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 Doc,
My wife & I did a IVF and today is the 15 dpt and we did a BETA HCG and turned negative. We had 3 frozen embryo. What should be the next process? Should our doc induce her for to get her periods, post which what is the usual protocol and what are our chances?
I cannot give input on the protocol you need here. However, the reason for failure needs to be assessed before proceeding further.
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 a decade 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
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).
My answer to patients who ask me when is the time to stop undergoing IVF is ….Aside from the weight of the financial burden, the time to stop is when in spite of thorough and comprehensive evaluation, there is no remediable and treatable explanation for repeated failure.
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.
•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
•Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
•Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for
•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
•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)
•Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
•Endometrial Thickness, Uterine Pathology and Immunologic Factors
•A personalized, stepwise approach to IVF
•How Many Embryos should be transferred: A Critical Decision in IVF.
•The Role of Nutritional Supplements in Preparing for IVF
Please call or email Julie Dahan, my patient concierge. She will guide you on how to set up an in-person or Skype consultation with me. You can reach Julie at on her cell phone or via email at any time:
Julie Dahan
•Email: Julied@sherivf.com
•Phone: 702-533-2691
?800-780-7437
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.
Hello Dr Sher,
just one quick question:is it ok to do estrogen priming when there are cysts?
My protocol says that one week after ovulation i start using estrogen patches-one every other day till i get a period. The patches are called Vivelle Dot(0.1 mg/patch).
However i know that i currently have cysts. Is it ok to start estrogen priming now ?
Thank you
It should not be a problem!
Good luck!
Geoff Sher
Wat could be the cause of failed ovulation trigger after 10000 iu of hcg followed by 0.2mg gnrha
Hi Ahmer,
Failure to respond to the trigger means that the preceding stimulation was off! I would need to now much more about your reproductive medical profile and review the entire process, to confirm and advise authoritatively.
Geoff Sher
Hello Dr Sher! I am about to make a major decision and really need your help and knowledge!
I am 41 with severely diminished ovarian reserve-fsh is very high but does fluctuate a lot, AMH is undetectable and my AFC is 2-3.
I am not ready to give up trying with my own eggs so i am planning to do ivf.
My RE advised Estrogen priming before i start cycling. I was given these instructions:
Once LH surge is confirmed i place an estrogen patch one week later. I will use one patch every other day until i get a period. When i do get a period i go have a blood test and ultrasound on day 2 and will be told to start stimulation.
The estrogen patches are called vivelle dot(0.1mg/patch).
My concerns are two:
1) i am not sure when i and if i have actually ovulated.
On CD12 E2 was 293 pg/ml LH 15.39
On CD13 E2 was 395 LH 17.80
On CD19 E2 is 368 LH 8.39 Pr0gesterone 3.81 ng/ml(lab range for luteal phase 1.7-20.3) tested today
Have i actually ovulated this month? I see E2 not dropping after CD13 and Progesterone is not that high!
If i haven’t really ovulated but my body did produce a follicle that may have turned into a cyst-can i still start using the patches?
2) My ultrasound today CD19 showed 6 cysts(4 on the one ovary and 2 on the other).
The nurse said to start patches tomorrow -but can i do estrogen priming if i have cysts? Won’t estrogen make them grow more or will it help them go? Should the doctor cancel or aspirate?
I haven’t talked to the RE yet, will do so in a few hours, but the instructions from his nurse are that ovulated on CD12, that i should start patches tomorrow CD 2o and she said not to worry about the cysts as estrogen priming will help them go away.
Doesn’t seem right to me-something is not sitting right here.
Can you please help me out?
I greatly appreciate all the help you give me.
This sounds like premature luteinization. I doubt that you ovulated at all and I agree that you need to get this confirmed before proceeding.
Frankly with the severity of DOR you describe, I doubt you will respond sufficiently and produce competent eggs of your own. My advice would be to go straight to egg donor IVF.
Good luck!
Geoff Sher
I have stage II endometriosis and will be undergoing my first IVF in the next 4 weeks. My RE is prescribing Medrol 16 mg/day x 7 days starting the day before egg retrieval and completing the day after embryo transfer. What is your opinion about doing a pulse dose of steroids vs placing me on a continuous dose of steroid therapy?
I would favor a continuous dose of steroid.
Geoff Sher