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.
Dear Dr. Sher
I posted the question for you last night, but I see neither the answer, nor the question. Was it deleted for some reason? 🙁
Oh, I see it now, when I posted the last message. I will appreciate your opinion about our case. Thank you
So sorry!
I did not see it come through. Please re-post it and I will respond promptly.
Geoff Sher
Hi Dr. Sher,
I have had two previous natural pregnancies ( easily conceived). We are in the process of IvF due to PGD testing because my husband and I are carriers to a rare genetic mutation. Our 3 yo son has the disease. I had an ivf cycle on May 9, and transferred two embryos of quality HB BB and HB BC. I found out I’m pregnant via the blood test however due to slow rise of hCG levels I was monitored closely. May 26-June 1, I had continuous spotting and some mild pain around my previous c section site, and informed the doctor. They assumed it’s normal:.. My pain became really sharp in one side by June 1 and I went to the ER, and taken to surgery due to an heterotrophic pregnancy. Ectopic pregnancy was removed but what was implanted in the uterus seemed smaller. I was monitored via u/s for another couple of weeks… I finally received the final word that there is no heart beat and the embryo never grew past 5 weeks 5 days ( which would be around the time of the ectopic surgery). My questions are as follows:
– if given an option of natural miscarriage va D&C which one would be appropriate at this point. Would D&C be able to collect enough tissue for pathology and is it worth to go that route ( since the embryo was Pgd and pgs tested).
– are there any specific tests you would think I should do to find out more about why I had a rare case of heterotrophic pregnancy? And to prevent such an incident from happening in the future?
Is there a waiting time frame I should wait before we have another embryo transfer?
Thanks
HBB
Heterotopic pregnancy is VERY rae (!:2000). No one knows why it happens and the likeelihood of recurrence is remote. A D&C might be able to yield tissue for genetic testing and I wouldm advise this. The likelihood is that it was an embryo issue (chromosomal or genetic).
Good luck and G-d bless!
Geoff Sher
Dear Dr. Sher
I am 40 years old. My husband is 65, diabetic (using insulin), not living very healthy lifestyle. Due to ED the ART is our only way to try to have baby.
We conceived thru second medicated IUI cycle in September 2014 with one opened fallopian tube and motile 5 mil. Unfortunately I lost the baby in wk 16 of the pregnancy. High possibility was that it happened due to incompetent cervix (painless contractions and no bleeding) and maybe an overseas flight contributed to the loss as well. No abnormalities were noticed on the baby, the prenatal tests were fine too.
We started to try to get pregnant again in March 2015. All of the attempts were the IUIs (7 or 8 from March 2015 to Feb.2016). I just couldn’t get over the fact, that it has to work, if it worked before so fast. Unfortunately that was not the case this time.
In October 2015 I had a tubal cannulation done to open the left fallopian tube.
In January 2016 I had a hormonal profile done. The numbers were: AMH 3.76, FSH 5.97. I always reacted well to the medication. Unfortunately the age is my enemy and I understand that.
My concern is about my husband’s sperm as well. I learned online, that sperm DNA fragmentation increases with the age and also diabetic patients have increased sperm DNA fragmentation too. I believe, that the combination of the two is even worse. Test of sperm DNA fragmentation was not done in our case. ICSI was recommended to us as a best option. I am very nervous about using it. My worries are that the sperm with highly fragmented DNA would be chosen. I know, that clinics in Europe and Australia use PICSI and MACS for the selection of the best sperm, that would be used with ICSI. I couldn’t find any clinic that would be offering these two methods in NJ, where I live. Why isn’t it standard in the US? According to publications these two methods increase success of pregnancy, not only success of fertilization. If that’s true, it would save couples so much heartache. I would like to know your opinion about using ICSI in our case. I read some study online comparing natural conception, conventional IVF and ICSI. Pregnancy that followed ICSI in this study had the highest risk of developmental problems of embryos and babies and also highest miscarriage rate. Is it too risky to use it without PICSI and MACS in our case? Would you recommend ICSI without these two methods and without sperm DNA fragmentation test? Would it be ok to use conventional IVF for us? We will do also PGS (NGS) It’s our first IVF.
