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 Dr. Sher,
I am Sreeja, married 4years back. 4 years before my marriage i was underwent an open surgery for right ovarian cystectomy and it was a benign cyst. After 2 month of my marriage got an ectopic pregnancy on left tube and salphinjectomy done for that and my doctor told me that the ectopic happened because of the adhesion that resulting from the open surgery. But right tube has no adhesion. After one year we were tried to conceive for 6 month but not. Consult an infertility doctor and he given ovulation induction, but not conceived and iui also tried for 4 times, result was negative. And my doctor suggested HSG and the tube is filled with dye and some spillage to peritoneum. He told me that there may be a distal block and he gave me 2 options. 1 is lap for tubal assessment (HLS) and 2 is IVF. Will HLS can remove the distal block? Which option is suitable for me?
I would definitely opt for IVF!
Geoff Sher
Hello Dr. Sher,
I tested positive for two copies – C677T/A1298C – of the mutation for MTHFR. Just wondering if I need to do a Homocysteine level check to decide on the Lovenox treatment
-or-
do I have to take the Lovenox anyways irrespective of the Homocysteine result.
Please let me know. Thanks
In my opinion, since dail Lovenox (started after a pregnancy is diagnosed) and continued throughout pregnancy is safe and will NOT affect the baby, I would take this treatment, regardless!
Thrombophilia (Hereditary Clotting Defect) is defined as the genetic predisposition to developing intravascular thrombosis. It is due to hypercoagulability of blood leading to impairment of initial vascularization that takes place during implantation.
Thrombophilia affects as many as one in five people in the United States and is responsible for pregnancy loss (most particularly after the 1st trimester) and “unexplained” infertility, as well as being a factor in some cases of “unexplained” IVF failure. Whether (and/or the extent to which) thrombophilia causes 1st trimester recurrent pregnancy loss (RPL) is the subject of debate and is controversial. In fact, first-trimester RPL is far more likely to be due to immunologic implantation dysfunction (IID) and/or irregularities in the contour of the uterine cavity or insufficient thickness of its lining (a thin endometrium). Thrombophilia has also been associated with late pregnancy-induced complications such as preeclampsia, premature separation of the placenta (abruptio placenta), placental insufficiency with intrauterine growth retardation, and in “unexplained” intrauterine death.
This having been said, it is a fact that most women with a thrombophilia go on to experience healthy pregnancies.
Diagnosis of Throbophilia
Thrombophilia is diagnosed when one or more of the following is detected:
•Mutational defect involving methylenetetrahydrofolate reductase (MTHFR), which occurs in at least 20% of affected cases. Homozygosity for a common C677T mutation in the MTHFR gene that is associated with hyperhomocysteinemia is the most common form of hereditary thrombophilia leading to a 3-fold increase in risk of complications.
•Mutation of factor V Leiden (FVL),
•A mutation of prothrombin G20210A,
•Deficiency of antithrombin III
•Deficiency of protein C
•Deficiency of protein S
Risk Factors
•Pregnant women with predisposing factors such as:
•A personal or family history of thromboembolism (deep vein thrombosis), pulmonary embolism (blood clot in the lung), cerebrovascular accidents (i.e. strokes)
•A personal history of pregnancy complications such as unexplained intrauterine death, preeclampsia, abruptio placenta, intrauterine growth retardation, placental insufficiency, should be tested for the condition.
Treatment
Treatment should be initiated as soon as possible after pregnancy is diagnosed biochemically (blood or urine hCG test) and be continued throughout gestation.
Severe thrombophilias (e.g. homozygous MTHFR mutations, protein C deficiency, prothrombin G20210A mutation) as well as cases of mild thrombophilias associated with one or more of the pregnancy complications mentioned above, are best treated with low-molecular weight heparin (LMWH).
For other (milder) thrombophilias and no history of prior pregnancy complications: Low-dose aspirin with the B vitamins folic acid, B6 and B12.
Geoff Sher
Hi Dr Sher,
I am a 33 yr old female. I was diagnosed with Premature Ovarian Syndrome. (CD3 testing: FSH 9.5, AMH 0.876, LH 6.3, Estradiol 43.1) I’ve done two IVF cycles in a three-month period. No transfers have been performed yet, only retrievals and PGS testing. IVF results have not been ideal. Before we embark on a third cycle we are pausing.
