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 Dr. Sher
I am writing to you to hopefully get some type of answer to my situation. I am 34 years old. I have no known “issues” that affect my fertility. At first, my IVF journey with my husband was due to a “male factor.” IVF was the best option for us. My first round of IVF was unsuccessful. My retrieval yielded 10 eggs, yet ALL were immature. This was a shock and my RE was “baffled” as my numbers were good and all was where it should have been. He gave me no explanation other than that this happens to .001% of people! Hearing this was a huge blow! I switched RE’s hoping that i could get a second go at this with a fresh perspective. My new RE looked at all of my records from the other clinic and noticed no real red flags as far as protocol and my numbers. He too said he was baffled and hoping this was just a case of “bad luck” or possibly human error. So instead of staring me on BCP, he said he wanted to start me on estrace as a change in protocol and using my natural cycle (thinking maybe the bcp suppressed me too much. I was told that the estrace does pretty much the same as bcp. I was on estrace for 10 days. On the 7th day of staring estrace,,,,,, i started my period and i continued estrace until day 3 of my period when i went in for bloodwork and Ultrasound. I then started injections that night. 150 Gonal F and 2 vials of menapur powder with 1 cc liquid for 3 days. After blood work and sonogram, I was bumped up to 225 of Gonal F and the meanpur dosage stayed the same (2 powder, 1cc liquid) for 2 more days. After another dr visit i was bumped again to 225 Gonal F and now 3 vials of menapur. I was on this dosage for 4 more days. I had 8 follicles that they could see from the sonogram and 6 were above 18mm (2 18mm, 2 19mm, 1 20, 1 22) and 2 were below 18mm. The nurse aid my numbers looked great and my bloowork came back great too. I then triggered with 10,000 of Pregnyl and 40 units of Lupron. At 8:50 the next morning i was told to inject another 40 units of Lupron. My RE wanted to give me a “double” trigger to really ensure maturation. My ER was the next day and i unfortunately had similar results with ALL 7 eggs retrieved immature. My RE is again baffled. I feel so defeated because i an get NO explanation as to why this is happening to me. I don’t have anything like PCOS or Endometriosis or any other diagnosis, Part of me wished i was diagnosed with something so at least I can go about getting it treated. Can I really be a part of a .001% statistic?! My eggs just don’t mature? I am told my only other option is a donor egg. My RE said that I’ve pretty much exhausted all the different variations of protocols and that it must be a genetic issue with me. This is hard to accept since no one in my family has any fertility issues. I hope you have some sort of insight. Thank you very much for your time
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 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
•Why did my IVF Fail
•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!
•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
•Endometriosis and Infertily
•Endometriosis and Infertility: Why IVF Rather than IUI or Surgery Should be the Treatment of Choice.
•Treating Ovarian Endometriomas with Sclerotherapy.
•Preventing Severe Ovarian Hyperstimulation Syndrome (OHSS) with “Prolonged Coasting”
•Understanding Polycystic Ovarian Syndrome (PCOS) and the Need to Customize Ovarian Stimulation Protocols.
•“Triggering” Egg Maturation in IVF: Comparing urine-derived hCG, Recombinant DNA-hCG and GnRH-agonist:
•The “Lupron Trigger” to Prevent Severe OHSS: What are the Pro’s and Con’s?
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
We are currently starting COS on our fourth ICSI attempt in the UK within 12 months. We had a daughter via ICSI in 2013. We are both 37 and I have male factor (poor motility/morph but normal count). My question is about the stimulation protocol. Previous 3 cycles we have been on 375iu Menopur. This cycle we are trying 300 GonalF and 75 Menopur to see if the LH reduction makes a difference to quality. Our embryo quality is quite poor and we rarely get to blastocyst. Do you think 75iu menopur is enough LH in this cycle? Your blog suggest some LH is needed. In a combined meds protocol like this what ratio is optimal? FSH is 5.5 and AMH is 13. Should the menopur be increased toward end of COS? Our RE effectively asked us to state what ratio of GonalF to Menopur we wanted as believes they are essentially the same in terms of response so I wonder if our somewhat arbitrary choice is right.
