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
Thank you for your time. I have PCO and Hashimotos and am 33. Last year we underwent our first round of ivf on an antagonist protocol with prednisolone. We were lucky enough to get pregnant from the fresh cycle however at 4.5 months amniocentesis confirmed our baby had a chromosomal abnormality (not inherited) and I was induced to give birth. We are 3 minths post and looking at starting a fet we have 4 frozen embroyos. We started estrogen however the cycle was cancelled as a small amount of placenta was retained. I just has a hysteroscopy last week and everything is clear. I have not cycled on my own since our loss which is common for me with PCO so im going back on bcp prior to a medicated fet. Is that okay? My last ultrasound showed lots of small folicules. My bloods have confirmed no ovulation as yet. I feel worried about how much my hormones have been through and if its okay to take bcp prior to starting estrogen on cd 2 after stopping bcp. Does this affect chances or success? Is the bcp okay prior to a fet?Weve been through so much I want to make sure were doing everything right. Thank you.
So sorry for your loss and what you went through. No! The BCP is the ideal way to launch the FET cycle. It sounds as if you are in good hands!
Good luck!
Geoff Sher
We had IVF Embryo Transfer last Tuesday. My wife had her 1st HGC test today (day 7) her level was only 3.2. Is this cause for concern? Thank You
It could be too early. Repeat in 2 days.
I know of no medical announcement associated with the degree of emotional anticipation and anguish as that associated with a pending diagnosis/confirmation of pregnancy following infertility treatment. In fact, hardly a day goes by where I am not confronted by a patient anxiously seeking interpretation of a pregnancy test result.
Testing urine or blood for the presence of human chorionic gonadotropin (hCG) is the most effective and reliable way to confirm conception. The former, is far less expensive than the latter and is the most common method used. It is also more convenient because it can be performed in the convenience of the home setting. However, urine hCG testing for pregnancy is not nearly as reliable or as sensitive e as is blood hCG testing. Blood testing can detect implantation several days earlier than can a urine test. Modern pregnancy urine test kits can detect hCG about 16-18 days following ovulation (or 2-3 days after having missed a menstrual period), while blood tests can detect hCG, 12-13 days post-ovulation (i.e. even prior to menstruation).
The ability to detect hCG in the blood as early as possible and thereupon to track its increase, is particularly valuable in women undergoing controlled ovarian stimulation (COS) with or without intrauterine insemination (IUI) or after IVF. The earlier hCG can be detected in the blood and its concentration measured, the sooner levels can be tracked serially over time and so provide valuable information about the effectiveness of implantation, and the potential viability of the developing conceptus.
There are a few important points that should be considered when it comes to measuring interpreting blood hCG levels. These include the following:
•All modern day blood (and urine) hCG tests are highly specific in that they measure exclusively for hCG. There is in fact no cross-reactivity with other hormones such as estrogen, progesterone or LH.
•Post conception hCG levels, measured 10 days post ovulation or egg retrieval can vary widely (ranging from 5mIU/ml to above 400mIU/ml. The level will double every 48–72 hours up to the 6th week of gestation whereupon the doubling rate starts to slow down to about 96 hours. An hCG level of 13,000-290, 0000 mIU/ml is reached by the end of the 1st trimester (12 weeks) whereupon it slowly declines to approximately 26,000– 300,000 mIU/ml by full term. Below are the average hCG levels during the first trimester:
o3 weeks LMP: 5 – 50 mIU/ml
o4 weeks LMP: 5 – 426 mIU/ml
o5 weeks LMP: 18 – 7,340 mIU/ml
o6 weeks LMP: 1,080 – 56,500 mIU/ml
o7 – 8 weeks LMP: 7, 650 – 229,000 mIU/ml
o9 – 12 weeks LMP: 25,700 – 288,000 mIU/ml
•A single hCG blood level is not sufficient to assess the viability of an implanting embryo. Caution should be used in making too much of an initial hCG level. This is because a normal pregnancy can start with relatively low hCG blood levels. It is the rate of the rise of the blood hCG level that is relevant.