Thank you
Dr.Sher,
I am an orthodontist and as one health care professional to another I am very impressed with your commitment to your profession and want to thank you for your zeal for excellent patient care . Here is my question :
Hypothetically a post menopausal woman in preparation for an FET uses the following protocol :
1) She goes on birth control pills and cycles about 3 times before starting her preparation with oral estradiol 2mg./3 times a day and because she has faith in your research she also uses Viagra troches for about 10 days. For the first time her lining goes to between 9-10 mm and she starts IM progesterone 1cc./day ( 50mg./ml ) and then from the 4th day goes to 2 c.c /day . She also starts low molecular weight heparin injection ( 40mg./.4ml ) and low dose aspirin with the IM progesterone to help improve the vascularity of a somewhat homogeneous endometrium. On the 6th day she gets 2 blastocyst embryos .
2) Her post embryo transfer protocol is :
a) Continue with Oral estradiol 2mg./ 3 times/day and after the transfer she also starts inserting a 2mg. estradiol tablet vaginally at night
b) continue 2 c.c of IM progesterone in the p.m and also starting the day after the transfer add 100m.g vaginal progesterone troche in the a.m
c) continue with the Heparin injection and aspirin
If she were a patient under your care what would your suggestions for a post FET protocol be for this post menopausal woman ?? Would you agree with what was outlined above or would you make some alternative or additional recommendation as well.
YOUR RESPONSE AND FEEDBACK WOULD BE VERY MUCH APPRECIATED .THANK YOU SO MUCH
Hi Sujata and thank you for your kind words. By band large I agree with the strategy except that I am not in favor of using oral Estrace because after ingestion and reaching the small intestine it is absorbed and travels via the portal venous system to the liver (where it is altered and only then reaches the systemic system and the uterus. This is less than ideal. I prefer using parenteralestradiol valerate (Delestrogen) by twice weekly subcutaneous injection or if this is not available then estradiol skin patches. This way the hormone directly accesses the systemic circulation reaching the uterus unaltered and much more bioavailable …in my opinion. I continue the twice weekly Delestrogen adding intramusculat progesterone in oil daily (or vaginal Crinone 8% twice daily). This continues to the 10th week of pregnancy or until pregnancy is discounted and is then stopped.
Good luck!
Geoff Sher .
Hi Dr Sher,
Im 33, had a daughter naturally who is now 4 and a half, and have “unexplained secondary infertility”. Had two IUI’s with Femara, one implanted but miscarried at 10.5 weeks, other was not successful. Moved to IVF.
I have had two failed IVF’s-first one was a study and could only stim with menopur and ganarelix with HCG trigger, 9 eggs, 6 fertilized, only one out of the six that fertilized made it to blast and it was genetically normal but did not implant.
Next month, got “pregnant” naturally and had a chemical pregnancy
Second ivf-New Dr-did birth control for two weeks, stimmed with follistim, low dose HCG, and ganerelix, lupron trigger over two days, 17 eggs, 14 fertilized, some slow growers but 5 made it to blast-all genetically abnormal for different reasons. Cancelled cycle.
Seen two doctors and both say bad luck or poor egg quality with no reason why, and its rare for my age.
My AMH is 5.5 and FSH is 4.6. All other tests are always normal. Healthy, in shape, use no chemicals in any products, don’t drink alcohol or coffee anymore. Now cutting out sugar.
is there anything you can offer in terms of an explanation of why at 33 yrs old I am having poor eqq quality but responding well to stimulation and fertilization is normal? Could sperm be the issue even though the sperm analysis showing great motility and great numbers? Husband was on Zoloft and a blood pressure medication past few years after having our daughter, supposedly they do not affect sperm but some studies have shown they do affect it.
The only other thing I can think of is I was a vegetarian for years and did not eat enough protein at all. I am currently working on eating more protein and protein shakes before cycling again. I believe this may have affected my egg quality….
I appreciate any insight you may have!!!!
Dear Traci,
You clearly have normal ovarian reserve and in view of you being only 33y of age and having conceived >1 time spontaneously, I strongly doubt that this has anything to do with a sperm or an egg issue. It could be one of 2 factors: 1) Either the protocol(s) used for ovarian stimulation were not optima, were not implemented ideally and /or the trigger was not optimal or 2) you ahve an implantation dysfunction. ..see below.
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.
•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 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
•Secondary Infertility: Addressing the Root Causes
•Blastocyst Embryo Transfers Done 5-6 Days Following Fertilization are Fast Replacing Earlier day 2-3 Transfers of Cleaved Embryos.
•Frozen Embryo Transfer (FET) versus “Fresh” ET: How to Make the Decision
•Frozen Embryo Transfer (FET): A Rational Approach to Hormonal Preparation and How new Methodology is Impacting 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
•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:
•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.
•Male Factor Infertility
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.