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,
I have PCOS and my husband had a vasectomy years ago. He had testicular sperm retrieved to be used with ICSI. I just underwent stimulation and had 31 eggs retrieved, 22 mature, and 20 fertilized. The report today at day 2 is that 10 of the embryos are excellent quality, 5 or 6 are a little behind, one arrested, and the rest aren’t very good. I understand that the sperm will begin playing a role in the embryo’s development very soon, and I’m concerned that they won’t make it to later stages because of issues with my husband’s immature sperm. The sperm seemed to be of excellent quality when it was retrieved, but I’m not sure if any testing was performed. I read a study that found that testicular sperm had fewer abnormalities than epididymal sperm, but I also read another study showing much lower pregnancy rates of those with ICSI and obstructive azoospermia. It was unclear if those with vasectomy were included in that study. I am just wondering if we have cause to be concerned that our embryos will arrest due to issues with the sperm. Thank you!!
It is possible that sperm issues might be involved, but in my opinion, a prior vasectomy should in and of itself not adversely affect aspirated sperm quality.
Geoff Sher
Dear Dr. Sher,
My wife and I are trying IVF to get pregnant. 2 five day blastocysts were transferred on August 16 (previously frozen embryos from egg donor who was 22 yrs old and donor sperm from male). First HCG test on Aug 26 was 218. We were thrilled. Then, second HCG was 3 days later (because of a weekend) and total was only 438. IVF doc not so happy anymore. Ordered third HCG test. That result was only 2 days later and amount was only 560. Now we’re very concerned. Doc fears possible ectopic pregnancy but also thinks b/c we transferred 2 embryos, one could still be growing properly (because we have no idea what blasts represents the HCG #s that give us the totals.) 4th HCG test is tomorrow morning. They requested a 6 week ultrasound on Sept 7 (which would be 6 wks pregnant) so we can hopefully eliminate ectopic BUT MAYBE POSSIBLY see a healthy embryo? Should we just plan on bad news? Is it still possible to have a healthy pregnancy? Wife is showing no standard ectopic symptoms other than the slowly rising HCG #s…. please provide your thoughts. HUGE THANKS IN ADVANCE!
It is possible that both embryos attached originally but that only one is healthy …thereby explaining the slower rise in hCG level. Hopefully this is the case. However, it can be an ectopic and this must be assessed as time passes.
I wish you well….Please keep me in the loop!
Geoff Sher
I’m 38 years old and my hubby aged 42. I’m a didelphy patient with two separate uterus and vagina. I’ve gone through twice IVF cycles n two times frozen 3-days embryo transfer. Regrettably both failed. The first frozen embryo transfer was due to my doctor negligence. He transferred two embryos one at each site. Without prior doing a mock transfer, during the actual procedure only he learnt that my left cervical opening too narrow n not being able to transfer my embryo to my left uterus. Causes bleeding n my immune system kicks in. The procedure failed n I wasted my two score 9 embryos.
I did the whole cycle again n out of 13 eggs, 7 fertilized and 5 quality embryos obtained. This time I transferred only one frozen 3 days embryo to my right site. Result same, fail.
My doctor evaluated and given me reason that particular embryo being transferred is incompetent. Not the right one.
I’ll be going for my third time embryo transfer again next month. Am I going to rely just on luck in choosing the right embryo? Is there any better way to increase my chance for a success?
The didelphys uterus should not reduce the chance of pregnancy following ET but the ET procedure must be performed with proficiency. Also do not rule out the possibility of an unrelated embryo or implantation dysfunction. I personally am against transferring anything but advanced embryos (blastocysts) on day 5-6.
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?
•Blastocyst Embryo Transfers Should be the Standard of Care in IVF
•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
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to 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.
Do you prefer Heparin or Lovenox during IVF?
My first IVF cycle I did Heparin 5000 IU twice daily and that cycle was successful.
My new clinic suggested once a day 40 milligram Lovenox. Once a day sounds great and all but I did get pregnant off of the Heparin so I didn’t know if there was the difference truly or if you had a preference?
Either or. Lovenox is much more convenient since it is only taken once per day and there is far less bruising.
Good luck!
Geoff sher
Hi – I have had 2 chemical pregnancies using donor eggs. A couple of weeks ago an pelvic MRI showed that I had a 1.7cm intramural fibroid pushing against the top part of endo lining. Because of the location of the fibroid, my RE would have to a surgery, that he referred to as a “mini c-section” and my recovery time would be 3-4 weeks. We also have an option to take Lupron for 2 months and hope it reduces the fibroid. If it does, we would do a FET cycle right afterwards. My question is..since Lupron would only shrink the fibroid for a few weeks, if the FET is positive, do i run the risk of having a miscarrage when the fibroid grows back? Is shrinking the fibroid a good option, despite the fact the the fibroid will return?
Respectfully,
In my opinion, the Lupron option is absolutely less ideal. Surgery would be needed.
Good luck!
Geoff Sher