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 i’am 34 years old, i have 3 children and am looking yo get pregnant with my fourth however after 5 months of a missed period i went in for some blood work and it turns out my AMH level is 0.2 and FSH level is 7. I used 100mg clomid this month on days 3-7. On day 8 of my cycle i had two follicles on my right side measuring 24mm and 15 mm and one on my left side measuring 13mm. During my follow up scan two days later the 24mm follicle ovulated naturally and the other follicle on the same side was now measuring 17mm and the one on the left side was measuring 15mm. On the 12 day of my cycle the 17mm follicle disappeared and the 15mm follicle on the left side wss now 18mm. My doctor gave me a 250mcg ovitrelle shot when the follicle was 22mm. 4 days later after the shot i went in to see if it ovulated however it regressed 1mm. So my question is what are my chances of getting pregnant with my initial follicle at 24mm that ovulated on its own? I have been testing out the shot and after 10 days post shot my urine tests are dark but getting lighter.
Ashley,
First, I am opposed to giving clomiphene to women who have diminished ovarian reserve. Also, Ovitrelle 250mcg is probably half the ideal dosage. It is not likely that this cycle will yield a viable pregnancy. Besides, you really need IVF ASAP. Time is not on your side, given your DOR.
Central to making a diagnosis of an immunologic implantation dysfunction (IID) is a need for the appropriate interpretation of Natural Killer Cell Activity (NKa). In this regard, one of the commonest and most serious errors, is interpret the blood concentration of natural killer cells as being relevant. Rather it is the activity (toxicity) of NK cells that matters as mentioned. This activity can best be measured using the blood, K-562 target cell test (the gold standard). and/ or endometrial biopsy for cytokine activity.
With the K-562 test, the most important consideration is the percentage of target cells “killed” in the “native state”. In most cases a level of >10% killing should be regarded with suspicion and >12% overtly abnormal. In addition to reporting the result of the K-562 test, in the “native state” (without adding, Immunoglobulin-G (IVIG) or Intralipid (IL) which many Laboratories erroneously do to try and determine whether either or both of these immune therapies would have a therapeutic benefit or is/are unlikely to be of clinical value. The entire premise upon which this assertion is based, is in my opinion flawed. Clinically such NK cell deactivation can only be significantly affected in vivo as it takes more than a week following infusion to occur. Thus, what happens to the percentage of target cells killed with the K-562 test, by adding IVIG or IL is in my opinion irrelevant
Another way to assess endometrial NKa is by measuring TH-1 and TH-2 cytokines in endometrial tissue derived through biopsy.TH-1 cytokines kill the trophoblast (the root system of the embryo). Thus if is an excess of TH-1 cytokine activity is found with/without a disruption in the TH-1: TH-2 ratio, this points to NK cell activation.
There are basically two causes of immunologic implantation dysfunction (IID), a) Autoimmune (85%) & , b) Alloimmune (15%). The former occurs when the body reacts to its own tissue and the latter (far less common) when the male and female partners share certain genotypic similarities involving DQ alpha and HLA genes. In both cases IID results in rejection of the pregnancy due to uterine Natural Killer (NK) Cell and T-cell activation leading to the release of an excessive amount of TH-1 cytokines. These, “toxins” attack the embryo’s root system (trophoblast), killing the cells and causing implantation to fail.
Autoimmune Implantation Dysfunction: Autoimmune implantation dysfunction, most commonly presents with presumed “infertility” due to such early pregnancy losses that the woman did not even know she was pregnant in the first place. Sometimes there as an early miscarriage. Tests required are: a) blood levels of all IgA, IgG and IgM-related antiphospholipid antibodies (APA’s) directed against six or seven specific phospholipids, b) both antithyroid antibodies (antithyroid and antimicrosomal antibodies), c) a comprehensive reproductive immunophenotype (RIP) and, c) most importantly, assessment of Natural Killer (NK) cell activity (rather than concentration) by measuring by their killing, using the K-562 target cell test and/or endometrial cytokine activity tests.
It is important to recognize that currently there are only about 3 or 4 Reproductive Immunology Reference Laboratories in the U.S.A that, are capable of reliably analyzing the required elements with a sufficient degree of sensitivity and specificity. I use a Reprosource, a laboratory located in Boston,MA.
