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.
Do you have a clinic in Portland, Oregon or to get an evaluation of an autoimmune fertility problem, does one need to go to Las Vegas?
Sorry No!
Geoff Sher
Dr. Sher,
I am 43 and pregnant with twins, almost 12 weeks. I go in for testing and meeting a doctor at Fetal Maternal health in the Seattle area. I have been encouraged to ask about reduction to a singleton. Could you tell me the average risk of miscarriage to the remaining embryo. I am aware that my doctor will take my health and personal issues into consideration and advise me, however I am new to this idea and though and have just begun research. This is my first child, conceived without fertility treatment after taking a break from fertility medications for 7 unsuccessful months. Any advice or good questions I should be asking? Thanks, Stacy
Th the risk of miscarriage with selective pregnancy reduction done in the 2nd trimester is about 5% and in my opinion is not significantly higher when fraternal (dizygotic) twins are reduced t a singleton than when higher multiplse are reduced to a twin pergnancy. But to reduce twins to a sigleton pregnancy it must first be established that you are not dealing with identical (monozygotic) twins because in such cases there is indeed a significant risk of losing both.
Below is an article I wrote a few years ago but it is equally applicable to the present day setting:
SELECTIVE FETAL REDUCTION (SFR): AN ETHICAL DILEMMA OR MORAL IMPERATIVE?
Geoffrey Sher MD
The introduction of ovulation induction drugs such as clomiphene citrate and urinary-derived gonadotropins (menotropins) in the 60’s, followed about 15 years later by in vitro fertilization (IVF), markedly improved the success of infertility treatment, but at the same time it heralded a virtual explosion in the incidence of multiple gestations. In spite of this, the likelihood in any given case of achieving a viable pregnancy by these methods still remains somewhat unpredictable.
The high cost of IVF treatment in the United States (>$14,000 per cycle) coupled with a relatively low birth rate per embryo transferred to the uterus has resulted in an unfortunate tendency for couples undergoing IVF as well as doctors performing IVF to transfer multiple embryos to the uterus in hopes of maximizing success potential. The downside to such practice, of course, is the risk multiple gestations , especially “high order multiples” (triplets or greater) with their serious incumbent medical risks to both the mother and babies as well as the substantial toll it takes on and on the healthcare system. The short and long-term health risks that the babies face is also a tremendous financial burden to the family and to society, as many of these babies face the prospect of “cradle to grave” medical care due to prematurity-related medical conditions. The cost of providing such care now exceeds two billion dollars per year in the United States alone.
It has been reported that in about 40% of high order multiple pregnancies, one or more of the babies will either not survive the neonatal period or will suffer chronic from physical and/or neurologic complications associated with premature birth. The magnitude of the problem is further evident from statistics’ that show that from 1980-2006 the number of annual live babies born from twin gestations rose > 50%, while the incidence of high-order multiple gestations (triplets or greater) increased by > 400%.
It is the prospect of such disaster that often prompts prospective parents to consider selective fetal reduction in the case of a high-order gestation (SFR). Though a heart-rending decision, SFR is a relatively safe procedure whereby it is possible to reduce the number of concepti in the uterus without harming the remaining one(s). It involves the injection of a lethal chemical under guidance by ultrasound, directly into the heart chamber(s) of one or more developing concepti around the end of the first trimester of pregnancy. This results in the conceptus immediately succumbing whereupon it is slowly absorbed over a number of weeks, without doing harm to the surviving concepti. Provided that it is not done to reduce “monozygotic” (identical) multiples that share the same blood supply, and that the procedure is conducted by an expert, selective fetal reduction rarely (i.e. in less than 5% of cases) will result in loss of the entire pregnancy. The procedure is performed in the early second trimester (after the 12th week).
The only sure way to avoid the risk of high order multiple pregnancies is to insure that no more than one embryo reaches the uterus. With IVF this can be achieved by limiting the number of embryos transferred. However, when it comes to methods of ovulation induction that do not involve IVF (e.g. the use of fertility drugs alone or in combination with intrauterine insemination), it is not possible to prevent this problem from occurring.
