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, I am pregnant via ivf and I was asked to stop my progesterone shots at 8 weeks and 3 days. On that day my level was 32 ng/ml. I was discharged from my clinic at 9 weeks and then my level was 18ng/ml. Is this something I should worry about. My embryo is pgs normal and I just turned 39
No reason for concern, in my opinion!
Good luck!
Geoff Sher
Hello Dr. Sher
I just had a transfer of two 5 day blastocyst one of which was hatching 7 days ago. 6 days past transfer my beta was 48. I have to do immune therapy so the immunologist wanted it tested early. Today 7 days past transfer I had a beta at a different lab and it was 43. Even though it’s only been 24 hours isn’t it suppose to go up not down? Does this sound like a chemical pregnancy or could it still be the trigger shot that I had 15 days ago? I really would appreciate your opinion. Thank you so much.
It is too early to tell. You need at least 9 days post blastocyst transfer for the first beta-hCG test.
Geoff Sher
Hi Dr. Sher,
After 4 IVF cycles. I’ve been advised by my RE that I need donor eggs despite normal blood work and a good response to medication. I have never tried to get pregnant naturally because I have a genetic mutation that I’ve been using PGT-A/PGT-M screening for. IVF has not worked well for me and I was originally told I was completely normal. My AMH is 6.146 ng/ml or 43.9 pmol/L LH 6.6U/L FSH 6.8 U/L. My uterine lining also struggles to get to 7mm.
IVF Cycle 1- Was antagonist cycle, 450 units of Gonal F and 150 of Luveris my estrogen was 8172 on day of trigger, I was diagnosed with empty follicle syndrome because they prescribed Cetrotide to take after the trigger and I triggered with triptorelin and they found I did not ovulate. 0 eggs were retrieved. Unsure of follicle size at time of trigger or trigger dose.
IVF cycle number 2, agonist I was on birth control for about 2 months as well as Lupron to down regulate, Lupron reduced from 10 to 5 units at start ot STIMS 300 of Gonal F, 150 of Menopur, triggered with 10 000 Pregnyl after 10 nightly doses of STIMS and also after my estrogen dropped from 3648 to 3502 overnight. Used 300 Gonal F 300 on the night I triggered (day 11). 23 eggs retrieved 12 mature 10 fertilized, 6 good enough for biopsy. 2 pgs normal. left ovary day of trigger 16, 15, 15, 15, 15, 15, 14, 13, 12, 10, 9 right ovary day of trigger 20, 19, 18, 18, 17, 16, 16, 15, 15, 14, 11, 11. ICSI was perfomed.
IVF cycle number 3 agonist- I spent less time on birth control only about 19 days, overlapping with Lupron 10 units, Lupron reduced to 5 units at start of STIMS with 300 Gonal F150 Menopur, triggered after 8 doses of STIMS with 7500 pregnyl and my estrogen was about 4889 on trigger day. 31 eggs retrieved, only 6 mature, 5 fertilized, 5 made it to day 5 but only 3 good enough to biopsy one pgs normal one inconclusive. Follicles on trigger were right ovary 16, 15, 15, 15, 15, 14, 13, 12, 12, 9 left ovary 19, 19, 18, 17, 16, 16, 15, 15, 14, 14, 13, 13, 12, 10. ICSI was performed.
Ivf cycle number 4- Antagonist protocol. Birth control for 19 days. Gonal F 300 Menopur 150. Antagonist Orglatron 250 starting on Day 5 without any bloodwork or ultrasound. Day of trigger estrogen was 5441 after 10 doses of STIMS follicles were on right ovary 18, 18, 18, 16, 16, 16, 15, 15, 15, 14, 14, 13, 13 and left ovary 19, 19, 18, 18, 17, 17, 17, 17, 17, 17, 16, 15, 15, 14, 14, 14, 13, 13, 12, 10 on trigger day. Trigger with 10000 Pregnyl. Retrieval was about 37.5 hours after retrieval. 23 eggs retrieved. 15 mature. 8 fertilized. only 4 fertilized normally. Three had 3 nucleus. ICSI was performed.
It seems like my eggs have a problem maturing properly during IVF or come out fried. Is it me or the protocol? I’m 31 and healthy BMI and healthy lifestyle. Very little caffeine and alcohol. Is there a point in trying naturally with termination for medical reasons or doing another IVF cycle or should I move to donor eggs? I’m open to donor eggs.
In my opinion, based on the information you provided, unless you are in your mid-40’s, you do NOT require an egg donor. Something else is going on here and I think the protocol used for ovarian stimulation may have a lot to do with it. Also, the timing of the trigger shot might have been too soon, in an effort to prevent OHSS. There are other ways to address the latter.
I think we can improve on your mature egg yield and also your blastocyst conversion rate. Also important is to exclude an implantation dysfunction, since the transfer og euploid eggs did not yield a pregnancy in you.
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 15y 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?
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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
I am on CD29, 12-13 DPO per temping (pos OPK on CD 16 and temp rise on CD 17). My typical cycle length is 27-28 days and my typical luteal phase is 11-12 days. Urine tested negative yesterday and today on FRER, and no period yet. Also, my temps usually peak around 8-9 DPO then gradually decline… this cycle, my temp dipped slightly at 8 DPO, then increased again on 9DPO, and have been higher than I’ve ever seen since. I had a quantitative beta HCG test done in 2016 ago when I was taking Isotretinoin and looked back to see that my levels were <1 mIU. Am I likely just too early to be testing with urine? At what point do I go to my OB if I continue getting negative urine pregnancy tests but don't get my period? I know I may still be "early" because of my shorter luteal phase, but am concerned because I don't have a thyroid so I know I need to be proactive about measuring my TSH and Synthroid dosage accordingly.
I cannot address all this authoritatively without a much more detailed background. I suggest you call my assistant Patti and set up ma Skype consultation with me to discuss.
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ADDENDUM:
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 assistant, (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 .
Geoff Sher
I have had 3 egg retrievals with the end result of one embryo out of 5 making it through testing. That transfer ended in a chemical pregnancy. All extensive testing has been fine other than one damaged but open Fallopian tube. Would you continue with retrievals using the same protocol or is there something else I can do to improve results? Is it harmful to continue retrievals in the span of 6 months?