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, congratulations on you very informative blog. My wife and i have been trying for 3 years without any success. I am 36 and she is 32 without any health problems, we had all known tests including hysteroscopy and the only thing we found was “mild” thromvophilia which is treated with heparin. Recently we had 2 sperm infusions and 2 IVF tries with day 5 “good quality blastocysts” both unsuccessful. The second IVF was in natural cycle using 2 blastocysts we manage to freeze in our first try. During the IVF the following were administered: Progesterone, heparine, prednisolone, folic acid, estradiol and Intralipids only in the second attempt to deal with immunologic factors. We didn’t do any tests for NK cells as our doctor said that tests arent so reliable, but recommend the IL which we used in the second IVF try. Clearly there is a problem that hasn’t been found, what would you suggest as our next step. Thank you in advance.
I am confident that you are aware that treating a perceived problem blindly is not ideal. You need to have a diagnosis first. Thus while IL/steroid therapy might ultimately be needed , the diagnosis comes first or you could simply find your self in a far more complex quagmire,
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?
•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.
Hello Dr sher, i am 37 years old and don’t ovulate very often. I wasn’t monitored for about 6 weeks and then suddenly my ultrasound showed a small structure in the uterus that sort of looks like a very early pregnancy . Blood test was negative so I guess my question is , is at all possible that it’s really really early and it’s not coming up in the blood ? Any chance at all or am I fooling myself ? What else can it be ? I have been getting ultrasounds for years and nothing like this ever showed up. I don’t have any fibroids or polyps. My concern is that I take Xanax I am worried . Thanks in advance.
It is not likely a viable pregnancy if the blood pregnancy test was -ve. This needs to be identified and addressed. It could be a “missed abortion” or a polyp or fibroid.
Good luck!
Geoff Sher
Dear Dr Sher,
I get bad headaches for Ganirelix if my LH drops too low while on it. I have been given 250 Ganirelix and was to take half dose morning and evening but I forgot the dose last night and took a full dose this morning and got a headache. My LH is 2 after taking the morning full dose but I have a 19.3 follicle and E2 is 170. I am doing mini IVF and not taking any menopur or Gonal F. Is taking full dose Ganirelix once a day as effective as taking half dose twice a day? And how long does the effect of 250 dose last? I am scared my LH will go too low but even more scared that without night dose I might surge.
Frankly, I am confused by the protocol you were on! I do not know how you develop an ovulating follicle if you have been on Ganirelix for se4veral days. It not only suppresses LH but also FSH which is needed for follicular development. However you cannot argue with success! The reduced dosage of Ganirelix will not be deleterious. 125mcg will probably do!
Good luck!
Geoff Sher
Dear Dr Sher
How much FSH is needed mid cycle in a natural cycle to properly mature an egg? My FSH is 7 on Day 11. Is that too low? LH 2 and E2 186.
Thanks for this informative forum.
Normal FSH levels for menstruating women range between 5 and 20 IU/L during the follicular or luteal phase of their menstrual cycle and 30 to 50 IU/L during their mid-cycle peak.
Geoff Sher
Dear Dr Sher,
I am 40 years old with DOR (due to surgery) and doing medicated natural cycle (no meds except the use of Ganirelix)
For trigger shot is Ovidrell 250mg as effective as Pregnyl 10,000 iu?
In my opinion it is not! The comparable dosage of Ovidrel would be 500mcg.
Geoff Sher