I am taking pre-natal, EPA/DHA Omega 3, and CoQ10 600 mg
(last one just started in December)
Blood tests and ultrasounds required for IVF treatment are normal, I’m not overweight and have a normal BMI. Stress levels are normal. Husband and I had the Horizon carrier screening test done and geneticist told us there was nothing we could pass on to the child. Husband semen analysis came back normal. In November, I had a laparoscopy cancelled since fertility doctor recommended not to do it ( OBGY suspected endometriosis).
First cycle protocol:
Gonal F 300 units evening only
Menopur 150 units evening only
Cetrotide
leupron 4 mg
Results:
12 eggs retrieved
9 mature
5 fertilized(icsi method)
2 made it to D5 (1 in excellent condition, 1 fair condition)
1 passed the PGS testing (the “excellent” one)
Second cycle protocol:
Gonal F 300 units evening only
Menopur 150 units evening only
*Added – HGH (Omnitrope)
Cetrotide
leupron 4 mg
Results:
8 eggs retrieved
8 mature
6 fertilized (icsi method)
3 made it to D5 (1 in excellent condition, 2 fair)
1 passed the PGS testing (the “excellent” one)
For the third cycle, doctor has suggested we follow the same protocol as the second one (see below for details) I am just wondering if this is a good idea? I am lost as to what else I could be doing /taking OR if we should change direction and look into a different protocol. This third cycle will be the last one that is covered by insurance too. (Our family goal is to have two kids, so we are planning for that, but with the results we’ve been getting with our embryos, we are just keeping our hopes in check)
Thank you in advance,
Veronica
Hi Dr Sher, I had pgs testing on my embryo. It came back as partial monosomy 8 (8q22.3-8qter) Do you know if this could still be transferred or would need to be destroyed?
I would probably transfer it in the hope of it being a mosaic. However please read below:
Human embryo development occurs through a process that encompasses reprogramming, sequential cleavage divisions and mitotic chromosome segregation and embryonic genome activation. Chromosomal abnormalities may arise during germ cell and/or preimplantation embryo development and represents a major cause of early pregnancy loss. About a decade ago, I and my associate, Levent Keskintepe PhD were the first to introduce full embryo karyotyping (identification of all 46 chromosomes) through preimplantation genetic sampling (PGS) as a method by which to selectively transfer only euploid embryos (i.e. those that have a full component of chromosomes) to the uterus. We subsequently reported on a 2-3-fold improvement in implantation and birth rates as well as a significant reduction in early pregnancy loss, following IVF. Since then PGS has grown dramatically in popularity such that it is now widely used throughout the world.
Many IVF programs that offer PGS services, require that all participating patients consent to all their aneuploid embryos (i.e. those with an irregular quota of chromosomes) be disposed of. However, growing evidence suggests that following embryo transfer, some aneuploid embryos will in the process of ongoing development, convert to the euploid state (i.e. “autocorrect”) and then go on to develop into chromosomally normal offspring. In fact, I am personally aware of several such cases having occurred in my own practice. So clearly, summarily discarding all aneuploid embryos as a matter of routine we are sometimes destroying some embryos that might otherwise have “autocorrected” and gone on to develop into normal offspring. Thus by discarding aneuploid embryos the possibility exists that we could be denying some women the opportunity of having a baby. This creates a major ethical and moral dilemma for those of us that provide the option of PGS to our patients. On the one hand, we strive “to avoid knowingly doing harm” (the Hippocratic Oath) and as such would prefer to avoid or minimize the risk of miscarriage and/or chromosomal birth defects and on the other hand we would not wish to deny patients with aneuploid embryos, the opportunity to have a baby.
The basis for such embryo “autocorrection” lies in the fact that some embryos found through PGS-karyotyping to harbor one or more aneuploid cells (blastomeres) will often also harbor chromosomally normal (euploid) cells (blastomeres). The coexistence of both aneuploid and euploid cells coexisting in the same embryo is referred to as “mosaicism.”
