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 recently contacted you from the UK to ask about the viagra pessaries.
I spoke to Robert at MDR pharmacy and he said to get them shipped to the UK I would need a prescription from a US doctor to be faxed over and he recommended that you could do this for me. Is this possible?
If not, do you know if the normal viagra oral tablets can be used as a pessary instead? A lot of women in the UK do this as we don’t have the pessaries here. Look forward to hearing from you.
Thank you
Natalie
Hi natalie,
Unfortunately, I can only prescribe for my patients.
Sorry!
Geoff Sher
Hi Dr Sher,
I’m on my 4th frozen embryo transfer. My lining was at 5.5 on day 7 of my cycle. I started viagra (inserted vaginally) on day 9 (50mg) and my lining got to 6.5 by day 11. I did 100 mg for a day and on day 12 my lining is at 6.7. I started an estrogen patch but because I’m doing a “natural” cycle I’m going to ovulate soon.
I doubt my lining will get to 8 before Wedn when I’m expect to ovulate. Would you suggest I cancel my cycle if I cannot get to 8mm?
I cannot tell you what to do. It is between you and your treating RE , but if I were treating you I would advise cancelation.
Geoff Sher
Dear Dr Sher,
(Apologies if you receive my question more times but my question doesn’t seem to go through).
I have been seen by many gynecologist in my life and over the past 6 years of TTC, also by 3 fertility specialists, had many ultrasounds, 1 round IVF with only 1 follicle growing and failed day 3 8 cell embryo transfer and none has been able to tell me why I’m not conceiving. None ever mentioned the findings below either. HCG clear.
These are the findings of the latest ultrasound:
1. 17 mm x 16 mm x 16 mm. Origin: right ovary. Internal structure: unilocular, septa: none seen,
echogenicity: ground glass, wall thickness: thin.
Doppler: colour flow: no detectable blood flow.
2. 11 mm x 10 mm x 6 mm. Origin: right ovary. Internal structure: unilocular, septa: none seen,
echogenicity: ground glass, wall thickness: thin.
Doppler: colour flow: no detectable blood flow.
3. 8 mm x 8 mm x 6 mm. Origin: left ovary. Internal structure: unilocular, septa: none seen, echogenicity:
ground glass, wall thickness: thin.
Doppler: colour flow: no detectable blood flow.
On ultrasound examination the uterus appeared morphologically normal and the endometrium was regular.
On Doppler examination there was no evidence of a polyp. There was no evidence of haematometra or
intrauterine adhesions. The cervical canal appeared normal.
The inferior pole of the left ovary contains a small unilocular cyst. The cyst contains old blood. Healthy
ovarian tissue could be seen adjacent to the cyst and Doppler examination did not reveal increased blood
flow to the cyst. The scan apppearances are those of an endometrioma.
The right ovary is also enlarged by the presence of two unilocular cysts. The cysts contain old blood and
healthy ovarian tissue could be seen adjacent to the cysts. Doppler examination did not reveal increased
blood flow to the cysts. The scan apppearances are those of endometriomas, however the differential
diagnosis includes haemorrhagic cysts. The antral follicle counts are 3 on the right and 3 on the left.
On palpation with the ultrasound probe the pelvic organs were mobile and non-tender.
The pouch of Douglas appeared free of adhesions.
The rectovaginal septum appeared thickened on the left side and these findings are suggestive of pelvic
endometriosis.
The anterior wall of the recto-sigmoid colon, urinary bladder and pelvic ureters appeared normal. Both
kidneys also appeared normal. I was unable to see endometriotic nodules on examination today.
Could the suspected endometriosis be the reason why I’m not conceiving? Please what should my next steps be? Do you know any doctor/clinic here in the UK you can recommend for me to see? I’m so lost and time is ticking.
Many thanks.
I’m 43, never had a kid or MC or pregnancy, had endometriosis twice and removed them via laparoscopy several years ago. Later diagnosed with adenomyosis in 2013.
Going to transfer my only one PGS normal frozen embryo by end of March 2021 and my RE ( after positive ReceptivaDX) put me on Lupron depot 3.75 for 2 months ( one shot/every 28days) along 5 mg of letrozole. Hysteroscopy ( one polyp removed) and ERA done.
Have an appt from a new OB to receive
Intralipid and prednisone since my RE is not a believer of this approach.
For years I’m taking levothyroxine, The dose that worked the best for me is 37 mcg. TSH usually was under 2.5 and on Nov 2020 was 1.6
I’ll do another test next week to adjust
thyroid pill if necessary.
