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.
Hi Dr. Sher,
I read pretty much everything on your site regarding endometriosis and DOR, but would like to have your opinion on my case. I am 39, I have a 2.5 cm endometrioma and DOR (AMH 0.5, 4-5 antral follicles in left ovary and 1-2 follicles in right ovary with the endometrioma). Should I have a laparoscopy to remove the endometrioma considering the very low number of follicles or just keep on trying natural cycle in vitro? I was told that the cyst was very thick and needle aspiration could not be performed, so surgical removal is the only option. I am afraid that this surgery might require the removal of my right ovary and I am not sure if it might require partial removal of the other ovary. My right ovary still produces dominant follicles and takes turns with the left one.
Thank you!
First,
Very respectfully, in all my years I have not seen an endometrioma whose wall (capsule) is impenetrable to to needle aspiration. Indeed , some cysts are loculated and all the content cannot easily be emptied and in some, the content is so viscous as to preclude aspiration, but these are very rare occurrences. The vast majority can be treated with sclerotherapy (see below), although not many doctors are familiar with this highly effective approach. So laparoscopy might not be needed, but even if it is needed, total removal of the ovary is not needed.
Clearly after the endometrioma has been dealt with you will need to consider doing IVF but here the emphasis needs to be on the selection of an optimal protocol for ovarian stimulation…one that will best protect your eggs. This is vital. Women who (regardless of age) have diminished ovarian reserve (DOR) tend to produce fewer and less “competent” eggs, the main reason for reduced IVF success in such cases. The compromised outcome is largely due to the fact that such women tend to have increased LH biological activity which often results in excessive LH-induced ovarian testosterone production which in turn can have a deleterious effect on egg/embryo “competency”.
Certain ovarian stimulation regimes either promote excessive LH production (e.g. short agonist/Lupron- “flare” protocols, clomiphene and Letrozole), augment LH/hCG delivered through additional administration (e.g. high dosage menotropins such as Menopur), or fail to protect against body’s own/self-produced LH (e.g. late antagonist protocols where drugs such as Ganirelix/Cetrotide/Orgalutron that are first administered 6-7 days after ovarian stimulation has commenced).
I try to avoid using such protocols/regimes (especially) in older women and those with DOR, favoring instead the use of a modified, long pituitary down-regulation protocol (the agonist/antagonist conversion protocol-A/ACP) augmented by adding supplementary human growth hormone (HGH). I further recommend Staggered IVF with embryo banking of PGS (next generation gene sequencing/NGS)-normal blastocysts in such cases. This type of approach will in my opinion, optimize the chance of a viable pregnancy per embryo transfer procedure and provide an opportunity to capitalize on whatever residual ovarian reserve and egg quality still exists, allowing the chance to “make hay while the sun still shines”.
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.
•The “Biological Clock” and how it should Influence the Selection and Design of Ovarian Stimulation Protocols for IVF.
•Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
•Controlled Ovarian Stimulation (COS) in Older women and Women who have Diminished Ovarian Reserve (DOR): A Rational Basis for Selecting a Stimulation Protocol
•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?
•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
•Endometriosis and Infertily
•Endometriosis and Infertility: Why IVF Rather than IUI or Surgery Should be the Treatment of Choice.
•Treating Ovarian Endometriomas with Sclerotherapy.
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.
Hi Dr. Sher,
Thank in advance if you are able to get to/answer my question. I am a 39 yo old female with Asherman’s syndrome secondary to retained placenta with my first pregnancy. After many failures we had our second child via gestational surrogate when I was 36 years old (success on first try with single fresh blastocyst). We still have several embryos from the first batch using my 36 year old eggs and we are going through IVF again with a different gestational carrier. We have had 2 failed frozen transfers with single high grade blastocysts this time. The most recent one was actually hatching. Our gestational surrogate had chemical pregnancies both times. She is 28 years old and has a beautiful lining as well as 4 healthy children of her own. Do you have any tips or pointers for our third try at IVF? Can you suggest anything that may improve our chances other than transferring multiple embryos?
While the article below does not take the use of a GS into account, the smae factors would apply.
Why did my IVF Fail?
Geoffrey Sher MD
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).
My answer to patients who ask me when is the time to stop undergoing IVF is ….Aside from the weight of the financial burden, the time to stop is when in spite of thorough and comprehensive evaluation, there is no remediable and treatable explanation for repeated failure.
I hope this helps!
Geoff Sher
PH: 702-533-2691
Hi Dr Sher!
I hope you are well! Thank you again for all that you do. I asked you a question last year when I was going through IVF and your answer was very helpful. Now I have a family member who is just finishing up her first IVF and I have two questions for you. Should this IVF not work, I would love for her to have a Skype consult with you when she is ready, but in the meantime…
My first question has to do with Antral Follicle Count. When she started IVF two months ago, her AFC was 9. Not great, but not terrible for someone over 35, I suppose (mine was only 8). Her clinic never tested AMH and, in my opinion, were not very aggressive in their protocol. She was on Long Lupron with low-dose of meds. She was also on birth control pills for 3 weeks prior. She only grew 2 eggs and was cancelled. They then had her cycle again immediately and started by putting her back on birth control pills for 2-3 more weeks. At the baseline appointment for IVF 1.2 her AFC was 4!!! Honestly, I’ve never heard of a variation like this in one month’s time. Unfortunately, she only had 5 eggs retrieved. Have you seen such a big difference in one month? Could it have been from all the time on birth control pills or because she did back-to-back cycles? I’m stumped.
