & Treatment Options.
•Deciding Between Intrauterine Insemination (IUI) and In Vitro Fertilization (IVF).
•Intrauterine Insemination (IUI): Who Needs it & who Does Not: Pro’s &
•Induction of Ovulation with Clomiphene Citrate: Mode of Action, Indications, Benefits, Limitations and Contraindications for its use
•Clomiphene Induction of Ovulation: Its Use and Misuse!
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. I had a successful fresh transfer at age 36 with my own eggs. I had a failed FET at age 38 with my own eggs. I am one week away from transferring 2 frozen donated embryos from a 38 year old and they have not been chromosomally tested. I am 41 years old now. My lining yesterday was a 10. Performing an ERA scratch next week instead of the transfer to narrow down the window of implantation was discussed. Would I really need to do this test since the fresh transfer was successful and I’m using the same implantation window on the transfer next week? If my implantation window was “off” by a few days, then wouldn’t the successful transfer have failed? Or does the “window” vary depending on age. I’m just frustrated and confused.
Also, I read about embryo “glue”. Should I try that with this FET of the 2 embryos? Thanks so much.
Hi Gina,
Very respectfully, I do not believe in the ERA test or the use of embryo glue. I do not think it has value.
Geoff Sher
Dr. Sher,
I would love to get your thoughts on discontinuing hormone therapy (estrogen and progesterone) after successful FET? Do you suggest 10 weeks or continuing for longer? What are the chances that the placenta does not adequately produce these hormones when discontinuing therapy?
10 weeks is the cut-off .
Geoff Sher
Hello Dr. Sher!
My current situation is that I have 2 beautiful baby boys that were easily conceived and I carried to term. My husband and I decided to try for another baby about a year ago. We conceived after 2 months but miscarried at 8 weeks. Following that, I’ve had about 4 chemical pregnancies and now, I don’t even think I get pregnant anymore. My situation sounds similar to this case study of yours:
https://haveababy.com/fertility-information/ivf-authority/dear-dr-sher-a-healthy-baby-followed-by-multiple-miscarriages
My only difference is that I’ve carried two babies to term. Is that unusual for someone experiencing IID, especially the alloimmune type? I am seeing an RE this week and was hoping to request the testing found in your case study, but I’m unsure if it is useful in my case.
Any help is appreciated. We just want one more little baby.
Thank you!
Hi Dr. Sher,
Best of luck with SFS! Will you continue to answer questions on this blog once you begin that role in March? Will the information / articles that you’ve posted on this site stay available?
Thanks!
The answer to both questions is YES!
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