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 a 43 year old woman; I have had 5 rounds of IVF since the age of 39. 2016 – Ist round of IVF (egg retrieval) produced 2 PGS tested embryos – 1st FET – BFN; 2nd FET – chemical pregnancy. 2016 – 2nd round of IVF (egg retrieval)produced no embryos. Then in late 2016 the option for AUGMENT Fertility Treatment was made publicly available in Canada. We decided to go for it; the last 3 rounds of IVF were conducted in Canada (Toronto, Ontario) (2017) and the AUGMENT treatment (use of my mitochondria from my ovaries; taken in Dec. 2016 after laparoscopic surgery) was used/injected into fertilized eggs (my own and my husband’s sperm). We ended up with 2 PGS tested top quality embryos. I birthed my son (2018) from the first embryo and sadly miscarried the second and our last embryo this past Dec. 2019. AUGMENT, unfortunately is no longer an option. I went for another consultation last month with my fertility clinic; my AMH is 2.5 and on Feb. 14/20 have started with a vitamin regime including: DHEA; PQQ; CoQ10; baby aspirin; fish oil with DHA; folic acid; magnesium; and vitamin c. Apparently, my clinic is now using Saizen or HGH for women over the age of 40 when leading up to the egg retrieval. In your opinion, how long should these vitamins be taken before proceeding with the egg retrieval protocol? Also, what is your recommendation for Saizen intake (when to start etc.)? I am reading many conflicting reports/medical journals that suggest either starting up to six weeks before the egg retrieval or several weeks before menstrual cycle. Any input would be greatly appreciated.
You can take the supplemental vitamens for as long as you wish. Ideally, at least for 1 month. Respectfully, I do not recommend DHEA.
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)
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,
Are you please able to comment on my HCG levels post transfer of a cavitating blastocyst – my team aren’t thrilled with the level of HCG, but it is doubling every 2 – 3 days. I posted previously, I’ve been bleeding light flow since a week after transfer (and still bleeding-spotting) and I’m on aspirin and plaquenil.
9 day post Tx – 28
11 days post Tx – 90
13 days post Tx – 198
16 days post Tx – 445
18 days post Tx (today) – 745
Progesterone steady at 50nmol/L throughout (on vaginal progesterone)
I appreciate your thoughts. I’ll be doing an ultrasound in a week
This could still be a viable pregnancy. I would wait about 10ndays and do an ultrasound for confirmation one way or the other.
Geoff Sher
Hello there Dr Sher,
My name is Claire and I am a very close family – friend of Dr Harry Johnson from all the way across the Sea’s in Bondi, Sydney, Australia. He invited me to contact you for some advice. As we don’t know of anyone over this way, whom are of your knowledge and expertise. I am a 46 year old women looking to conceive. However, my hormonal levels are basically very low. What form of treatment would you recommend to increase my levels? Love and gratitude.
Hi Claire!
Yes, Harry is my very dearest frriend.
I suggest you contact my assistant, Patti Converse at 702-533-2691 and set up an online discussion with me and I will try to help.
However, I know this is not what you want to hear but at 46y, ther only rational alternative for you nwould be to consider IVF with egg donation.
G-d bless and please send my fondest wishes to Harry and his wife Anita!
Geoff
Hello Dr. Sher,
Does freezing sperm affect its ability to fertilize the egg in any way? Last month, I did a retreival and 15 eggs were retreived. 12 of the eggs were mature and 10 had fertilized using frozen sperm and the ICSI method. After 3 days only 5 out of the 10 had acheived cleavage (although 2 were fragmented). These 5 also made blastocyst at day 6 (although slow growing and small expansion). Interestingly, all 5 of the embryos PGS tested female and only 1 was normal. The odds of all 5 (5/5) being female is very low so I having been wondering if somehow the freezing destroyed the Y sperm? My husband does have another son and plenty of males in his family. Any thoughts on this?
If the sperm frozen was derived from a fertile male, the freezing would have no advese effect on its fertilizing capacity>
Geoff Sher
Hello Dr. Sher,
Wondering what are your thoughts on Low Dose Naltrexone for helping with fertility problems? The doc at our clinic prescribes it at a daily dose of 4.5 mg to help decrease inflamation and possibly help with autoimmune problems.
In my opinion, there is no proven benefit!
Geoff Sher