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.
I am 39 with diminish ovarian reserve. My Amh is .8 and fsh 16. We did mini IVF and got two eggs. They were frozen on day 3, a 10cell A and the other 10 cell AB. I’m conver these embryos are fast for day 3. What are you thoughts and what do you think are the chances on the FET working?
I guess only time will tell!. I would have been able to be more predictive had the embryos been allowed to go to blastocyst before freezing them. Yes they were growing a little fast but that could be in the margin of error. As you know I am against mini-IVF and natural cycle IVF in women with DOR. In my opinion, this does not optimize the ovarian hormone environment and the risk of egg/embryo aneuloidy is increased.
You would in my opinion be better served by a modified, robust, long pituitary down-regulation protocol. I would use an agonist/antagonist conversion protocol with human growth hormone (HGH) augmentation and would recommend Staggered IVF with embryo banking of PGS (next generation gene sequencing)-normal blastocysts, to make hay while the sun still shines.
Please visit my new Blog on this very site, http://www.DrGeoffreySherIVF.com, find the “search bar” and 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
•Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
•Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
•The “Biological Clock” and how it should Influence the Selection and Design of Ovarian Stimulation Protocols for IVF.
•Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
•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?
•IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
•Traveling for IVF from Out of State/Country–
•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
•Implications of “Empty Follicle Syndrome and “Premature Luteinization”
•Premature Luteinization (“the premature LH surge): Why it happens and how it can be prevented.
•IVF Egg Donation: A Comprehensive Overview
•The Fundamental Requirements For Achieving Optimal IVF Success
•Advancing Age of the Woman and IVF: How Old is too old?
I invite you to arrange to have a Skype or an in-person consultation with me to discuss your case in detail. If you are interested, please contact Julie Dahan, at:
Email: Julied@sherivf.com
OR
Phone: 702-533-2691
I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoff Sher
Hi Doctor,
Done another Beta HCG test todays after 25 days of ET and it comes as 7937.
Please see below all the results.
04/20 – 14 days after ET – 646.9
04/27 = 21 Days After ET = 1500
05/01 = 25 Days After ET = 7937
Are the results good. USG has been scheduled on 05/04. Is it OK. Please help with your opinion
You now need do an US to confirm what is happening.
Good luck!
Geoff Sher
Dear Dr.Sher iam writing from overseas iam 40 years old and my husband is 38 years we just got married june 2015 we consulted a fertility specialist and underwent some tests I had hew polyps which were removed by hysteroscopy my husband has low sperm count& motility issues so the Dr suggested IVF/ICSI cycle our first cycle was in feb we got 13 eggs and total 10 embryos in the first fresh cycle 3 embryos were transferred and 8 were frozen the first cycle failed ,we started with an FET cycle April 2 I was given cetrotide injections from 2nd day of my period , and taking progyluton 3 times a day and cyclogest pessaries twice a day on 19th April 2 frozen embryos were transferred 5 days blastocyst stage ,on 27th April was my first Beta HCG and result was 7.2 doctor told me this was a faint positive and I should retent again after 48 hours but in the next test the beta levels were less that 1 since 29th April I started a little spotting with tiny clots my period has not fully started iam very anxious and confused as to understand what went wrong and this is really emotionally draining , we still have 3 frozen embryos and are contemplating to try again this month itself but my periods haven’t started ,what do you suggest or please could you help me understand whats going wrong should I do something different
Hi Mamta,
Sorry for your disappointment. It is more than likely that the blastocysts transferred were not chromosomally normal in spite of their microscopic grade. This would not be surprising at age 40Y. I am wondering why the embryos were not subjected to PGS before freeezing them. To now thaw and test them only to have to refreeze while awaiting results of the testing, would in my opinion be rather traumatic for the remaining frozen embryos. Being that time impacts your biological clock I would thus transfer the remaining embryos ASAP. If that fails, next time round I would suggest selective banking of PGS-normal blastocysts along with a thorough review of your uterine implantation potential before FET. If you would need to startagain, you would in my opinion be bst off using a modified, long pituitary down-regulation protocol. I would use an agonist/antagonist conversion protocol with human growth hormone (HGH) augmentation and would recommend Staggered IVF with embryo banking of PGS (next generation gene sequencing)-normal blastocysts, to make hay while the sun still shines.
Please visit my new Blog on this very site, http://www.DrGeoffreySherIVF.com, find the “search bar” and 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
•Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
•Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
•The “Biological Clock” and how it should Influence the Selection and Design of Ovarian Stimulation Protocols for IVF.
•Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
•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?
•IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
•Traveling for IVF from Out of State/Country–
•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
•Implications of “Empty Follicle Syndrome and “Premature Luteinization”
•Premature Luteinization (“the premature LH surge): Why it happens and how it can be prevented.
•IVF Egg Donation: A Comprehensive Overview
•The Fundamental Requirements For Achieving Optimal IVF Success
•Advancing Age of the Woman and IVF: How Old is too old?
I invite you to arrange to have a Skype or an in-person consultation with me to discuss your case in detail. If you are interested, please contact Julie Dahan, at:
Email: Julied@sherivf.com
OR
Phone: 702-533-2691
Dr. Sher, thank you so much for this forum. I have endometriosis, thyroid problems, age is 36, low AMH (0.38), and FSH (11). My question is would it hurt to take a small dose steroid, LDN, and prograf without the proper testing? My husband and I have been trying for over a year and had three IUI’s. Our next step is IVF my next cycle. I know time isn’t on our side and want to do everything we can to have the best outcome.
There is no evidence of efficay for use of LDN or Progaf and there are risks. I would not do so.
