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 my last period is on 20 dec 19 and today is 17th jan. I was taken some support medicine for egg release injection on 6th jan. I checked pregnancy test but there is no faint line then I took a beta hcg test today and result is 1.65 and is there any chance of pregnancy or implantation??
I would repeat in 4-7 days.
Geoff Sher
Good evening Dr. Sher,
I have a question about the length of time a 3.75mg IM shot of Lupron stays in the body for. The reason I’m asking is that I was prescribed the shot in Nov 2019, approximately a month before my FET in Dec. I’m currently 9 weeks pregnant with this FET but worried about going off estrace and progesterone at the 12 week mark if the Lupron is still suppressing my reproductive system. Do you have any experience with this particular situation? I should also mention I am of advanced maternal age (40). Thank you so much!
for an FET, WHAT IS THE optimum thickness of the lining that one should consider doing a transfer at ? A lot of websites mention 8mm as a minimum. But don’t mentioned what is the right or good lining thickness. I’m 41, and have only a couple of embryos and I don’t want to transfer until I have the best chances.please advice.
Hello Dr Sher,
I have done 3 ERA tests and it shows that my window of implantation is only 12 hours. From your expertise have you ever come across this and what did you do to help them? Can you lengthen the window of implantation? Thank you in advance.
The blastocyst and the endometrium are in a constant state of cross-talk. In order for successful implantation to take place, the blastocyst must be at the appropriate stage of development, and needs to signal a well synchronized endometrium to ‘accept it”. This dialogue between embryo and endometrium involves growth factors, cytokines, immunologic accommodations, cell adhesion molecules, and transcription factors. These are all mostly genetically driven but are also heavily influenced by numerous physiologic, pathophysiologic, hormonal and molecular mechanisms capable of profoundly affecting the receptivity of the secretory endometrium to the overtures made by the embryo, to implant.
Embryo implantation takes place 6-9 days after ovulation. This period is commonly referred to as the “window of implantation (WOI)”. In the past it was believed that as long as the embryo reached the uterus in this 4 day time frame, its chance of implanting would not be affected.
In 2013, after evaluating 238 genes in the secretory endometrium and applying bioformatics, Ruiz-Alonzo, et all introduced the Endometrial Receptivity Array (ERA). Using this test, they categorized mid-secretory endometria into 4 categories: “a) proliferative, b) pre-receptive, c) receptive or d) post-receptive”. They claimed that women with pre-receptive or post-receptive endometria were more likely to experience failed implantation post-embryo transfer (ET).
It was in large part this research which suggested that the concept of a relatively “wide” (4day) WOI, was flawed, that an optimal WOI is likely much narrower and could be a critical factor in determining the success or failure of implantation post-ET. Ruiz-Alonzo also reported that about 25% of women with recurrent IVF failure (RIF), have pre, or post-receptive endometria. They presented data suggesting that viable IVF pregnancy rates could be enhanced by deferring FET by about 24 hours in women who had pre-receptive endometria and bringing ET forward by the same amount of time, in women with post-receptive endometria,
There is no doubt that ERA testing has opened the door to an intriguing arena for research. Presently however, available data is inconclusive. Here, following recent studies are 2 dissenting opinions regarding the value for ERA:
•Basil and Casper (2018) state: “Performing the ERA test in a mock cycle prior to a FET does not seem to improve the ongoing pregnancy rate in good prognosis patients. Further large prospective studies are needed to elucidate the role of ERA testing in both good prognosis patients and in patients with recurrent implantation failure”
•Churchill and Comstock (2017) conclude:” In our preliminary observations, the non-receptive ERA group had similar live birth rates compared to the receptive ERA group. It appears the majority of the pregnancies conceived in the non-receptive group occurred during ovulatory cycles and thus a non-receptive ERA in a medicated cycle likely does not have prognostic value for ovulatory cycles. Larger studies are needed to assess the prognostic value of ERA testing in the gen-eral infertility population.”
There are additional negatives that relate to the considerable emotional and financial cost of doing ERA testing:
1.First, the process costs $600-$1000 to undertake
2., Second, it requires that the patient undergo egg retrieval, vitrify (cryobank) all blastocysts, res for 1 or more cycles to allow their hormonal equilibrium to restore, do an ERA biopsy to determine the synchronicity of the endometrium, wait a few weeks for the results of the test and thereupon engage in undertaking an additional natural or hormonal preparation cycle for timed FET. This represents a significant time lapse, emotional cost and additional expense.
Presently, ERA testing is only advocated for women who have experienced several IVF failures. However, some authorities are beginning to advocate that it become routine for women undergoing all IVF.
The additional financial cost inherent in the performance of the ERA test ($600-$1000), the considerable time delay in getting results, the fact that awaiting results of testing and preparing the patient for FET, of necessity extends the completion of the IVF/ET process by at least a few months, all serve to increase the emotional and financial hardship confronting patients undergoing ERA. Such considerations, coupled with the current absence of conclusive data that confirm efficacy, are arguments against the widespread use of ERA. In my opinion, ERA testing should presently be considered as being one additional diagnostic and be confined to women with “unexplained” RIF.
Gold standard statistical analyses require that all confounding variables be controlled while examining the effect of altering the one under assessment. There is an obvious interplay of numerous, ever changing variables involved in outcome following ET, e.g. embryo competency, anatomical configuration of the uterus and the contour of the endometrial cavity, endometrial thickness, immunologic and molecular factors as well as the very important effect of technical skill/expertise in performing the ET procedure …(to mention but a few). It follows that it is virtually impossible to draw reliable conclusions from IVF-related randomized controlled studies that use outcome as the end-point. This applies equally to results reported following “gold standard” testing on the efficacy of ERA and, is one of the main reasons why I question the reliability of reported data (positive or negative).
