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.
Hello, Dr Sher.
From a previous cycle I had embryos frozen. I only recently learned that two of the embryos were fully hatched (AA and BA). I have read that fully hatched and frozen is not a good sign. The clinic said they only consider the letter grading as most important. Please can you advise? Thank you for the blogs and Q&A. Very informative.
Freezing hatched embryos is not a problem, in my opinion. They do well!
Geoff Sher
For alloimmune issues with a blood clotting issue as well, when do you start Prednisone in the cycle and when do you start Lovenox? Do you do 40 units of Lovenox for patients or 80? Thanks !
Lovenox and prednisone start at the beginning of the cycle. I use 40U Lovenox!
Good luck!
Geoff Sher
I did a transfer on April 6th and went to RE on the 13th for progestrone and est test and got the results what is a good number for prog following a transfer. I also then will be going in on 20th for first beta what is typically the number that it should be for viable pregnancy?
P4 should be >10ng/ml and hCG >10U but preferably >20.
Good luck
Geoff Sher
Hi Dr Sher
I’m hoping you can help advise me in preparation for my upcoming review with my IVF clinic. I’ve had 2 unsuccessful IVF cycles with them and have been trying to conceive for 2.5 years.
I’m 32 and my partner is 31. I have AMH level of 15.1 pmol/L, my partner has low sperm concentration and low morphology, and so we have used ICSI for both IVF cycles. My TSH was normal when checked last year (1.16mU/L) and free T4 was 15.4pmol/L. I also have regular cycles with no other menstrual issues or diagnoses.
In my first cycle in Sept 2020 the protocol was
Down regulation – Prostap on Day 20 of my menstrual cycle
Stimulation – Menopur 300 for 10 days, this was lowered to 225 as my E2 level on Day 10 of stimulation was 11416pmol/L, on Day 13 of stims my E2 was 22245pmol/L. At my scan on day 13 of stims the clinic were worried about a high response and noted a ‘reduced trigger’ may be needed. This scan showed 5 follicles at 13-14mm, 1 at 15-16mm, 12 at 17-18mm and 2 at 19-20mm – 20 follicles total.
Trigger – I triggered that evening with 125 Ovitrelle. At egg collection only 7 eggs were collected. 7 were micro-injected with my partners sperm and 2 fertilised, of these 1 was transferred and the other discarded. The transferred blastocyst was Grade A.
Luteal – I used crinone gel during the 2 week wait and a period came 7 days after my 5 day blastocyst fresh transfer
In my second cycle earlier this year in Feb 2021 the protocol was
Down regulation – Norethisterone from Day 21 of my menstrual cycle
Stimulation – Menopur 300 alone for 2 days and then Fyremadel 0.25 was added daily, and both were taken for 10 days. On day 12 of stims my E2 was 14198pmol/L and my scan on this day showed 4 follicles at 13-14mm, 3 at 15-16mm, 3 at 17-18mm, 3 at 19-20mm and 3 over 20mm – 16 follicles in total.
Trigger – I triggered on Day 12 of stims with 250 Ovitrelle. At egg collection 9 eggs were collected, 7 were micro-injected with my partners sperm and 3 fertilised, 1 was transferred, 1 frozen (Grade C) and 1 discarded. The transferred blastocyst was Grade C
Luteal – I used crinone gel during the 2 week wait and a period came 8 days after my 5 day blastocyst transfer
Currently I have 1 embryo frozen but am hoping to do another ICSI cycle this summer, but I have a few questions. Having read your blogs and watched some of your youtube videos I realise my protocols were different to what you would recommend and so I’m hoping you can help.
Would the reduced Ovitrelle trigger have affected the number of eggs that were collected?
In reading your blog I realised you recommend 500 units of Ovitrelle, I fear my clinic would be reluctant to allow this as my E2 was high, would you still recommend it for me in this case?
I’m wondering why my protocol was changed (the down regulation med change from Norethisterone to Prostap, and the addition of Fyremadel during stims) fro the first to second cycles. Is Fyremadel used if the clinic thought I ovulated prematurely? Does this seem likely to you, or is it more likely to do with the lower Ovitrelle dose? After my first cycle the embryologist checked as he thought I may have ovulated but said that didn’t seem likely, but Fyremadel was added to my second cycle protocol, could there be another reason for using Fyremadel?
I’m finding it hard to work out which cycle worked better – the first brought a high E2, fewer eggs and none suitable for freezing but I got a better quality (Grade A) blastocyst to transfer, the second resulted in fewer eggs but with 1 blastocyst to freeze and 1 Grade C to transfer. I will ask the clinic at my review, but in your opinion is the second cycle more successful?
I bled early in each case (day 7 and day 8 after 5 day transfer), is this significant?
My clinic noted I had ‘soft eggs’ during the micro-injection stage of both my ICSI cycles, is this significant or telling of any issues? Would this account for why the fertilisation rate is so low?
The embryologist also noted the embryos were oval shaped during my second ICSI cycle. Both went on to make it to Grade C blastocyst, would this be a cause for concern?
Are there any further tests I should enquire about with my clinic?
Many thanks for any advice
C
This is too complex to discuss substantively here. I think that a lot may have to do with the protocol used for ovarian stimulation and the reduced “trigger dosage”… but there could be a lot more issues. We should talk. I recommend that you contact my assistant, Patti Converse (702-533-2691)to set up an online consultation with me, before going any 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 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.
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
My blood test just came back and my hcg level is 10, 253. The first day of my last period was approximately February 24th 2021. Is this a normal level? Should I request another blood testbon a couple of days? I don’t know if this is a normal level or not? Thank you for your time!
You need an US ASAP to establish viability of the pregnancy!
Good luck!
Geoff Sher