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.
What is your recommendation in regards to the semen collection for IVF? How many days before should the man ejaculate? Is it important to have sex/ejaculate in the weeks leading up to the collection? What about alcohol/cigar smoke/other factors that affect quality? In the past, the fertility clinic has always said my husband’s sample was amazing; however at our last IVF, they said it was good, but not amazing.
Remembering that the sperm ejaculated began its development 3 months prior. Thus in my opinion, it follows that regardless of whether ejaculation occurred soon prior to collection of the specimen for IVF or a week before, should not alter the quality of the specimen. However, it might well affect the volume of the ejaculate and sperm concentration. Thus, in my opinion, the only time this could be important is in cases of men with low sperm counts and poor sperm parameters.. No doubt …over-use of alcohol and chronic smoking can adversely affect sperm parameters, but modest alcohol consumption and isolated smoking of a cigar or two, should in my opinion not do harm.
Good luck!
Geoff Sher
Hi Dr Sher, My wife (37) and I (40) have been trying unsuccessfully to have a second child for the past 3 years. We have unexplained secondary infertility. All tests are normal. we had 2 years of trying naturally and in the past year have had 4 failed IUI and 1 IVF fresh (Chemical Preg) and 1 IVF frozen(beta hgc of 16 then failure). The tests for my wife have all come back normal. My wife does seem to get bloated and get a saw stomach around ovulation. we have had a few times over the time trying naturally where my wife has been a few days late and it has been the same as the chemical pregnancy. She is thinking now we know what one is like that she has had this before. We have 2 blastocysts left and would like to know what tests we should ask for or suggestions to improve out chances. Thanks
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?
•Blastocyst Embryo Transfers Should be the Standard of Care in IV
•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.
•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)
•Intralipid (IL) Administration in IVF: It’s Composition; How it Works; Administration; Side-effects; Reactions and Precautions
•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,
A)In a normal menstrual cycle, what follicle size does ovulation occur?
B) I am 36 years old but I surge when follicles are 15mm and ovulate. What is the cause of this?
C)What is the typical follicle size at which a LH surge occurs?
D)Can ovulation occur with E2 less than 150? And at what E2 level is ovulation inevitable in a normal cycle?
1)In a normal menstrual cycle, what follicle size does ovulation occur?
A: When the leading (dominant) follicle is >18mm
2) I am 36 years old but I surge when follicles are 15mm and ovulate. What is the cause of this?
A: That could be due to “premature luteinization) sometimes seen in women with diminished ovarian reserve (DOR)
3)What is the typical follicle size at which a LH surge occurs?
A: When the leading follicle is >18mm
D)Can ovulation occur with E2 less than 150? And at what E2 level is ovulation inevitable in a normal cycle?
A: Possible but uncommon.
Geoff Sher
Dr. Sher, My question is related to one of your articles related to vitamins. In the article you had prescribed some of the following vitamins: Co-enzyme Q10 (100mg daily ), amino acids such as L-Carnitine (3 grams daily) and L-arginine (1 gram per day ), ETC.
Should a patient with age related DOR take higher dosages of the vitamins. Our doctor recommends 800 Mg of Ubiqunol and 3 gms of L-Argine among higher dosages of other vitamins. Are higher dosages harmful for egg quality ? Conversely, are standard dosages e.g. 100 mg ubiqunol effective for patients with age related DOR ?
There is no harm in increasing the dosages in my opinion…But in all honesty, there is just no conclusive evidence that any of it really enhances egg/embryo quality.
Geoff Sher
Dr. Sher,
I had 6 chemical pregnancies, but every time my HCG is lower than the previous one.
Here are the maximum levels it reaches respectively (800 – 330 – 300 – 210 – 190 – 90)
What problem should this indicate?
note: I had clexane + baby aspirin + progestrone