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.
Dr. Sher, My first question is, are Nurse Aides included in your First Responder Discount? My second question is, what are the success rates for IVF for couple with Endo, PCOS and borderline Morphology (if it’s possible to give a rough estimate with only that information)? Thank you.
Hi Veronica,
There are so many variables that affect outcome with IVF that I would need much more information to provide an authoritative opinion.
Geoff Sher
I just confirmed my second chemical pregnancy in a row (4 months apart). I have a history of infertility (age 41, one successful live birth from an IVF cycle with my own eggs at age 38, fresh day 3 transfer) due to being a poor responder and having poor egg quality. We have since moved to donor eggs and this is the second FET resulting in a chemical pregnancy. The embryos tested normally and were already hatched, perfect quality, 2 each FET cycle. I have no issues with my lining, this cycle the lining was 12mm a couple of days before the transfer, hysteroscopy didn’t show anything out of the ordinary. Thyroid function is good. I do have the MTHFR gene (homozygous) and was on heparin and added folic acid for both cycles. We added Intralipids for this cycle and changed folic acid to folate.
I am at my wit’s end and don’t know, how to proceed. There seems to be nothing wrong with my uterus and the embryos implant. They just stop growing. What do I have to look into?
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).
Good luck!
Geoff Sher
Hi. I am approximately 8 weeks along. I had my first Dr appointment 2 days ago. The doctor gave me a physical and said my uterus felt approx. 8 weeks. I had my blood drawn for my HgC levels to be tested at my request. They were at 49,900. I retested today 48 hrs later and they only went up to 51,400. I have an ultrasound Tuesday but am so concerned that the levels didn’t rise enough. I feel queezy and tired still. Any guidance or reassurance? I had a miscarriage at 7 weeks pregnant 2 years ago. And 2 live births 14 and 17 years ago. I am 41 y.o. in perfect health.
Once the hCG level rises above 6000, it no longer doubles every 2 days. However, an US would be definitive.
Geoff Sher
Dr. Sher,
I have just turned 39 years old and have been through 4 ivf cycles in the past two years. I was told I had a small fibroid in the lower part of my uterine cavity that would likely not affect the IVF or implantation. All hormone levels were normal – we started IVF based on my husband having had radiation treatment and with all my levels normal, Dr. thought it was a slam dunk! My first IVF was right after my 37th birthday – I was on Bravelle/Menopur and ended up with 10 eggs, 4 making it to blast, 2 transferred, 2 frozen. The outcome was an ectopic pregnancy – at 7 weeks, after a diagnosis of miscarriage, my HCG levels were 32,000 so they looked again and found the fetus and heartbeat on my right tube. Emergencey surgery and wound up losing the tube. Over the course of the next 6 months transferred both frozen embryos with no success. One year after first IVF, we went through another fresh cycle using Bravelle/Menopur which resulted in 8 eggs, 2 blasts transferred, none frozen. This time I was on extended antibiotics and steroids prior to transfer and steroids and blood thinner after transfer. Results – chemical pregnancy. Post consultation, Dr. revealed it may be a good move to get the fibroid out prior to trying again. Went to a different clinic and had the fibroid removed 12/15. Was convinced by new clinic to try IVF there – “they could do better”. I went through a cycle there in 2/16 using Follistim – resulted in 3 eggs, 2 fertilized – transferred 2 3day embryos (one was 4 cell, one was 6 cell). Had very little hope – was right – negative. Just last month I started stimulation at the original clinic for IVF #4 using Menopur only. We got 12 eggs, transferred 3-3 day embryos (two “perfect” 8-cell and one “slightly fragmented” 10 cell), one of remaining embryos made it to blast for freezing. Extended antibiotics again, but no extended steroids, blood thinners post transfer. Results were chemical pregnancy again! Now i have one frozen embryo and zero patience remaining. We plan to do the FET asap, because we want to move on with our lives, but do you see anything in my history that would cause you to test for or try anything different before the FET? I have always had good lining according to US, never been tested for NKA, and again have some scarring from the fibroid that was removed but it was located in the lower cavity, where both doctors said it was not in the area an embryo would impant and it would not be a factor. I have 2 other small fibroids within the muscle of the uterus, but they do not protrude into the cavity. Thoughts??
thank you!
H.S.
In my opinion, a fibroid protruding ibto the uterine cavity can and does cause implantation dysfunction and should be removed.
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
•Ovarian Stimulation in Women Who have Diminished Ovarian Reserve (DOR): Introducing the Agonist/Antagonist Conversion protocol
•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?
•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
•Egg Donation
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.
I had my ET on 30th July 2016, and I got B-HCG Positive on 13th Aug 2016.
On 18th Aug 2016, on US Abdomen scan, gestation sac was found and it measured 1.14 mm but no heart beat yet since it was 5W4D from LMP(10/July/2016). Report says its development is 2 days lagging (Actual Development: 5W 2D). My concern is:
(a) Is it okay, if development is 2 days lagging?
(b) If it is 2 days lagging, when can I expect Fetal heart beat to appear on US Scan?
Thank in advance.
Shwetha
I have responded elsewhere..that I do not think the 2 day lag is relevant.
Good luck!
Geoff Sher