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, I am 29 and started treatment a year and a half ago with 2 failed IUIs. After that failed we decided to do Ivf. We were able to get 30 eggs, and by day 5 we had 11 healthy great quality blastocyst. We went through 1 miscarriage with round 1 and a d&c; a very low beta and miscarriage/chemical pregnancy with round 2, and no luck at all round 3. We then sent the 8 blastocyst we had left to get genetically tested (my husband and I were both tested before we started and had nothing that we or the dr thought would be an issue). We had 5 come back perfect. 2 had abnormalities and 1 something went wrong on the reading or test so they had to disguard it. After that, we did a transfer with what was a perfectly healthy and graded embryo and had another chemical pregnancy. Beta was only 22. After that I had my third HSG with normal results like the previous ones. have never had any test or ultrasound they ran come back with bad results. I am told I am perfectly healthy with a think uterus lining and fantastic blood results. At this point I went for a second opinion and even that dr went through all of my charts and couldn’t seem to make sense of why I wasn’t pregnant at this point. He suggested going a endometrial function test. Since he was out of town, I went back to my dr for a follow up after the last cycle and asked him what he thought we should do at this point and I also mentioned I went to seek out a second opinion. At that meeting he suggested doing an endometrium receptive array test and a uterus biopsy with a scratch. Since it was more convenient to do that since it is in the same city I live in I decided to go his rout and try 1 more time with him. After being on a FET drug protocol but doing the ERA instead of a transfer my results showed that I am on the edge of maybe being a little late to implant. The test showed to wait 12 hours later than what we have done in the past and the biopsy and scratch results came back normal. Really? 12 hours makes that big of a difference? And my embryos have implanted, they just haven’t grown so I am not convinced that is the issue. I have always been told after my second blood (12 days post transfer day)draw my beta hasn’t doubled so stop my meds and let it pass. And they have, except for the first round. I am now on day 16 of lupron 10 units and I decrease it to 5 tomorrow (August 10th) and start estrace 2mg and 1 .1mg patch of minivelle. I will continue estrace daily and have a scedule for patch changes up until 8/23 at what point I start adding crinone am and pm and prog.in oil 1ml every other day to the estrace daily and minivelle patch schedule. I am to the point I don’t know what to do and a friend told me about your site and said I should run things by you to maybe ease my mind. It’s very frustrating to be told you are perfectly healthy to carry a baby but still after 2 IUIs, a fresh transfer, 3 frozen, and no luck it’s very discouraging. I don’t know what I am really asking, but after reading my book (sorry) do you have any suggestions on what I should be doing different or trying? Thank you for your time. I look forward to hearing from you.
Amy
Respectfully, I have no confidence in the efficacy of ERA.
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
•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
•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.
•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
•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.
Hi Dr Sher,
Can you explain why it is that a trilaminar-appearing lining is more receptive than a homogenous lining? My lining has thickened appropriately (12mm) but it is NOT trilaminar. I am concerned for my transfer, since I have read literature that suggests miscarriage rates are higher with non-trilaminar linings.
I used to believe that it was necessary for there to be a trilaminar lining. Now we know that as long as the lining is >9mm thick it is likely to be fine. 8-9mm is a “gray zone”.
Good luck!
Geoff Sher
Hi Dr Sher, You asked me to repost my question …. what would happen if you take Suprefact nasal spray on day 21 but happened to be unknowingly pregnant. Would the medication have an impact on the health of the unborn baby?
No! It should not!
