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 came across your blog by chance and I have read some incredible stories. I am 37 years old and I started my ivf cycle this year. During the beginning of the process, the cycle was canceled because the forlicules were not growing. The next cycle came and I was put on the stimulating injections including Lupton and just today, the cycle was still canceled. .with the forlicules not growing the way they are expecting to grow,do I stand any chance at all, I am so devastated and emotionally breaking down. Please help. Thank you.
Miriam Enokpa.
I’ve had 3 ivf fails own eggs, 1 fail with de, I have pcos with underactive thyroid and autoimmune issue, I recently had a zfb done, results came back, with enzyme cd57 in the nkcs as active hostile, my new treatment is, clexane, steroids, intralipids, I started my ivf journey aged 27, clomid then ivfs, I’m now 35, and losing hope, any slight chance my new treatment will work or am I just clutching at straws. It’s been 8 years, this will be my 5th attempt. It’s draining financially, emotionally. I’ve already done so many tests, meds, treatments. I’m on eltroxin, metformin, always, eat healthy.
Bear in mind that immunologic implantation dysfunction can be due to autoimmune or alloimmune factors and treatment differs. It is essential to differnentiate between the two before starting treatment…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.
•The “Biological Clock” and how it should Influence the Selection and Design of Ovarian Stimulation Protocols for IVF
•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
•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.
Dear Dr Sher, I had a Hysteroscopy Polypectomy + D&C.
One week later, I took Prednisolone under a doctor’s inc for allergic dermatitis (20mg per day for 5 days).
I am scheduled for FET about approx. 5 weeks after the Hysteroscopy Polypectomy + D&C.
Now I am paranoid and I hope u can help.
Will the Prednisolone interfere or impede the healing from Hysteroscopy Polypectomy + D&C?
Will my womb heal in time for the FET end of this month?
Thank u!
There is unlikely to be any adverse effect!
Good luck!
Geoff Sher
I am a Type 2 diabetic my Blood sugar was recently not controlled about 5 months ago. Everything is back under control again I am happy to say. However, I am trying to father kids with my fiance and desperately am nervous of infertility. Sad thing is that I do masturbate kind of a lot I believe when i’m bored. My semen is usually watery with some white to it as well. What can I do to get sperm volume thick and white again to produce a child? Should I be concerned? Please help me, I’m ready to help myself please .
There is probably no need for concern Anthony!
Good luck!
Geoff Sher
Hi Dr Sher,
I have just turned 40 (on 8th June) and have been trying to conceive for 4 years. I have PCOS, but all other fertility tests (AMH, LH etc) have come back normal. I am slim and very healthy. My husband has no known fertility issues.
I wanted to ask your expert advice on the results from my two recent IVF PGS cycles, both undertaken when i was 39 years old. The first produced eight excellent quality blastocysts, all of which failed PGS testing. The second produced 14 excellent quality blastocysts and only one came back as normal following PGS testing. So out of 22 embryos, 21 were categorised as ‘abnormal’ following PGS, although eight only had fragments of a single chromosome either delated or duplicated, so whilst the genetics lab has said these eight are still officially abnormal, they have told me they may still be capable of producing a viable pregnancy, which i find very confusing.
The protocol I was on for both cycles was:
-One preparatory month of cycle progynova to regulate my cycle.
-Day 2 of next cycle, started merional 75iu and Gonal F 150iu daily, as well as Dexamethesone 0.5mg x 2 daily and Zomacton 4mg every other day.
-From day 7 until day 12, added cetrotide 0.25mg.
-Gonal F reduced to 75 iu from day 9.
-Trigger shot on day 12 was 1ml of buserelin for first fresh cycle (the one in which all eight blasts failed PGS)
-The trigger shot for the second cycle was also on day 12, but this time 11ml of buserelin and a low dose of 1500 of HCG
– egg collection on day 13 for both cycles. We did ICSI for the first cycle. The first cycle produced 15 eggs, of which 12 were mature, 10 fertilised and 8 became high quality blastocysts.
-We did IMSI for the second cycle which produced 21 eggs, of which 19 were mature, 15 fertilised and 14 became high quality blastocysts.
My main question is whether you would do anything differently in my protocol, for a woman now just 40 with PCOS. From these last two cycles I don’t have any issues producing lots of eggs and have a high blastocyst conversion rate, but the rate of chromosonally damaged embryos per number PGS tested is far higher than the average for my age group- given these were all collected when i was 39, having only 1 PGS normal embryo out of 22 is very low.
I want to continue trying with my own eggs whilst I still can, but I don’t want to embark on another fresh cycle without making some changes. The only thing we changed between the above two cycles was to add in a very small amount of HCG to the trigger shot on day 12 and we did IMSI. My clinic therefore are suggesting just trying exactly the same again given i’m producing a lot of blastocysts. I’m really worried that if we do exactly the same, we’ll still have the same proportion coming back chromosonally abnormal.
Thank you very much in advance for any advice. Nikki
Hi Nikki,
What most readers of this blog are probably coming to realize is that IVF is an “art-science blend”. There is a wide variation in approaches to stimulation with gonadotropins.In many respects this is very unfortunate but also inevitable. The reason I say this is because the protocol used for ovarian stimulation is in my opinion singly the most important determinant of egg/embryo quality (and thus IVF outcome), particularly when it comes to older women, women with DOR and women with PCOS who tend already to over-produce ovarian male hormones (especially testosterone) which if present in excess will adversely affect egg/embryo development (see below). Also, I am not in favor of triggering with an agonist such as Lupron/Buserelin/Superfact..(see below).
I urge you to 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.
•Preimplantation Genetic Testing (PGS) in IVF: It Should be Used Selectively and NOT be Routine.
•Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
•PGS in IVF: Are Some Chromosomally abnormal Embryos Capable of Resulting in Normal Babies and Being Wrongly Discarded?
•PGS and Assessment of Egg/Embryo “competency”: How Method, Timing and Methodology Could Affect Reliability
•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
•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.