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.,
I just did a FET with a 5 day blast that was genetically tested to be normal. On day 11 my HCG was 81.1 and day 14 no change at 81.6. My lining was 7.4. So looking like I had a chemical pregnancy. I’m confused as to why? And what are the statistics that in a few days my HCG will actually double like it should have been doing? Thank you!!
It is possible but not likely at all Kerri!
sadly, this does not look good.
Geoff Sher
hey Doc, my wife saw some spotting today and is extremely worried since this is around the same time she miscarried previously with IUI and this time around we’re doing IVF and everything been fine for last 6 weeks since transfer. is it common?
Vaginal bleeding occurs in about 25% of all pregnancies. When it happens, it almost invariably raises the concern of pregnancy loss (miscarriage). Bleeding can also be a sign of a tubal (ectopic) pregnancy, and in cases where the distended Fallopian tube ruptures it can precipitate a life-threatening crises. However, a small amount of painless vaginal bleeding can also be the result of normal embryo implantation (i.e. implantation bleeding) or it can result a local erosion of the vagina or cervix and/or trauma during intercourse.
Notwithstanding, in virtually all cases the occurrence of early pregnancy vaginal bleeding congers concerns or even alarm regarding the possibility of miscarriage. And when this happens to women who conceived following infertility treatment, the alarm often turns into panic. However, the truth is that in most such cases the bleeding soon stops and the pregnancy proceeds unabated to the birth of a healthy baby.
Good luck!
Geoff Sher
So what is a good estrogen level to have for an FET?
With the regime I use (estradiol Valerate I.M twice weekly). I aim or between 500 and 1000pg/ml.
Geoff Sher
thanks doc, turns out everything was ok. more than ok, TWINS!?!?! this was 3 days ago but today she had another bleed, browning and a bit heavy. could this be because its multiples and or that she started using suppository progesterone? again she’s a little anxious
Dear Dr Sher,
I am 41 years old and my husband is 44. Just failed our first IVF. We do not have any particular problems with health (category unexplained), and actually everything was going on fine until I’ve got a negative HCG test (no implantation at all). During stimulation I had 28 eggs retrieved, 19 out of them were fertilised and 4 made it to 5 day blastocysts. I had 2 out of them transferred on day 5, and 2 frozen (4BB and 4BC). None had implanted… Despite my age, my AMH was around 50 (never diagnosed with POCS) and all other tests looked promising. I was told that I responded very well to stimulation, although the doctor was a little bit worried about OHSS, as my E2 level was really high (around 13000) by the time of ER (they had to postpone it by couple of days to be sure it started to go down). We haven’t had a follow up consultation yet to see what exactly went wrong and I guess there are no simple answer to that question. But the main question I have now is what to do next, should we use our frozen blastocysts next time or would it be better just to start a fresh new cycle? Thank you very much.
Consider the fact that between 40 and 43 of age, the success rate per cycle of treatment with injectible fertility drugs alone, with or without intrauterine insemination (IUI) is 2- 3%. Since it is 6-8 times higher with “conventional” With “conventional IVF” it follows that for such infertile for whom the biological clock is “ticking” IVF is the treatment of choice.
In most cases, an embryo’s “competence” (its potential to propagate a normal pregnancy) is determined by the chromosomal integrity (ploidy) of the egg, rather than the sperm that fertilizes it. Age progressively increases the incidence of abnormal numerical chromosomal egg integrity (aneuploidy) from about 50% in the early 30’s to >80% by the time the woman reaches her 40’s. To make matters worse, most women ages over 40 years of age develop diminishing ovarian reserve (DOR) as evidenced by rising basal FSH and declining blood AMH levels. This results from the decline in ovarian egg population, which once it drops below a certain threshold level and accompanied by an increased incidence in dysfunctional ovulation, a progressive resistance to fertility drugs , , a lower yield of eggs/follicles in response to fertility drugs and growing vulnerability to “suboptimal” protocols for ovarian stimulation. Simply stated, unless the protocol used for ovarian stimulation is carefully individualized, women over 40Y and those who (regardless of age) have DOR, will be more likely to propagate chromosomally normal (euploid) eggs that upon fertilization are capable of implanting and propagating normal offspring. To add to the problem, there is nothing that can be done to mitigate this age-related decline.
Thus, the only way to increase the overall likelihood of successful IVF in older women is to:
1.Individualize (“customize”) the ovarian stimulation protocol so as to meet individual needs avoiding a “same size fits all” approach,
2.Improve availability of and access to of embryos available by cryobanking or stockpiling “competent” embryos, selected through preimplantation genetic screening (PGS), using reliable testing such as next generation gene sequencing (NGS), over several cycles and then selectively transferring one or two at a time to the uterus in later cycles (i.e. “staggered IVF”).
Unfortunately many infertile women in their 40’s, make the mistake of deliberately deferring the decision to do IVF until they have tried less expensive alternatives such as ovarian stimulation with or without IUI. In the process they often ignore the fact that the differential does not lie in the cost of a procedure. Rather it is lies in the cost of having a baby and it comes in the form of emotional as well as financial currency. The unfortunate reality is that once on the move the biological clock can unfortunately not be reset. Thus in my opinion infertile women of 40-43 years of age (and especially those who have never had a baby before) should consider doing IVF preferentially….from the get-go.
For women over 43 years, where fewer than one in ten of their eggs are likely to be euploid, IVF with egg donation is in my opinion, the treatment of choice.
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
•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.
•Preventing Severe Ovarian Hyperstimulation Syndrome (OHSS) with “Prolonged Coasting”
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
Hello Dr Sher,
I have a question following a series of IVF failures. The first one: 2 embryos transferred with my own eggs – failure to implant. The second one: natural pregnancy – implantation successful, no heartbeat at 5 weeks. The third one: after switching to donor eggs, transfer of 1 embryo – implantation successful, heartbeat at 4 weeks, no more heartbeat at 9 weeks. The fourth one: transfer of 1 frozen embryo from previous donor egg cycle, this time PGD done – failure to implant. I am 43.
We have the opportunity to do an endometrium biopsy at MatriceLab here in France to test for overactive natural killer cells. But I’m not sure that this test applies to me as I’ve already had implantations.
Any advice would be most appreciated.
Thank you so much.
Laila
Hello again Dr Sher,
I would like to add that embryos transferred were all 5-day blastocysts.
Thanks again,
Laila
I think you have an implantation dysfunction (immunologic or anatomical). In my opinion, the immune tests you have done are not the ideal ones.
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
•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–
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.