Patients with Alloimmune implantation Dysfunction usually present with a history of unexplained (usually repeated) miscarriages or secondary infertility (where the woman conceived initially and thereupon was either unable to conceive again or started having repeated early miscarriages. However, it can also present as “presumed” primary infertility. Alloimmune dysfunction is diagnosed by testing the blood of both the male and female partners for matching DQ alpha genes and NK/CTL activation. It is important to note that any DQ alpha match (partial or complete) will only result in an IID when there both a DQa/HLA match exists along with NK cell activation. With the exception of cases where both partners have a total (absolute DQa match and treatment requires the use of sperm from a non-matching sperm donor, about 90% of cases alloimmune implantation will have a partial match where 1: 2 embryos will match the woman’s DQa genotype and half will not. In cases of an alloimmune dysfunction (with associated NKa), treatment with IL or IVIG will in my opinion, will not protect against a matching embryo being rejected. It can only clear the NK environment for an embryo that does not match the woman’s DQa genotype. For this reason, it is my opinion that only 1 embryo should be transferred at a time because, given the fact that i:2 embryos will match, transferring >1 embryo at a time creates a risk that the matching embryo will evoke a local NKa/’cytokine response that will “muddy the water” for both. Thus, in cases of a “partial” DQa match I recommend against transferring more than a single embryo at a time.
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.
•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) Why did my IVF Fail
•Recurrent Pregnancy Loss (RPL): Why do I keep losing my Pregnancies
•Genetically Testing Embryos for IVF
•Staggered IVF
•Staggered IVF with PGS- Selection of “Competent” Embryos Greatly Enhances the Utility & Efficiency of IVF.
•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 in IVF: Are Some Chromosomally abnormal Embryos Capable of Resulting in Normal Babies and Being Wrongly Discarded?
•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!
•Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
•Should IVF Treatment Cycles be provided uninterrupted or be Conducted in 7-12 Pre-scheduled “Batches” per Year.
•A personalized, stepwise approach to IVF
•Nutritional supplements in IVF
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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.
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Geoff Sher
Dear Doctor, Is the IVF treatment successful for patients for those where sperm has no acrosome and are morphologically abnormal? Do you have a webinar or article on this issue?
Thanks and God bless you .
Globozoospermia is a s characterized by round-headed acrosomeless spermatozoa. Even in such cases, successful pregnancies have been reported following intracytoplasmic sperm injection (ICSI).
Good luck!
Geoff Sher
Dear Doctor.
I am approaching 40. I recently (July) had a frozen blastocyst transfer (two embryos were transferred) which resulted in implantation ( both embryos implanted) . I was continuing to take various medications ( e.g. Divigel, Progesterone, etc. ) prescribed by my fertility doctor until around week 5/ 6 pregnancy when I started experiencing bleeding and strong labdominal pain and ended up in hospital. My twin pregnancy was still confirmed at the time of hospital admission. Few hours later however miscarriage happened. Following the miscarriage doctors performed an operation to remove any remaining tissue. During the same procedure the doctors noticed that my left ovary was raptured resulting in internal bleeding. They couldn’t see any cyst and I lost around 800ml of blood. So I wanted to ask what might have caused this ovary rapture? And could the rapture itself and internal bleeding have caused the miscarriage.
It sounds like you ruptured an ovarian follicular cyst (probably a corpus luteum cyst). This is sometimes referred to as “Halban’s syndrome”. It will resolve!
Sorry for your loss!
Good luck!
Geoff Sher
HCG level at 14 days post IUI was 93. Progesterone 94. Second HCG day 16 was only 115. I am scheduled for 3rd HCG draw tomorrow, day 18. Does this at all sound hopeful?
Hx: PCOS Took clomid this cycle. First try.
This is not very encouraging. However, the e next hCG test (2 days later) will be more revealing .It needs to be ovver 220.
Good luck!
Geoff Sher
I have had 3 previous miscarriages. I am currently 5 weeks pregnant with a progesterone level of 18. Is this predictive of another non viable pregnancy? Should I take supplements?
The progesterone should probably be boosted. Talk to your RE!
Good luck!
Geoff Sher