Geoff Sher
Dear Dr. Sher, First I would like to thank you for taking time to provide your insight on this matter to all of us that are seeking some advice. August of 2015 – we had spontaneous chemical pregnancy .I was 40 at that time and turned 41 nov 1 – I , will be 42 this Nov 1. my partner is 30years old. 1st Ivf jan 2016 resulted in 9 retrieved all fertilized eggs, 4 transferred( 1x 10 cell/2 x 8 cell and 1 x 7 cell) cell embryos) on day 3 resulting ultimately in D & C at 8 weeks ( no heartbeat)chromosome abnormal
the rest ( 5 from this cycle ) were frozen at day 3. The 2nd Ivf -5 follicles – by day 7 – 2and thus out of 5 we retrieved 2 mature eggs( which fertilized) , 3 were dark brown and did not fertilize. We tranfered the 2 at day 3 both 3 at 11 & 12 cells – implantation did not occur. I’ve just completed my 3rdIVF .. same protocol as other – Gona;F/menopur/ganarelix/ trigger shot 10,000 units HCG. I initially went for an IUI cycle but found 6 follicles so we decided that IVF maybe the best option. on the trigger day all 8 follicles were all at approx. the same size. Dr said even the smaller ones were still at a size that it could mature and be retrieved and the dr’s expected all eggs to be retrieved. It seemed like a very good cycle. last sonogram fr measurements were on sat- I was given last ganarelix and gona F that morning , 10,000 units of HCG at 10 pm sat night – retrieval scheduled for Monday morning t 10 am
..however -I was devastated to hear only 2 eggs were retrieved , I was told that the other follicles were empty but as you said all follicles contain an egg. I questioned what went wrong. Could it be that the retrieval was scehuled at the wrong time ? Perhaps too late ? is there anything you can identify in this protocal that could have affected the retrieval outcome ? I’m completely lost on what happened here- I’m so frustrated and ate endof my rope with tis .. I’m thinking its time to give up
Dear Dr,
just to clarify , so you are saying that this is all probably because of my age that the follicles were ’empty” at the time of retrieval? I have contacted Julie for consultation
Dear Dr. Sher,
Thank you for providing this platform.
I am 32 years old and based in Nigeria. I have been trying to conceive since January 2014; past 32 months. I had a laparoscopic myomectomy done in December 2014 which revealed sub-serosal fibroids and moderate to severe endometriosis. The fibroids were removed and endometriosis was partly removed. Also dye test performed showed my tubes were open.
Attempted unsuccessfully to conceive naturally over the next 13 months and this led me to my first ever IVF in March 2016. Two Grade A embryos transferred led to my first ever pregnancy with twin heart beat at 6+ weeks. However, no heart beats detected at 7 weeks. A medical evacuation was done subsequently, however no testing was done on the products of conception as this isn’t available in Nigeria.
The IVF doctor in Nigeria suspects the cause of miscarriage as the presence of raised NK Cells, however testing is not available in Nigeria and advised that i travel abroad for testing. I came to America two weeks ago after speaking with a few doctors, they all told me the same thing – “they do not believe that Raised NK Cells theory as a cause of miscarriage” and refused to test me for this.
During the IVF procedure, my doctor in Nigeria treated me with IVIG and Intralipids pre-implantation and post pregnancy to maximise my chances “just in case in had elevated NK Cells”. However, this treatment is quite expensive in Nigeria and i also fear it may be unsafe. Thus, I would really love to test for the Raised NK so as to know if this treatment is required for my subsequent cycles.
I am currently in the Washington DC area till Friday 12 August, when i will be returning to Nigeria, Can you please let me how and where i can get tested for the Elevated NK Cells.
Thank you so much.
Bidemi
Very respectfully, for you to be told that ther e is no basis for a relationship between NK cell activation and failed implantation is in my opinion wrong . I can understand someone telling you that they do not believe in this but to outright refuse to test you is arrogant. However, the tests you need are >than simply an NK activity test. You need to be tested for both autoimmune and alloimmune implantation dysfunction and this will require your blood being tested for the NK cell activation test (using the K-562 target cell assay), antiphospholipid antibodies and an immunophenotype and antithyroid antibodies and both your and your husband’s blood being assessed for DQ alpha/HLA genetic matching…see below. You need to contact Reproductive Immunology Associates (RIA) in Van Nuys, CA and have your blood sent there. Go to google and find their contact information. Call them , mention my name and have your blood drawn anywhere and then transported to them , following their directives to do so.
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
•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
•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
•Endometriosis and Infertily
•Endometriosis and Infertility: Why IVF Rather than IUI or Surgery Should be the Treatment of Choice.
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.