It is my intent to rapidly move to single embryo (blastocyst) transfers (SET). Blastocysts are much more viable than day 2 or day 3 embryos. Besides, embryos that do not reach the blastocyst stage in culture are almost always “incompetent” (chromosomally abnormal) and unworthy of being transferred, anyway. Thus I believe that it would be prudent, to transfer the first blastocyst fresh and then vitrify all left over embryos. Thereafter, if this does not result in a live birth, the remaining frozen blastocysts could be transferred one at a time in ensuing cycles until a pregnancy results or all are used up. Most important is the fact that such an approach would yield the same overall baby rate per egg retrieval conducted as would the transfer of all available multiple births.
Since embryo quality declines with the age of the egg provider age, a SET policy might not be suited to women over 35 years of age. In such cases a double embryo (blastocyst) transfer (DET) policy conducted along the same lines, might be more appropriate.
Notwithstanding the above, the occurrence of high order multiple pregnancies are and will for some time remain a harsh reality. And when that happens, I would respectfully submit that given the gravity of the risks associated with high order multiple pregnancies, SFR, rather than being decried from the bully pulpit as being unethical, might better be described as a moral decision whose purpose it is to optimize the quality of life after birth. Furthermore, given the heart- rendering nature of such a decision, it should perhaps even be regarded as a brave and laudable attempt to optimize the quality of life after birth.
I hope this helps
Geoff Sher
Dear Dr Sher,
A) What causes a period to get delayed after egg retrieval? My RE said I should get my period 14 days after failed fertilisation egg retrieval. It has been 20 days and still waiting.
B) Is there anything I can do to get my period? Vitamins etc
C) Can I start IVF cycle when the period comes? Given that I am 40 I do not want to skip a cycle if I can help it. Unless the drugs reduce egg quality.
Thank you
Sheila
Outside of a pregnancy (excluded through pregnancy blood testing and ultrasound examination) theusual reason is the presence of retained post ER-ovarian cysts.
You could just wait it out until a period comes or if there is a cyst it can be aspirated. If there is no cyst then the administration of oral progesterone for 5-10 days and then stopping will usually rresult in bleeding within a week.
I would not start another cycle until the period ensues.
Please visit my new Blog on this very site, 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)
•The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF
•The Role of Nutritional Supplements in Preparing for IVF
•Measuring and Interpreting Blood hCG to Assess Pregnancy Viability Following ART Treatments.
I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
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 currently doing preparation for FET at the end of this month. At this time I am off of the BCP now. Per my husband, just asking if unprotected intercourse at this time is not recommended. I don’t want any disasters (accidental pregnancy on the protocol) as were preparing for this transfer.
Thanks
I would agree with those who advise trying to avoid an accidental pregnancy in the interim.
Geoff Sher
Doctor Sher,
After fertilization takes place what are the causes for embryos to stop growing between days 1-5? Egg? Sperm? Both or unknown? Looking good on day 3 and fall away by day 5?
Can a trigger of 5000 instead of 10000 impact egg quality?
Could daily menopur 250 impact egg quality? Is this dosage too high in your opinion?
5CB – Would you consider this a good quality embryo?
Apologies if duplicate postings – not sure if it went through initially.
Thanks
M
Looking good on day 3 and stopped by day 5?
Thank you,
M
Hi Mick!
1. After fertilization takes place what are the causes for embryos to stop growing between days 1-5? Egg? Sperm? Both or unknown? Looking good on day 3 and fall away by day 5?
A: Aside from age and severely diminished ovarian reserve, the commonest reason relates to the choice and implementation of the protocol for ovarian stimulation….(see belw
2.Can a trigger of 5000 instead of 10000 impact egg quality?
A: In my opionion…yes indeed it can and does. 5,000U ofhCH or 250mcg Ovidrel is too little. You need 10,000U hCG or 500mcg of Ovidrel
3. Could daily menopur 250 impact egg quality? Is this dosage too high in your opinion?
A: I prefer not to use >75u Menopur daily. The rest is given as purified FSHr (Follistim/Puregon or Gonal-F)
4. 5CB – Would you consider this a good quality embryo?
I am not familiar with this classification…sorry
Please visit my new Blog on this very site, 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)
•Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
•Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
•IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
•Unexplained IVF Failure
•Recurrent Pregnancy Loss (RPL): Why do I keep losing my Pregnancies?
•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)
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF
•The Role of Nutritional Supplements in Preparing for IVF
I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
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
M
Looking good on day 3 and stopped by day 5?
Thank you,