•In some cases the initially hCG level is within the normal range, but then fails to double in the ensuing 48-72hours. In some cases it might even plateau or decline, only to start doubling appropriately thereafter. When this happens, it could be due to:
oA recovering implantation, destined to develop into a clinical gestation
oA failing implantation (a chemical pregnancy)
oA multiple pregnancy which is spontaneously reducing (i.e., one or more of the concepti is being lost) or,
oAn ectopic pregnancy which will either absorb spontaneously (a chemical-tubal gestation), or evolve into a full blown tubal pregnancy continue and declare itself through characteristic symptoms and signs of an intraperitoneal bleed.
•The blood hCG test needs to be repeated at least once after 48h and in some cases it will need to be repeated one or more times (at 48h intervals) thereafter, to confirm that implantation is progressing normally.
•Ultimately the diagnosis of a viable pregnancy requires confirmation of the presence of an intrauterine gestational sac by ultrasound examination. The earliest that this can be achieved is when the beta hCG level exceeds 1,000mIU/ml (i.e., around 5-6 weeks).
•Most physicians prefer to defer the performance of a routine US diagnosis of pregnancy until closer to the 7th week. This is because by that time, cardiac activity should be clearly detectable, allowing for more reliable assessment of pregnancy viability.
•There are cases where the blood beta hCG level is extraordinarily high or the rate of rise is well above the normal doubling rate. The commonest explanation is that more than one pregnancy has implanted. However in some cases it can point to a molar pregnancy
•Finally, there on rare occasions, conditions unrelated to pregnancy can result in detectable hCG levels in blood and urine. They include ovarian tumors that produce hCG, such as certain types of cystic teratomas (dermoid cysts) and some ovarian cancers such as dysgerminomas.
Geoff Sher
PH: 800-780-7437
Hello Dr. Sher. I’m looking at the A/ACP protocol vs A/ACP+ E2V. In your articles you mention you use the A/ACP protocol in most of your patients
1) when do decide to add E2V to the protocol
2) is there a statistical significant improvement in outcome (egg quality or # of eggs) for DOR patients using A/ACP protocol with E2V verse those that do not use E2V.
3) I’m trying to locate as many scientific articles on the A/ACP protocol but am having difficulty. Would you be able to post any references? Or perhaps give me another protocol title to search for?
1) when do decide to add E2V to the protocol
In women who have VERY severe DOR.
2) is there a statistical significant improvement in outcome (egg quality or # of eggs) for DOR patients using A/ACP protocol with E2V verse those that do not use E2V.
A: Not really.
3) I’m trying to locate as many scientific articles on the A/ACP protocol but am having difficulty. Would you be able to post any references? Or perhaps give me another protocol title to search for?
Sorry! I just do not have the latitude of time. BUT I can tell you to go to the Pubmed search and look for an article by Jeffrey Fish and myself, published a few years ago.
Geoff Sher
Hello Dr. Sher,
I just had my first failed FET with one embryo that tested as normal. My BETA showed positive at first, but HCG was very low at 8.2. Re-testing 48 hours later showed as negative, so I assume this was a “chemical pregnancy.” My lining and estrogen levels were great the day of transfer.
I’m nervous about doing another FET with the same protocol. Is there anything you would recommend that I ask my doctor or tests you would suggest before my next FET? My saline sonogram and HSG were fine, but I have a feeling that I have had chemical pregnancies before (naturally). We only have have one embryo remaining.
Thank you.
Me (35) – DH (41)
Diagnosed with unexplained infertility
3 months on Clomid unsuccessful
3 failed IUIs
IVF (one time) – resulted in two normal genetically tested embryos (8 total retrieved)
Failed FET transfer of one embryo (chemical pregnancy)
One embryo remaining
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).
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.
•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)
•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
•Traveling for IVF from Out of State/Country–
•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
Geoff Sher
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.
Dear Dr Sher
My wife and I are about to start a frozen transfer cycle in the US. We live outside the US and must fly to get there and back. My wife is an extremely nervous flyer and we are concerned that the stress caused to her by flying home too soon after the transfer may endanger successful implantation. The flight lasts approximately one hour.
This will be our second transfer. The first was sadly not successful.
Is there a minimum period of time that you would recommend my wife wait before getting on a plane? Can high levels of stress affect the chances of implantation?
Many thanks in advance for any suggestions you can make.
Best regards
Tom
There is no reason for any concern. Flying in a pressurized cabin will have no ill-effects.
Good luck!
Geoff Sher