Just to add, we are on long protocol with buserilin.
75U Menopur is fine!
Geoff Sher
Hello Dr. Sher,
I’m 44 and planing our 4th FET (DE). But this is being postponed again and again:
– In April, my cycle shortened to 15 days (usually 25 days) and at that time a polyp was discovered.
– Polyp was removed during next cycle in May (I was given BCP for ~18 days then bleeding started).
– I was supposed to wait one natural cycle….But now it is already 44 days and I still didn’t get my period.
– Nine days ago: lining 8.6, visible 3.5 cm simple ovarian cyst, P4 11,1 and E2 94.7
– 15 days ago: E2 was 260, LH 14.8 and FSH 7.5
My questions:
1. Can this 3.5 cm cyst be a reason to postpone FET again?
2. Am I correct to believe that once finally the bleeding starts, all those irregularities that happened in the previous cycles don’t matter since my natural cycle will be overwritten with Estradiol from 2nd day of my cycle and Progesterone starting 5 days before transfer?
3. Because of all the delays it turned that I am taking Dexamethasone for 74 days already and I am told to continue – can this become a problem?
4. Is there anything you would recommend?
I am told to just wait… But all this is so nerve wrecking and it is so difficult to be patient and “just wait” without understanding of what is going on with my cycle and if this can have impact on the results of embryo transfer in the next cycle.
I cannot say thank you enough for this forum and for what you are doing.
Thank you!
Zuza
1. Can this 3.5 cm cyst be a reason to postpone FET again?
A: As long as the cyst is not hormonally active to the point that it is delaying your period…no need to delay. It is easy to aspirate it if need be and this could start your period going.
2. Am I correct to believe that once finally the bleeding starts, all those irregularities that happened in the previous cycles don’t matter since my natural cycle will be overwritten with Estradiol from 2nd day of my cycle and Progesterone starting 5 days before transfer?
A: I believe so!
3. Because of all the delays it turned that I am taking Dexamethasone for 74 days already and I am told to continue – can this become a problem?
A: I do not see the need to start the dexamethasone until the treatment cycle begins.
4. Is there anything you would recommend?
Have your estradiol measured. If it is >70pg/ml, I would aspirate the cyst and anticipate a period within less than a week.
Good luck!
Geoff Sher
HI Dr Sher,
I have done 3 IVF cycles with my eggs. 1st one pregnant ended in missed miscarriage :(; 2nd cycle canceled a week into Stims. 3rd cycle bfn. We then flew to Prague to use donor eggs as my amh was.3. Fresh cycle was a bfn. My fet I’m currently 5w2d. My transfer was June 10th. My question is 13 days after transfer my HCG was 221; 2 days later it was 317. I’m completely stressing out and dreading my ultrasound on July 8th. What do you think of the numbers? Thx
It is hard to say…but there is hope. Repeat the test in 2 days to see if it doubles and then an US 2 weeks later for a definitive answer.
Geoff Sher
Hello my name is Caitlin I’m 19 yrs old from New Orleans . Me and my fiance have been desperately trying to have a family. We a same sex couple. My partner being 35 yrs old with pcos I have decided to carry using my own eggs. I’ve have 3 iui with 1 ending in a miscarriage at 5weeks. Each cycle I took letrozole and a hug trigger for all 3 all included monitoring . Not knowing what steps to take next, I was thinking another iui but maybe try natural with monitoring and hcg shot. Paying out of pocket is stressful but expected and the fertility dr in New Orleans are a little shallow. Just seeking a little professional advice dr that seems to care a bit to ease my mind. My health is petty good . What do you think I should do in my next steps in getting pregnant ? Thank u in advance
Perhaps we should talk!
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.