It is against this background, that an ever-increasing number of IVF practitioners, rather than summarily discard PGS-identified aneuploid embryos are now choosing to cryobanking (freeze-store) certain of them, to leave open the possibility of ultimately transferring them to the uterus. In order to best understand the complexity of the factors involved in such decision making, it is essential to understand the causes of embryo aneuploidy of which there are two varieties:
1.Meiotic aneuploidy” results from aberrations in chromosomal numerical configuration that originate in either the egg (most commonly) and/or in sperm, during preconceptual maturational division (meiosis). Since meiosis occurs in the pre-fertilized egg or in and sperm, it follows that when aneuploidy occurs due to defective meiosis, all subsequent cells in the developing embryo/blastocyst/conceptus inevitably will be aneuploid, precluding subsequent “autocorrection”. Meiotic aneuploidy will thus invariably be perpetuated in all the cells of the embryo as they replicate. It is a permanent phenomenon and is irreversible. All embryos so affected are thus fatally damaged. Most will fail to implant and those that do implant will either be lost in early pregnancy or develop into chromosomally defective offspring (e.g. Down syndrome, Edward syndrome, Turner syndrome).
2.Mitotic aneuploidy (“Mosaicism”) occurs when following fertilization and subsequent cell replication (cleavage), some cells (blastomeres) of a meiotically normal (euploid) early embryo mutate and become aneuploid. This is referred to as “mosaicism”. Thereupon, with continued subsequent cell replication (mitosis) the chromosomal make-up (karyotype) of the embryo might either comprise of predominantly aneuploid cells or euploid cells. The subsequent viability or competency of the conceptus will thereupon depend on whether euploid or aneuploid cells predominate. If in such mosaic embryos aneuploid cells predominate, the embryo will be “incompetent”). If (as is frequently the case) euploid cells prevail, the mosaic embryo will likely be “competent” and capable of propagating a normal conceptus.
Since some mitotically aneuploid (“mosaic”) embryos can, and indeed do “autocorrect’ while meiotically aneuploid embryos cannot, it follows that an ability to reliably differentiate between these two varieties of aneuploidy would potentially be of considerable clinical value. The recent introduction of a variety of preimplantation genetic screening (PGS) known as next generation gene sequencing (NGS) has vastly improved the ability to reliably and accurately karyotype embryos and thus to diagnose embryo “mosaicism”.
Most complex aneuploidies are meiotic in origin and will thus almost invariably fail to propagate viable pregnancies. The ability of mosaic embryos to autocorrect is influenced by stage of embryo development in which the diagnosis is made, which chromosomes are affected, whether the aneuploidy involves a single chromosome (simple) or involves 3 or more chromosomes (complex), and the percentage of cells that are aneuploid. Many embryos diagnosed as being mosaic prior to their development into blastocysts (in the cleaved state), subsequently undergo autocorrection to the euploid state (normal numerical chromosomal configuration) as they develop to blastocysts in the Petri dish. This is one reason why “mosaicism” is more commonly detected in early embryos than in blastocysts. Embryos with segmental mosaic aneuploidies, i.e. the addition (duplication) or subtraction (deletion), are also more likely to autocorrect. Finally, the lower the percentage of mitotically aneuploid (mosaic) cells in the blastocyst the greater the propensity for autocorrection and propagation of chromosomally normal (euploid) offspring. A blastocyst with <30% mosaicism could yield a 30% likelihood of a healthy baby rate with 10-15% miscarriage rate, while with >50% mosaicism the baby rate is roughly halved and the miscarriage rate double.
As stated, the transfer of embryos with autosomal meiotic trisomy, will invariably result in failed implantation, early miscarriage or the birth of a defective child. Those with autosomal mitotic (“mosaic”) trisomies, while having the ability to autocorrect in-utero and result in the birth of a healthy baby can, depending on the percentage of mosaic (mitotically aneuploid) cells present, the number of aneuploid chromosomes and the type of mosaicism (single or segmental) either autocorrect and propagate a normal baby, result in failed implantation, miscarry or cause a birth defect (especially with trisomies 13, 18 or 21). This is why when it comes to giving consideration to transferring trisomic embryos, suspected of being “mosaic”, I advise patients to undergo prenatal genetic testing once pregnant and to be willing to undergo termination of pregnancy in the event of the baby being affected. Conversely, when it comes to meiotic autosomal monosomy, there is almost no chance of a viable pregnancy. in most cases implantation will fail to occur and if it does, the pregnancy will with rare exceptions, miscarry. “Mosaic” (mitotically aneuploid) autosomally monosomic embryos where a chromosome is missing), can and often will “autocorrect” in-utero and propagate a viable pregnancy. It is for this reason that I readily recommend the transfer of such embryos, while still (for safety sake) advising prenatal genetic testing in the event that a pregnancy results.