My transfer will be end of March.
I’m fully vaccinated against covid in
January.
I’m running out of time to be able to do further testing regarding IID, so I just gonna take Intralipid infusion and prednisone by my OB order.
Any word of advice is highly appreciated. What else I can do to increase my chance of success. I already lost 20lbs and my BMI is 22 now. Diet since 4 months ago, gluten and dairy free.
Alcohol and caffeine free.exercise 30-60 min of walking/ day.
We need to talk!
When women with infertility due to endometriosis seek treatment, they are all too often advised to first try ovarian stimulation (ovulation Induction) with intrauterine insemination (IUI) ………as if to say that this would be just as likely to result in a baby as would in vitro fertilization (IVF). Nothing could be further from reality It is time to set the record straight. And hence this communication!
Bear in mind that the cost of treatment comprises both financial and emotional components and that it is the cost of having a baby rather than cost of a procedure. Then consider the fact that regardless of her age or the severity of the condition, women with infertility due to endometriosis are several fold more likely to have a baby per treatment cycle of IVF than with IUI. It follows that there is a distinct advantage in doing IVF first, rather than as a last resort.
So then, why is it that ovulation induction with or without IUI is routinely offered proposed preferentially to women with mild to moderately severe endometriosis? Could it in part be due to the fact that most practicing doctors do not provide IVF services but are indeed remunerated for ovarian stimulation and IUI services and are thus economically incentivized to offer IUI as a first line approach? Or is because of the often erroneous belief that the use of fertility drugs will in all cases induce the release (ovulation) of multiple eggs at a time and thereby increase the chance of a pregnancy. The truth however is that while normally ovulating women (the majority of women who have mild to moderately severe endometriosis) respond to ovarian stimulation with fertility drugs by forming multiple follicles, they rarely ovulate > 1 (or at most 2) egg at a time. This is because such women usually only develop a single dominant follicle which upon ovulating leaves the others intact. This is the reason why normally ovulating women who undergo ovulation induction usually will not experience improved pregnancy potential, nor will they have a marked increase in multiple pregnancies. Conversely, non-ovulating women (as well as those with dysfunctional ovulation) who undergo ovulation induction, almost always develop multiple large follicles that tend to ovulate in unison. This increases the potential to conceive along with an increased risk multiple pregnancies.
So let me take a stab at explaining why IVF is more successful than IUI or surgical correction in the treatment of endometriosis-related infertility:
1.The toxic pelvic factor: Endometriosis is a condition where the lining of the uterus (the endometrium) grows outside the uterus. While this process begins early in the reproductive life of a woman, with notable exceptions, it only becomes manifest in the 2ndhalf of her reproductive life. After some time, these deposits bleed and when the blood absorbs it leaves a visible pigment that can be identified upon surgical exposure of the pelvis. Such endometriotic deposits invariably produce and release toxins” into the pelvic secretions that coat the surface of the membrane (the peritoneum) that envelops all abdominal and pelvic organs, including the uterus, tubes and ovaries. These toxins are referred to as “the peritoneal factor”. Following ovulation, the egg(s) must pass from the ovary (ies), through these toxic secretions to reach the sperm lying in wait in the outer part the fallopian tube (s) tube(s) where, the sperm lie in waiting. In the process of going from the ovary(ies) to the Fallopian tube(s) these eggs become exposed to the “peritoneal toxins” which alter s the envelopment of the egg (i.e. zona pellucida) making it much less receptive to being fertilized by sperm. As a consequence, if they are chromosomally normal such eggs are rendered much less likely to be successfully fertilized. Since almost all women with endometriosis have this problem, it is not difficult to understand why they are far less likely to conceive following ovulation (whether natural or induced through ovulation induction). This “toxic peritoneal factor impacts on eggs that are ovulated whether spontaneously (as in natural cycles) or following the use of fertility drugs and serves to explain why the chance of pregnancy is so significantly reduced in normally ovulating women with endometriosis.
2.The Immunologic Factor: About one third of women who have endometriosis will also have an immunologic implantation dysfunction (IID) linked to activation of uterine natural killer cells (NKa). This will require selective immunotherapy with Intralipid infusions, and/or heparinoids (e.g. Clexane/Lovenox) that is much more effectively implemented in combination with IVF.
