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,
Can I be refused IVF treatment if I refuse a pap smear? I have no history of cancer in my family and I have not been sexually active for quite some time. However my IVF nurse told me she will not do anything till I get the test. This is giving me a lot of stress. I am from UK and they do not insist like this there. I am in US for my cycle. This is giving me a lot of stress to think I can be denied IVF if I am not wanting a pap smear. Thank you for helping.
Hi Gina,
In my opinion, that is not right. You do have the right to decide. Your treating doctor can request that you sign a waiver, but that is about it.
Geoff Sher
Dear Dr Sher,
I read your article on the previous website that is very interesting and talks about trigger shot timing. Basically does it mean that a trigger shot given a bit earlier or later is not the cause of a bad egg? Whether you trigger at 18mm or 22mm is ok if egg quality is ok?
There is an optimal time to trigger. Waiting a day too long or triggering a day too early can impact egg quality, but a few hours should not be crritial.
Geoff Sher
Hi Dr Sher,
I am about to begin treatment with donor embryos due to my low amh and 4 failed IVF attempts with my own eggs and husbands sperm.
I am worried because I take 800mg acyclovir daily for suppression of HSV2. My consultant said to continue taking this through treatment. Without it I have continuous prodrome symptoms. Would you think that it is more dangerous to take the medication or experience the symptoms?
Thankyou for your time.
In my opinion, the acyclovir should not be a problem…but you need to take this under advisement from your treating doctor.
Geoff Sher
Dear Dr,
May you please advise, I am 30 years old and he is 33. I had an ectopic pregnancy in which my left tube was removed, before the ectopic we only tried for 6 months before falling pregnant with the ectopic. We then tried for 7 months to conceive again to no avail? Further tests revealed that my remaining tube is partially blocked. That’s when we started the IVF journey. My protocol was Lucrin 0.1ml for 10 days and Gonal F 150ml for 8 days. The results were 24 eggs harvested, and only 8 made it to blastocyst stage. When they checked how the follicles are growing they checked the lining of my uterus which mine was already 8cm (or mm) not sure how it’s measured at that time. We transferred 2 five days blastocyst and froze 6. I was then taking Ecotrin and vaginal progestogen after the transfer. I started bleeding heavily 3 days before my Blood test. The blood test results were negative.
FET journey, out of the 6 frozen embryos only 3 were viable to be used again. They have transferred all three of them at the time; the embryologist did assisted hatching on the 2 embryos and left the one that was already hatching on its own. My uterus lining was again more than 8cm at the day of transfer. I was then taking Ecotrin, vaginal progestogen and estrogen after the transfer. The blood test came back negative again.
What could be the problem, is it my Uterus? My eggs, do I have one on those uterus diseases that will mean I need a surrogacy mother? I should mention that my partner’s semen analyses came back normal so as all tests I have done before IVF.
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.
•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
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,
How many mg of progesterone per day and starting when do you recommend during a FET cycle? I’m 31 w/no know progesterone insufficiency but Hx of mmc and IVF failure due to autoimmune issues (currently doing IL and dex on this cycle).
Thank you
Luteal support commences 5 days prior to the ET, with IM P4 at the initial dose of 50 mg (P4-Day 1). Starting on P4-Day 2 P4 is increased to 100 mg daily continuing until the 10th week of pregnancy, or until a blood pregnancy test/negative ultrasound (after the 6-7th gestational week), discounts a viable pregnancy.Commencing on the day following the ET, the patient inserts one (1) vaginal progesterone suppository (100 mg)in the morning + 2mg E2V vaginal suppository (in the evening) and this is continued until the 10th week of pregnancy or until pregnancy is discounted by blood testing or by an ultrasound examination after the 6-7th gestational week.
Geoff Sher