Second, her clinic does HCG boosters after transfer. She took her final one last Sunday, June 12. She tested the HCG out with home pregnancy tests and was quite disappointed when the line got lighter and then disappeared. She thought it would get lighter and then darker. Anyway, by Thursday she was getting negative pregnancy tests. All of a sudden, on Sunday morning, one week after her last booster, she is getting faint positives…after three days of negatives. She is still getting light positives today, which is 14 days past a 3 day transfer. I’m not asking if she is pregnant, as I feel this late in the game it would not be viable. But it would be noteworthy to understand if her embryos actually got to Day 5 and tried to implant. She has a beta test on Wednesday, but do you think it’s possible to test out HCG and then a few days later for it to show up again? Or can we conclude this may be a chemical pregnancy?
Thanks, as usual, for your honest and timely advice. I hope you have a nice day!
Thank you!
AFC is at best a rough estimate and can in fact vary somewhat from month to month. The AMH is far more reliable as a measure of ovarian reserve. Your family member should seriously consider embryo banking with PGS embryo selectionWomen who have diminished ovarian reserve (DOR) tend to produce fewer and less “competent” eggs, the main reason for reduced IVF success in such cases. The compromised outcome is largely due to the fact that such women tend to have increased LH biological activity which often results in excessive LH-induced ovarian testosterone production which in turn can have a deleterious effect on egg/embryo “competency”.
Certain ovarian stimulation regimes either promote excessive LH production (e.g. short agonist/Lupron- “flare” protocols, clomiphene and Letrozole), augment LH/hCG delivered through additional administration (e.g. high dosage menotropins such as Menopur), or fail to protect against body’s own/self-produced LH (e.g. late antagonist protocols where drugs such as Ganirelix/Cetrotide/Orgalutron that are first administered 6-7 days after ovarian stimulation has commenced).
I try to avoid using such protocols/regimes (especially) in older women and those with DOR, favoring instead the use of a modified, long pituitary down-regulation protocol (the agonist/antagonist conversion protocol-A/ACP) augmented by adding supplementary human growth hormone (HGH). I further recommend Staggered IVF with embryo banking of PGS (next generation gene sequencing/NGS)-normal blastocysts in such cases. This type of approach will in my opinion, optimize the chance of a viable pregnancy per embryo transfer procedure and provide an opportunity to capitalize on whatever residual ovarian reserve and egg quality still exists, allowing the chance to “make hay while the sun still shines”.
You are correct, hCG boosters present more problems than benefits and I do not advocate or prescribe this approach.
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.
•The “Biological Clock” and how it should Influence the Selection and Design of Ovarian Stimulation Protocols for IVF.
•Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
•Controlled Ovarian Stimulation (COS) in Older women and Women who have Diminished Ovarian Reserve (DOR): A Rational Basis for Selecting a Stimulation Protocol
•Induction of Ovulation With Clomiphene Citrate: Mode of Action, Indications, Benefits, Limitations and Contraindications for its ue
•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
•Why did my IVF Fail
•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.
•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
•IVF Egg Donation: A Comprehensive Overview
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,
I am a 35 year old woman dealing with secondary infertility. I have 8 frozen euploid embryos but my lining is consistently thin — both naturally and on artificial estrogen, which I took orally and vaginally but the cycle was cancelled. My doctor and I reviewed your Viagra protocol and added it to a natural cycle, but we found after just 2-3 days that it resulted in fluid in my uterus., which we could see on the ultrasound and which I was passing vaginally. We stopped the viagra and the fluid disappeared. We did not re-start the viagra but went ahead and transferred with a 5mm lining just to “see” what happens, given that I had a child naturally previously, potentially on a thin uterine lining.
My question is: have you ever experienced fluid in the uterus from vaginal viagra suppositories? Is there any insight you can offer on why that might have occurred and if I ought to try viagra again in a future cycle, given the success you’ve had with it?
Our next step if the current transfer doesn’t work is to try intramuscular injections to thicken the lining. I welcome your thoughts on my situation. I realize I’m early in the process, but if my uterine lining won’t thicken, I will turn to surrogacy sooner rather than later. Thank you!
Best,
Jill
I have never encountered fluid in the uterus from vaginal Viagra. All it does is improve uterine blood flow and delivery of estrogen to the endometrium. Something else is going on here. I wish you well but I am sure you recognize that it would be a miraculous blessing if the treatment succeeded with a 5.5mm limning.
Good luck and G-d bless!
Geoff sher
Dr Sher,
Due to multiple IVF failures ( 5 fresh cycles) and unexplained diagnosis my wife and I are going to pursue egg donation. My wife just turned 38. We want to do a guarantee program (refund if no success) and the only one out there seems to be with frozen eggs. With that said, is there a big difference between using fresh cycle eggs or frozen eggs?
Many Thanks,
Mark
Mark,
I wish you good luck with egg donation. However, please rule out any underlying implantation issue before proceeding.
ASS for fresh versus frozen cycles. Be assured that frozen is “at least” as successful as is fresh and may even have a slight edge.
Good luck!
Geoff Sher
702-533-2691