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.
In the UK, the tests for immunological implantation dysfunction (usually known as the Chicago tests, as most clinics send bloods to RFU) test for NK cell activation via the NK cells cytoxicity assay (the battery of tests includes immunophenotyping, TH1:TH2 ratio etc)
I’ve had these tests, however from your very helpful blog posts and comments on this forum, I know that you recommend a different NK cells test (K-562 target cell test).
In your opinion, what makes this particular test the gold standard?
Very many thanks for all the amazing information and guidance you offer. It has been the most spectacular resource and mine of useful info throughout my infertility journey!
Warmest regards
Katy
Because this is the test upon which we have based efficacy of treatment. Frankly, it tends to correlate with uterine cytokines, but there is as yet no data upon which to use the results interchangeably.
Geoff Sher
Dear Dr Sher,
I have endometriosis following several historic scans via fertility centre and laparoscopies in 2014 and July 2016 to remove some of it. These were successful however, the last operation showed some scarring and endo lifting the left side of my bladder slightly so they were unable to remove this part on the left sacral ligament due to the tricky location. I also had a uterine polyp removal during this operation which was successful. I was advised to try to conceive for 6 months naturally with my now partner, following the polyp removal. Whilst it has reduced menstrual bleeding, and seemed to have introduced ovulation spotting and initial implantation bleed signs following conception, which is useful, we have had 2 unsuccessful months so far (and we were unsuccessful for several months before the polyp removal). My partner has high sperm count (150 mill) and normal motility. I feel that I am conceiving, as I go through many early conception symptoms however, these fade several days before my period is due, and I think I am having implantation problems due to endo, rather than anything else. I recently turned 40 and was pregnant when I was 31, but never since. My consultant advised against IVF for now due to its harsh effects on women or the emotional toll, however, could you advise on whether I would still be wasting my time trying naturally for a further 4 months. There is also the problem that here in the UK not many clinics specialise in treating the uterine immunological factors you talk about, NKa, APA (and over production of prostaglandins for endo patients triggering new cycle and failed implantation). Grateful for your advice. I only now have endo on the left sacral ligament following the operation but I would like to know what really can be done about the uterine endo factors.
Kind Regards
Rachael H, United Kingdom.
Endometriosis is a complex condition where, the lack or relative absence of an overt anatomical barrier to fertility often belies the true extent of reproductive problem(s). All too often the view is expressed that the severity of related infertility is directly proportionate to the anatomical severity of the endometriosis itself, the implication being that the primary reason for endometriosis –related infertility is anatomical interference with egg transport to the Fallopian tube(s). This over-simplification and an erroneous view is often used to justify the performance of many unnecessary surgeries for the removal of small innocuous endometriotic lesions, on the basis of such “treatment” evoking an improvement in subsequent fertility.
It is indeed indisputable that even the mildest form of endometriosis can compromise fertility. It is equally true that, mild to moderate endometriosis is by no means a cause of absolute “sterility”. Rather, when compared with normally ovulating women of a similar age who do not have endometriosis, women with mild to moderate endometriosis are about three to four times less likely to have a successful pregnancy. Two important reasons for such reduction in fertility potential are:
a) Toxic Pelvic Environment: Endometriosis is associated with the presence of local pelvic toxins that significantly reduces the fertilization potential of eggs as they pass from the ovary to the fallopian tube via the pelvic cavity and,
b) Immunologic Implantation Dysfunction (IID): Given that the pathogenesis of endometriosis almost certainly involves an abnormal immune response. In about one third of cases, activation of uterine natural killer cells (NKa) causes the uterus to reject the embryo (fertilized egg) as it attempts to gain attachment to the uterine lining (endometrium).
The reported annual birth rate for normally ovulating women under 35 yrs who are free of endometriosis or any other pelvic disease, is about 70-80%. For women 35-40yrs of age, the comparable annual rate is about 40-50%, for women in their early 40’s, it is probably less than 20% and by the mid-forties, …around 10%. In contrast women in similar age categories who have even the mildest degree of endometriosis can expect a 3-4-fold reduction in the annual birth rate.
Since, the reason for women with mild to moderate endometriosis having a much poorer reproductive performance has little to do with ovulation dysfunction or anatomical disease, it should come as no surprise that the use of fertility drugs, surgery to ablate small endometriotic deposits and minor adhesions, and/or intrauterine insemination is unlikely to any improvement in pregnancy rate over no treatment at all. Women under 35 years who fit this profile, and who conceive following fertility hormone therapy, intrauterine insemination (IUI) or surgery, should consider that they probably conceived in spite of (rather than due to), such treatment. Failure to recognize this reality carries with it the risk that when it comes to planning for another baby, the woman will erroneously belief that having conceived before means that there should be no difficulty in doing so again and be lulled into a false sense of complacency. In reality, the achievement of a viable pregnancy by a woman with mild/moderate endometriosis, whether it occurred spontaneously or following such treatment probably does not improve her subsequent ability to conceive.