Given our ability to recognize “mosaicism” through karyotyping of embryos, the question arrases as to which “mosaic” embryos are capable of auto-correcting in-utero and propagating viable pregnancies. Research suggests that that virtually no autosomal monosomy embryos will propagate viable pregnancies. Thus, the transfer of such mosaic embryos is virtually risk free. Needless to say however, in any such cases, it is essential to make full disclosure to the patient (s), and to insure the completion of a detailed informed consent agreement which would include a commitment by the patient (s) to undergo prenatal genetic testing (amniocentesis/CVS) aimed at excluding a chromosomal defect in the developing baby and/or a willingness to terminate the pregnancy should a serious birth defect be diagnosed.
I strongly recommend that you visit http://www.SherIVF.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.
•A Fresh Look at the Indications for IVF
•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.
•Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
•Controlled Ovarian Stimulation (COS) in Older women and Women who have Diminished Ovarian Reserve (DOR): A Rational Basis for Selecting a Stimulation Protocol
•Optimizing Response to Ovarian Stimulation in Women with Compromised Ovarian Response to Ovarian Stimulation: A Personal Approach.
•Hereditary Clotting Defects (Thrombophilia)
•Blastocyst Embryo Transfers done 5-6 Days Following Fertilization are Fast Replacing Earlier day 2-3 Transfers of Cleaved Embryos.
•Embryo Transfer Procedure: The “Holy Grail in IVF.
•Timing of ET: Transferring Blastocysts on Day 5-6 Post-Fertilization, Rather Than on Day 2-3 as Cleaved Embryos.
•IVF: Approach to Selecting the Best Embryos for Transfer to the Uterus.
•Fresh versus Frozen Embryo Transfers (FET) Enhance IVF Outcome
•Frozen Embryo Transfer (FET): A Rational Approach to Hormonal Preparation and How new Methodology is Impacting IVF.
•Staggered IVF
•Staggered IVF with PGS- Selection of “Competent” Embryos Greatly Enhances the Utility & Efficiency of IVF.
•Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
•Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation
•Preimplantation Genetic Testing (PGS) in IVF: It should be Used Selectively and NOT be Routine.
•IVF: Selecting the Best Quality Embryos to Transfer
•Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
•PGS and Assessment of Egg/Embryo “competency”: How Method, Timing and Methodology Could Affect Reliability
•IVF outcome: How Does Advancing Age and Diminished Ovarian Reserve (DOR) Affect Egg/Embryo “Competency” and How Should the Problem be addressed.
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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.
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
Are you still taking patients at this time and would you recommend waiting to start ivf given the current Corona Crisis?
I am definitely consulting online, but I would not start doing IVF until this Pandemic is over.
Until very recently, I have been personally treating patients as well as performing their IVF-related procedures. But there is a season for all things. Thus ,I have decided to step away from performing hands-on treatment and have elected to recommend to my patients that they undergo IVF treatment with my esteemed associate and close friend, Aykut Bayrak MD, at LA-IVF, 2080 Century Park East, Century City, Los Angeles, CA 9006. As has always been the case with me in the past, treatment with Dr Bayrak at LA-IVF will require your spending no more than 7-14 days in West Los Angeles at a pre-designated time and with advanced notice.
About LA-IVF: Dr. Bayrak is an outstanding RE with whom I worked hand in hand in NY and LA for about a decade during his tenure with me at Sher Institutes for Reproductive Medicine (SIRM). I chose to work with Dr. Bayrak because of his clinical prowess, his outstanding standard of care (and caring) and due to the fact that when it comes to the practice of IVF and related procedures, he and I have grown to think and act very much alike. Moreover, Dr. Bayrak has undertaken and committed to apply my recommendations as well as the protocols I prescribe. You can also be assured that I will make myself available to the entire LA-IVF team with regard to the implementation of your treatment, every step along the way.
Another strong incentive for me to work with LA-IVF is that Levent Keskintepe PhD, recently joined the LAI-VF team as Chief embryologist. I originally (about 20 years ago) recruited Dr. Keskintepe to manage all the IVF laboratories at multiple Sher Institutes for Reproductive Medicine (SIRM) located throughout the United States. Ever since, he and I have worked hand-in-hand and together in 2006 developed and introduced preimplantation genetic testing- PGT (currently used in >4,000IVF centers worldwide). We since, published numerous articles on this important advance, which proudly has greatly improved IVF outcomes universally.
If you are interested in having me involved in your treatment at LAIVF, please contact my assistant, Patti Converse by email at concierge@sherivf.com or by phone (702-533-2691).
Sincerely,
Geoff Sher