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.
Thank you in advance for your time, Dr Sher.
I am 31 and my husband is 40. TTC for 3 years. All baseline testing is normal, including AMH (3.4). Follicle count ~30. Husband had an A+ semen analysis, <10% DNA Frag test, and normal capacitation test. I ovulate on my own and have consistent 29 day cycles. LP is 11-12 days. In last 3 years I have had 2 normal HSGs, 2 normal hysteroscopies, and 1 normal exploratory laparoscopy. I have had one natural chemical pregnancy. I have done 2 rounds of clomid, 4 rounds of Femara, 3 with IUIs. All medicated protocols have yielded 2-3 mature follicles at trigger and 8+ lining but all BFN. First IVF (75 Menopur, 225 Gonal, Lupron trigger) with 30 follicles yielded 10 eggs, 8 mature, 4 fertilized with ICSI, 2 day5 blasts (untested). First FET = BFN, second FET (with aspirin, medrol) = chemical. NEW CLINIC: Second round of IVF with 30 follicles (150-225 Menupor, 225 Gonal with HCG trigger) yielded 18 eggs, 12 mature, 7 fertilized with ICSI, 3 day5 blasts, 2 tested normal. ERA test revealed extra day of progesterone needed (146 hrs). First FET = chemical. I was part of an ERA study group so could not add steroid/blood thinner. Trying to figure out where to go from here with last blast in freezer. Our second round of IVF was out of pocket, and this embryo is our last chance. RE wants to add aspirin, medrol, lovenox for this last FET. We are starting to worry about possible immune/alloimmune issue (DQa)?? Never had combo of extra progesterone AND steroid/lovenox, so maybe that’s the trick? RE not sold on immune testing with limited data.
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/” competence” (capable of propagating a viable pregnancy)”. As stated, the woman’s age plays a big role in determining egg/embryo quality/” competence”. 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). Here, activated uterine natural killer cells (NKa) release excessive TH-1 cytokines that attack the embryo and prevent it from attaching. This is seen in cases of endometriosis where 1/3 of the patients have NKa, in patients with a personal or family history of autoimmune diseases (e.g. autoimmune hypothyroidism /Hashimoto’s disease; Rheumatoid arthritis , Lupus erythematosus etc) and in cases of alloimmune matching between woman and the designated sperm provider.
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?
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ADDENDUM: PLEASE READ!!
INTRODUCING SHER FERTILITY SOLUTIONS (SFS)
Hitherto I have personally performed IVF- treatment and related procedures on patients who, elected to travel to Las Vegas to be managed by me. However, with the launching of Sher-Fertility Solutions (SFS) in April 2019, I have taken on a new and expanded role. Now, rather than having hands-on involvement I confine my services to providing hour-long online Skype consultations to an ever-growing number of patients (emanating from >40 countries), with complex Reproductive problems, who seek access to my input, advice and guidance. All Skype consultations are followed by a detailed written report that meticulously describes and explains my recommendations for treatment. All patients are encouraged to share this report with their personal treating doctor(s), with whom [subject to consent and a request from their doctor] I will, gladly discuss their case with the “treating Physician”.
Through SFS I am now able to conveniently provide those who because of geography, convenience and cost, prefer to be treated at home or elsewhere by their chosen Infertility Physician.
“I wish to emphasize to all patients with whom I consult, that in the final analyses, when it comes to management, strategy, protocol and implementation of treatment, my advice and recommendations are always superseded by that of the hands-on treating Physician”.
Anyone wishing to schedule a Skype consultation with me, can do so by: Calling my concierge (Patti Converse) at 1-800-780-7437 (in the U.S.A or Canada) or 702-533-2691, for an appointment. Patients can also enroll online on my website, http://www.SherIVF.com, or email Patti at concierge@SherIVF.com .
I was very recently greatly honored in receiving an award by the prestigious; International Association of Top Professionals (IAOTP). For more information, go to the press release on my website, http://www.sherIVF.com .
PLEASE HELP SPREAD THE WORD ABOUT SFS!
Geoff Sher
Hi Doctor,
I’m 36 and we had an ICSI fresh transfer. This is my first pregnancy (no previous natural or miscarriages, chemicals, ectopic) after 2 failed cycles where 6 embryos (fresh and fet) were transferred. My first hcg 11dp3dt was 49 and the second 15dp3dt was 379. Are these numbers low?
This looks promising!
Good luck!
Geoff Sher
Hello,
I have been trying for a second child for 5 years and I am 38.