The fact is that IVF (and related technologies) constitute neither a “pure science” nor a “pure art”. Rather they represent an “art-science blend”, where scientific principles applied to longitudinal experience and technical expertise coalesce to produce a biomedical product that will invariably differ (to a greater or lesser degree) from one set of clinical circumstances to another.
Since, the ultimate goal of applied Assisted Reproductive Medicine is to safely achieve the birth of a viable and healthy baby, the tools we apply, that are aimed at achieving this end-point, are honed through the adaptation of scientific principles and concepts, experience and expertise, examined and tested longitudinally over time. Needless to say, the entire IVF/ET process is of necessity subject to change and adaptation as new scientific and technical developments emerge.
This absolutely applies to the ERA as well!
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ADDENDUM: PLEASE READ!!
INTRODUCING SHER FERTILITY SOLUTIONS (SFS)
Founded in April 2019, Sher Fertility Solutions (SFS) offers online (Skype/FaceTime) consultations to patients from > 40 different countries. All consultations are followed by a detailed written report presenting my personal recommendations for treatment of what often constitute complex Reproductive Issues.
Patients are encouraged to share the information I provide, with their treating Physicians and/or to avail themselves of my personal hands-on services, provided through batched IVF cycles that I conduct every 3 months at Los Angeles IVF (LAIVF) Clinic, Century City, Los Angeles, CA.
If you wish to schedule an online consultation with me, please contact my assistant (Patti Converse) by phone (800-780-7437/702-533-2691), email (concierge@SherIVF.com) or, enroll online on then home-page of my website (www.SherIVF.com).
PLEASE SPREAD THE WORD ABOUT SFS!
Geoff Sher
Hi Dr Sher,
My partner just received the result of her blood test today 16th of Jan 2020, and it shows an HCG level of 84. It is 9 days since the transfer of our donor egg in Spain, ( we live in Australia)
My concern is that she has also had some dark discharge today as well.
Is there cause for concern or should we be positive about the 84 HCG result ?
Thanks you in advance
I would be guardedly optimistic!
Good luck!
Geoff Sher
Hi Dr. Sher, I had my first frozen embryo transfer in the spring, which was successful but resulted in a miscarriage at 12 week due to chromosomal abnormalities. I had a d&c after the miscarriage. We have tried two frozen embryo transfers since then and both have been cancelled due to thin lining. My lining during the FET in the spring was 8mm (trilinear pattern) when I started progesterone and 8.8mm on transfer day. The FET was done immediately following a freeze-all egg retrieval. The protocol I used during the second FET was exactly the same as the first (oral estrace 2mg/3 times a day, 2 patches every 3 days, and vaginal viagara), but my lining got just above 7mm (not trilinear pattern) and then decreased to 6.5mm (trilinear pattern). On the third cycle, we tried vaginal estrace 2mg/3 times a day and estrogen IM injections every 3 days with vaginal viagara. The lining only got to about 6.5mm (trilinear). I was also taking baby aspirin, vitamin E, and L-arginine. I took birth control pills before both the 2nd and 3rd FETs. Do you have any thoughts on why my lining is not responding as well and what we can do next time to get it thicker? In the alternative, what are your thoughts on doing a transfer with a lining under 7? Thank you!
My only hope is that the miscarriage and/or the circumstances surrounding the uterine evacuation did not damage the basal endometrium rendering it refractory to estrogen-induced proliferation. The thickness of the lining as measured by US at the time of ET is somewhat irrelevant because progesterone, by inducing the production of endometrial gland secretions will invariably thicken the endometrium. What counts is endometrial thickness on the day of the “trigger” with ovarian stimulation and on the day of initiating progesterone administration for embryo recipiency. At these times the endometrium needs (in my opinion) to measure >8mm in sagital thickness.
It was as far back as 1989, when I first published a study that examined the correlation between the thickness of a woman’s uterine lining (the endometrium), and the subsequent successful implantation of embryos in IVF patients. This study revealed that when the uterine lining measured <8mm in thickness by the day of the “hCG trigger” (in fresh IVF cycles), or at the time of initiating progesterone therapy (in embryo recipient cycles, e.g. frozen embryo transfers-FET, egg donation-IVF etc.) , pregnancy and birth rates were substantially improved. Currently, it is my opinion, that an ideal estrogen-promoted endometrial lining should ideally measure at least 9mm in thickness and that an endometrial lining measuring 8-9mm is “intermediate”. An estrogenic lining of 40 different countries. All consultations are followed by a detailed written report presenting my personal recommendations for treatment of what often constitute complex Reproductive Issues.
Patients are encouraged to share the information I provide, with their treating Physicians and/or to avail themselves of my personal hands-on services, provided through batched IVF cycles that I conduct every 3 months at Los Angeles IVF (LAIVF) Clinic, Century City, Los Angeles, CA.
If you wish to schedule an online consultation with me, please contact my assistant (Patti Converse) by phone (800-780-7437/702-533-2691), email (concierge@SherIVF.com) or, enroll online on then home-page of my website (www.SherIVF.com).
PLEASE SPREAD THE WORD ABOUT SFS!
Geoff Sher