3.Surgical treatment of mild to moderate endometriosis does not usually improve pregnancy potential:. The reason is that endometriosis can be considered to be a “work in progress”. New lesions are constantly developing. So it is that for every endometriotic seen there are usually many non-pigmented deposits that are in the process of evolving but are not yet visible to the naked eye and such evolving (non-visible) lesions can also release the same “toxins that compromise fertilization. Accordingly, even after surgical removal of all visible lesions the invisible ones continue to release “toxins” and retain the ability to compromise natural fertilization. It also explains why surgery to remove endometriotic deposits in women with mild to moderate endometriosis usually will fail to significantly improve pregnancy generating potential. In contrast, IVF, by removing eggs from the ovaries prior to ovulation, fertilizing these outside of the body and then transferring the resulting embryo(s) to the uterus, bypasses the toxic pelvic environment and is therefore is the treatment of choice in cases of endometriosis-related infertility.
4.Ovarian Endometriomas: Women, who have advanced endometriosis, often have endometriotic ovarian cysts, known as endometriomas. These cysts contain decomposed menstrual blood that looks like melted chocolate…hence the name “chocolate cysts”. These space occupying lesions can activate ovarian connective tissue (stroma or theca) resulting in an overproduction of male hormones (especially testosterone). An excess of ovarian testosterone can severely compromise follicle and egg development in the affected ovary. Thus there are two reasons for treating endometriomas. The first is to alleviate symptoms and the second is to optimize egg and embryo quality. Conventional treatment of endometriomas involves surgical drainage of the cyst contents with subsequent removal of the cyst wall (usually by laparoscopy), increasing the risk of surgical complications. We recently reported on a new, effective and safe outpatient approach to treating endometriomas in women planning to undergo IVF. We termed the treatment ovarian Sclerotherapy. The process involves; needle aspiration of the “chocolate colored liquid content of the endometriotic cyst, followed by the injection of 5% tetracycline hydrochloride into the cyst cavity. Such treatment will, more than 75% of the time result in disappearance of the lesion within 6-8 weeks. Ovarian sclerotherapy can be performed under local anesthesia or under conscious sedation. It is a safe and effective alternative to surgery for definitive treatment of recurrent ovarian endometriomas in a select group of patients planning to undergo IVF
I am not suggesting that all women with infertility-related endometriosis should automatically resort to IVF. Quite to the contrary…. In spite of having reduced fertility potential, many women with mild to moderate endometriosis can and do go on to conceive on their own (without treatment). It is just that the chance of this happening is so is much lower than normal.
IN SUMMARY: For young ovulating women (< 35 years of age ) with endometriosis, who have normal reproductive anatomy and have fertile male partners, expectant treatment is often preferable to IUI or IVF. However, for older women, women who (regardless of their age) have any additional factor (e.g. pelvic adhesions, ovarian endometriomas, male infertility, IID or diminished ovarian reserve-DOR) IVF should be the primary treatment of choice. I strongly recommend that you visit 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. •Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) 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) •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! •Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas •Should IVF Treatment Cycles be provided uninterrupted or be Conducted in 7-12 Pre-scheduled “Batches” per Year •A personalized, stepwise approach to IVF •How Many Embryos should be transferred: A Critical Decision in IVF? •Endometriosis and Immunologic Implantation Dysfunction (IID) and IVF •Endometriosis and Infertility: Why IVF Rather than IUI or Surgery Should be the Treatment of Choice. •Endometriosis and Infertility: The Influence of Age and Severity on Treatment Options •Early -Endometriosis-related Infertility: Ovulation Induction (with or without Intrauterine Insemination) and Reproductive Surgery Versus IVF •Treating Ovarian Endometriomas with Sclerotherapy. •Effect of Advanced Endometriosis with Endometriotic cysts (Endometriomas) on IVF Outcome & Treatment Options. •Deciding Between Intrauterine Insemination (IUI) and In Vitro Fertilization (IVF). •Intrauterine Insemination (IUI): Who Needs it & who Does Not: Pro’s & •Induction of Ovulation with Clomiphene Citrate: Mode of Action, Indications, Benefits, Limitations and Contraindications for its use •Clomiphene Induction of Ovulation: Its Use and Misuse! ______________________________________________________ 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
Hi,
We have an abdominal ultrasound at 14 weeks 5 days and baby’s size was measuring 13 weeks 5 days. Doctor mentioned that they can’t accurately calculate the baby size because baby is curl inside and things looks good. Just wanted to check if this is not a concern and everthing is okay with this size.Heartbeat is 152.
Should not be a reason for ant concern, at all!
Geoff Sher