Younger women (under 30 yrs) with mild/moderate pelvic endometriosis (who have patent fallopian tubes, are ovulating normally and have fertile male partners), have about a 40% chance of having a baby within 3-4 years. Accordingly they justifiably can choose taking a “wait and see “approach, avoiding surgery, fertility drugs and intrauterine insemination (which in my opinion would be unlikely to improve the chance of a successful pregnancy over no treatment at all) and In Vitro Fertilization which by involving the direct extraction of eggs from the ovaries and initiating the fertilization process in the Petri dish/incubator, the IVF procedure facilitates fertilization, is much likely to be successful, but might have been avoided by a “wait and see approach”.
Finally, I wish to point out that in addition to an inevitable toxic “peritoneal factor” present in all women with endometriosis, about 1/3 of women with endometriosis (regardless of its severity), also have an immunologic barrier to implantation involving NKa and possibly the action of antiphospholipid antibodies. This population of women are not likely to achieve a viable pregnancy conceive until/unless the IID is addressed through selective immunotherapy involving Intralipid, heparinoids (Lovenox/Clexane) and low dosage (short term) steroid therapy. It therefore behooves all women with endometriosis who are planning to have a family to be thoroughly tested which in my opinion should be performed in a reproductive immunology reference lab of which to my knowledge no more than a half dozen in the United States, capable of performing these tests with the required sensitivity. I preferentially use Reproductive Immunology Associates (RIA) in Van Nuys, CA.
Given the effect of the accelerating biological clock, women over 35yrs who have endometriosis-related infertility, do not have time to waste and should, in my opinion do IVF as a first line approach, regardless of their immunologic status. In the absence of clear evidence of increased NK cell activity, I often recommend a conservative approach in women under 35years (who potentially can afford the time to wait). However, regardless of age, women who have increased NK cell activity, should in my opinion undergo IVF accompanied with immunotherapy with Intralipid (and sometimes heparin, Clexane or Lovenox) because without such treatment they are not likely to conceive regardless of the approach to treatment) undergo IVF.
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.
•The “Biological Clock” and how it should Influence the Selection and
•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: The first Choice for Infertile Women 40 to 43 Years of Age!
•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!
•Endometriosis and Infertily
•Endometriosis and Infertility: Why IVF Rather than IUI or Surgery Should be the Treatment of Choice.
•Treating Ovarian Endometriomas with Sclerotherapy.
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 there,
I have just done my 4th unsuccessful IVF round. First was FET 5 day and next 3 were frozen – all negative. IN terms of health I am 41 and have a 3 and a 2 year old both conceived naturally first time too (I am told that’s very rare). My doc says there is nothing wrong but I cant help wonder. Should I do some tests? I fell pregnant naturally in January 2016 but it ended in chemical pregnancy. What would you advise me to do at this stage? I am with one of the “best” doctors in Sydney. Thanks
I have a very low AMH (2.5pmol) yet I have had good numbers in my eggs collections for freeze (16 eggs first & then 10 eggs – all mature! done 2 years apart) The embryologist said they were nice “fluffy & plump” good looking eggs. How does that happen? All you hear about low AMH is doom and gloom and it is very depressing, although my Doctor often comments on how I seem to be an exception to the rule. Doesn’t low AMH mean I have DoR which means I wouldn’t get those numbers? I also have a consistently good FSH level (between 5 – 7mIU/ML) for the past 2 years, so the 2 things contradict? Does it mean that because you have low reserve that those eggs are of poor quality?
If your basal FSH is <9.0MIU/ml in association with an E2 of <70pg/ml, I would question the reliability of the test result relating to your AMH.
Geoff Sher
I am 41.5 and have been on DHEA in preparation for IVF for the past 5 months. My RE recently advised that DHEA was no longer recommended so I have stopped (was doing 75mg daily). We are planning on beginning IVF on my next cycle and the recommendation is do to 2 frozen cycles with PGS. I am wondering if I should be concerned with the previous DHEA regimen affecting embryo quality as it relates to my upcoming IVF cycles. Thank you in advance for your advice.
If you have stopped DHEA, it will have left your system and not affect stimulation any longer.
Geoff Sher