Bigger issues are:
1. Whether you have autoimmune implantation dysfunction linked to NK cell activation (NKa), which occurs in 1/3 of women who have endometriosis. If you do there are tried and tested methods to address this. If you do not have NKa (as measured by the K-562 target cell blood test), then you do not need any immunotherapy (see below)
2. Urgency to undergo IVF ASAP given theat you have diminishing ovarian reserve. AAnd for this, the protocol used for ovarian stimulation is critical (see below). Also the need to consider Staggered IVF and Embryo banking of PGS-normal blastocysts so as to make hay while the sun still shines, is very relevant. You would in my opinion need a modified, robust, long pituitary down-regulation protocol. I would use an agonist/antagonist conversion protocol with human growth hormone (HGH) augmentation (see below)
Please visit my new Blog on this very site, http://www.DrGeoffreySherIVF.com, find the “search bar” and 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
•Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
•Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
•The “Biological Clock” and how it should Influence the Selection and Design of Ovarian Stimulation Protocols for IVF.
•Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
•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?
•Frozen Embryo Transfer (FET): A Rational Approach to Hormonal Preparation and How new Methodology is Impacting IVF.
•Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
•Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
•Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
•PGS in IVF: Are Some Chromosomally abnormal Embryos Capable of Resulting in Normal Babies and Being Wrongly Discarded?
•IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
•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)
•Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
•Uterine Fibroids and Fertility
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF
•The Fundamental Requirements For Achieving Optimal IVF Success
•Being Overweight with a high BMI: How Does it Affect Fertility and IVF Outcome?
•Advancing Age of the Woman and IVF: How Old is too old?
I invite you to arrange to have a Skype or an in-person consultation with me to discuss your case in detail. If you are interested, please contact Julie Dahan, at:
Email: Julied@sherivf.com
OR
Phone: 702-533-2691
I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoff Sher
Dr.Sher,
I am writing from overseas. I am a 36 year old and we (my husband and I) are trying to conceive for 4 years.
1. I had a natural pregnancy in April, 2012 that ended as missed abortion in the 8th GW, after non detected heartbeat.
2. After that we were trying to conceive naturally for 1 year with no success. The doctors suggested AIH: we had 3 AIHs in the period January 2014-June 2014 (0.5mil/ml; 2mil/ml; 0.5mil/ml), negative beta HCGs in all three.
3. Due to the weak spermogram they suggested IVF:
First IVF (August, 2014) was a long protocol: 4 oocytes received, ISCI 1 fertilized oocyte, successful implantation: missed abortion in the 9th GW, heartbeat appeared than disappeared
In order to find the reasons for the abortions, we did examinations: karyotype, imunological (AFA, ANA, peripheral CD3-CD56+ NK lymphocytes, NK cells activity, antithyroid antibodies), thrombophilic mutations.
Everything was negative, except thrombophylia was found and I was suggested using Clexane during future pregnancies
My next IVFs are the following:
May 2015
IVF Microflare: 250IU (5*50IU) Puregon 7 days (day 2-day 8), Suppression: Suprefact 0.1ml+Aqua 0.1ml ( half of the solution) starting 21st day of the previous cycle
Echo 5-6 follicles: OPI 11th day
2 oocytes received: one was in M1 stage
ISCI 0 fertilized oocyte
July 2015
Natural cycle puncture:
Echo 4 follicles: OPI 10th day
0 oocytes received:empty follicle
September 2015
Natural cycle puncture:
OPI 14th day
0 oocytes received:empty follicle
October 2015
IVF Modified natural cycle: 150IU (2*75IU) Gonal F (day 5- day 9), Cetrotide 0.25mg on day 10
2 oocytes received: OPI 12th day
ISCI 1 fertilized oocyte, transferred on 5th day as blastocyste
implantation did not occur
—-Supplements for 3 months : DHEA 25mg, Ubiquinol 600mg, Prenatal vitamins with Omega 3- 300mg, Vitamin D3 -2000IE, Folic acid 800mg
February 2016
IVF agonist-antagonist protocol: Decapeptyl 0.1 (9 days) in the previous cycle
6amp. Fostimon (day 2-day 4), 5amp. Fostimon + 1amp. Merional (day 5-day 11), Cetrotide 1/2 (day 1 -day11)
OPI 12th day
4 oocytes received after denudating cumulus-oocytes complexes: two MII, one MI and one GV.
Both mature oocytes were with irregularities and big polar bodies. After injecting spermatozoa, next day the oocytes were not fertilized and started to degenerate.
MI was matured to MII, ICSI performed, but the result was 4PN.
I was surprised that supplements intended for improving eggs quality resulted in worse egg quality…or maybe it is the protocol result?
What is the reason for empty foliciles?
Otherwise my hormones are in refference range and FSH is 6.5-7. Uterine lining has always been good.
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
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 know that you said that you had been tested for NK cells and these were normal. However, unless the test done was for NK cell activation-NKa (I use the K-562 target cell test) rather than NK cell concentration in the blood, the results are in my opinion without value. The concentration of NK cells is unimportant…rather it is the activation that matters. As for your thrombophila, this in my opinion will notexplain your IVF failures.
Please visit my new Blog on this very site, http://www.DrGeoffreySherIVF.com, find the “search bar” and 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
•Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
•Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
•The “Biological Clock” and how it should Influence the Selection and Design of Ovarian Stimulation Protocols for IVF.
•Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
•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?
•Frozen Embryo Transfer (FET): A Rational Approach to Hormonal Preparation and How new Methodology is Impacting IVF.
•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)
•Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF
•The Fundamental Requirements For Achieving Optimal IVF Success
I invite you to arrange to have a Skype or an in-person consultation with me to discuss your case in detail. If you are interested, please contact Julie Dahan, at:
Email: Julied@sherivf.com
OR
Phone: 702-533-2691
I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoff Sher