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,
My husband (41) and I (36) have been trying to conceive over the last 4 years. We have been doing infertility treatments for the last three years. We have had approx. 9 failed IUIs and 4 failed IVF cycles. We used ICSI (sometimes the sperm go right in, sometimes not, so the last few cycles we have used ICSI) They retrieve anywhere from 23, 11, 16 etc eggs and most, if not all fertilize. Most die by Day 3 and we are usually left with one maybe two preblasts or morula by Day 5. This last cycle we implanted a Stage 3 Blast and Morula. We have never been successful and I have never been pregnant. We have no infertility conditions that we know of. We are heartbroken by these continued failed cycles and are not certain what are next steps should be. No one in our families have ever had fertility issues. We can’t understand why we never have a good enough embryo for PGD. Help? Are there tests that we should be having? Should we be doing something different?
Thanks!
Hi JJ,
You certainly have been through a great deal. My heart goes out to you. BUT perhaps I can help!
First let me say that selection of a strategic stimulation protocol is in my opinion the most important consideration.
You know, 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.
•The “Biological Clock” and how it should Influence the Selection and Design of Ovarian Stimulation Protocols for IVF.
• A Rational Basis for selecting Controlled Ovarian Stimulation (COS) protocols in women with Diminished Ovarian Reserve (DOR)
•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
•Optimizing Response to Ovarian Stimulation in Women who Have Compromised Ovarian Response to Ovarian Stimulation in Women who Have Compromised Ovarian Reserve: A Personal Approach.
•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
•Secondary Infertility: Addressing the Root Causes
•Recurrent Pregnancy Loss (RPL): Why do I keep losing my Pregnancies
•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.
•Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
•Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
•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
•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,
My husband and I, we are both 36, we we want to do embryo banking w/ PGS since we are not ready to have a baby yet. We have been studying the SART statistics, but we are really confused. It seems like the statistics vary across clinics widely. From a convenience/cost standpoint the clinic near where we live and work would be ideal, but their statistics are really low (their <35 live birth rate is 20%). Their SART page (on the top) says they do a lot of natural cycle IVF, so we are assuming the lower statistical results are because of the natural cycle IVF averages. Is that true? If we are banking embryos with PGS, how important are these statistics for us to be able to take home a healthy baby in the future?
Thank you so much!
Tara
Unfortunately SART statistics are not audited and thus and subject to misrepresentation. I invite you to call 800-780-7437 and set up a Skype consultation with me to discuss your case in detail.
Geoff Sher
Hi Dr. Sher I have been reading about your series on Immunological Implantation Dysfunction and have some questions. I have just received a negative result on my 5th IVF cycle this week. I am concerned that not enough is being looked into regarding the autoimmune issues I have and am wondering if you can suggest further testing I should consider. I am 38 yrs old and have been trying to conceive for 2 years. I have rheumatoid arthritis (which is being treated with Enbrel), hypothyroidism (under control with thyroxine) and pernicious anaemia. I was diagnosed with juvenile arthritis at 18 months. I had a successful pregnancy when I was 24yrs old and was diagnosed with hypothyroidism just before this. We discovered the pernicious anaemia when my daughter was 6 days old as she had no B12 in her system at all. So it seems I had all these conditions when I conceived before. I have had some antibody tests and have been told it is almost certain that I have anti ovarian antibodies. I had a blood test for NK cells a year ago which was ‘negative’ but from what I’m reading from your information, I should probably have a biopsy taken from my uterine lining to check the cells in there. Can you think of any further investigations or therapies I should be considering? At the very least I am thinking prednisolone may help? Can I also ask, in your opinion, do you think these 3 conditions can be controlled to a point that they will not impeded on implantation? I’m just trying to work out if there is any point at all. Many thanks, Amy
Given your history I strongly suspect that you indeed do have an immunologic implantation issue. The blood test for NKa is more important that uterine biopsy for cytokines. However it must be the K-562 target cell blood test along with APA/ATA and immmunophenotype. Also you and your partner should be matched for DQ alpha?HLA genotype.
I invite you to call 800-780-7437 to set up a Skype consultation with me to discuss your case.
Geoff Sher
Hi, I’m currently on my 2nd ivf cycle. This was a FET of a grade 5AB Blastocyst. It has been 7 days since my transfer. Today I had a very tiny light pink discharge. Does this mean it’s implantation bleeding? Ectopic ? irritation from the progesterone suppositories? Or is my cycle coming on? Will it be reliable to take a pregnancy test this early? The only meds I’ve been on this cycle are estrace pills and progesterone suppositories. I’ve had light cramping and back pain. Thank you.
I don’t think it means much. It could be local irritation of the cervix by the suppositories. I doubt it is implantation bleeding and it is far to early to indicate an ectopic. I also do not think it is coming from the implantation site. All you can do is sit it out and wait.
Sorry!
Geoff Sher
Hi Dr. Sher,
I just went through egg retreival for IVF and something strange happened so I was hoping you could shed some light on it for me.
I had a few follicles growing nicely on my right side this month, and the left side was fewer and smaller. During the egg retreival procedure, my doctor had a problem retrieving my eggs on my right side. He said he tried two different ways – to flush them out, and I forget the other way. He could not get any out. He said it could be for a few reasons:
1) they might be cycts
2) there might not be any eggs inside the follicles
3) maybe I needed an additional hcg shot (though last year when I did IVF everything went fine and I only used one trigger shot).
I took Pregnyl from Merck. The clinic told me to inject in into my stomach but now when I look at the box, it says to only inject it intramuscular. So did my clinic give me the wrong advice? If I had injected Pregnyl into a muscular area, would it have worked?
In the end my doctor managed to get four eggs out of my left side, and one of them lacked any genetic material, so really there is three eggs.
Is my doctor competent? Does this sort of thing happen? What could cause this? I am really disappointed because my right side had much more follicles and they were growing nicely.
Please share your opinion with me. Thank you so much.
Jennifer
Jennifer, I have already addressed this post!
Please find my response from earlier on today.
Geoff Sher