I have just gone through my 11th failed transfer with 2 good quality blastocysts (5bb and 4ab). I have been given everything to help with implantation but have only ever got 1 chemical and 1 blighted ovum the rest were BFNs. My first child was conceived first month of trying naturally. I always get around 3 blastocysts per cycle and they are good quality however on one cycle I was given high dose of drugs (merinol and fostimon) (450) and on this cycle I did not get any good blastocysts. However we have since lowered the drugs and I got the three blastocysts (4ab, 4ab, 5bb) but none have implanted.
I really do not know what else to try. I have done the ERA Test three times and my window of implantation has come back as only 12 hours! I am early receptive at 152 hours and late receptive at 164 hours. On the transfers that we achieved implantation we transferred at 152 hours of progesterone and I was on ivig, prednisone, neuprogen washes and injection, clexane and antibiotics, but we just repeated it all exactly again and this time put 2 blastocysts in and it’s a negative. I don’t know why it did not work this time. I have had LIT in the past and been on suprecur for 3 months to supress my uterus before an FET.
I just really don’t know what to do next. Is there anything else we can do? Is there any way of making my window of inplantation longer? And if not would I need to transfer a hatching blastocyst at 152 hours instead of a 5bb to ensure it is ready to implant? Have you ever seen a patient with a window of inplantation of only 12 hours?
Can taking humira/ ivig/ LIT have a positive affect of the quality of your eggs? Or are these drugs just for implantation? I am really trying to find out why when I followed the exact medications why not even one implanted this time.
Sorry for all the questions. I just really do not know what to do next.
Dr. Sherr,
I am re-posting my original question, at your request. I had not understood your first answer (maybe a language barrier) and by that time, my original post left your queue. This is my original post:
“I have recently read your articles and I’ve realized that at age 40, I should not have been taking 75mg/day of DHEA , so I ordered a number of blood level test myself. The results were: free+WB testosterone 83 ng/dl. It represents 13%. Total testosterone 10.6. DHEA-s: 855. I have seen the normal range and already know they are very high. I am definitely not going to take DHEA anymore, but I would like to know:
– if it is likely these levels had a negative impact on my past cycles?
– should I have rather looked at the rate of conversion?
– I am discontinuing DHEA and I’m guessing I should not start a new protocol until the levels dropped. How far down do we want them? At maximum normal? Will this happen rather fast?
– if hyperthecosis occured, is it permanent?
I will also share the results with my doctor.”
You answered: “It really does not matter. Stop for a few weeks and then retest the level. That will be more significant!”.
Well, here my not being a native speaker comes into play.
– A- I am not sure I understand what you are referring to when you state that ‘IT really does not matter’. Is it 1. the DHEA and testosterone blood levels do not really matter OR 2. checking the rate of conversion does not matter at this point?
– B – I will be testing again in a few weeks, as you suggested. You stated “that will be significant”. What will be significant? Whether testosterone levels have remained permanently high or dropped? Do we expect them to have already dropped all the way to normal levels by then?
Thank you so much again!
A: Is it likely these levels had a negative impact on my past cycles?
A: It is possible yes
2. I am discontinuing DHEA and I’m guessing I should not start a new protocol until the levels dropped. How far down do we want them? At maximum normal? Will this happen rather fast?
A: It likely will take a week or 2 to come down. If it does so, that would be likely a permanent drop. If not, further investigation is required.
Geoff Sher
– if hyperthecosis occured, is it permanent?
Hello,
I have just gone through my 11th failed transfer with 2 good quality blastocysts (5bb and 4ab). I have been given everything to help with implantation but have only ever got 1 chemical and 1 blighted ovum the rest were BFNs. My first child was conceived first month of trying naturally. I always get around 3 blastocysts per cycle and they are good quality however on one cycle I was given high dose of drugs (merinol and fostimon) (450) and on this cycle I did not get any blastocysts. However we have since lowered the drugs and I got the three blastocysts (4ab, 4ab, 5bb) but none have implanted.
I really do not know what else to try. I have done the ERA Test three times and my window of implantation has come back as only 12 hours! I am early receptive at 152 hours and late receptive at 164 hours. On the transfers that we achieved implantation I was on ivig, prednisone, neuprogen washes and injections, clexane and antibiotics, but we just repeated it all exactly again and this time put 2 blastocysts in and it’s a negative. I don’t know why it did not work this time. I have had LIT in the past and been on suprecur for 3 months to supress before an FET.
I just really don’t know what to do next. Is there anything else we can do? Is there any way of making my window of inplantation longer? And if not would I need to transfer a hatching blastocyst at 152 hours instead of a 5bb to ensure it is ready to implant? Have you ever seen a patient with a window of inplantation of only 12 hours?
Sorry for all the questions. I just really do not know what to do next.