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.
Hello there Dr Geoffrey Sher – I’m so impressed with your blog and advice you give your patients and help you offer to us on your website forum. I’m 43 have 4 embryos left after my last round of stimulated IVF. I’m not convinced doing another stimulated cycle would work as we only had 1 egg that made it to blasts and this implanted but resulted in early miscarriage. We also transferred 2 embryos which were from frozen eggs when I was 38 but these also resulted in early miscarriage 7 weeks. I’ve had 2 x natural pregnancies which resulted in miscarriage at the same time. I’m at a loss as to what to do as it seems there is a good strong heartbeat 6-7 weeks which then fails, it’s devastating. I’ve had everything checked – the only thing that was picked up was immune – overactive immune system which my clinic treated with humira and ivig and also natural killer cells which were also treated. I went through a natural frozen cycle and the only thing that was picked up was that on day 20-21 (day before likely transfer) my estrodial plummeted to the point they wouldn’t (rightly so) do the transfer. I’m reading your blog and looking to do a laporoscopy to check that my previous endometriosis has all gone as you said it can’t be picked up easily on a scan or hysteroscopy. Could you let me know if you think this plumeting estrodial is the reason I’m not carrying beyond 7-8 weeks? Would this be corrected with a medicated cycle. I have incredibly heavy periods which makes me think that perhaps every month my estrodial drops and there is too much progesterone for successful implantation – my lining is 11mm by day 20-21. Is this hormone imbalance all I would perhaps need to correct. Please advise me as I’m completely lost as to what to do and once the last 4 embryos are gone they are really gone. Thanks so much
I do not think you should give up if you are indeed conceiving with IVF. This having been said, the cause of these losses must be more carefully addressed. There are 2 factors to consider. The 1st is the obvious one and that is age and its inevitable toll on egg/embryo chromosomal integrity and this can be addressed through embryo PGS and banking. The 2nd is an implantation dysfunction which could be anatomical (uterine lining) or immunologic. I suspect the latter. If correct then it is necessary to distinguish between an autoimmune and an alloimmune cause because treatment would differ. To start with I would NOT use Humira. Rather, I would use intralipid and steroid therapy and if it is alloimmune and a partial DQ alpha match then the type and duration of steroid therapy would differ and only a single blastocyst should in my opinion, be transferred at a time.
The older a woman becomes, the more likely it is that her eggs will be chromosomally/genetically “incompetent” (not have the potential upon being fertilized and transferred, to result in a viable pregnancy). That is why, the likelihood of failure to conceive, miscarrying and of giving birth to a chromosomally defective child (e.g. with Down Syndrome) increases with the woman’s advancing age. In addition, as women age beyond 35Y there is commonly a progressive diminution in the number of eggs left in the ovaries, i.e. diminished ovarian reserve (DOR). So it is that older women as well as those who (regardless of age) have DOR have a reduced potential for IVF success. Much of this is due to the fact that such women tend to have increased production of LH biological activity which can result in excessive LH-induced ovarian male hormone (predominantly testosterone) production which in turn can have a deleterious effect on egg/embryo “competency”.
While it is presently not possible by any means, to reverse the age-related effect on the woman’s “biological clock, certain ovarian stimulation regimes, by promoting excessive LH production (e.g. short agonist/Lupron- “flare” protocols, clomiphene and Letrozole), can make matters worse. Similarly, the amount/dosage of certain fertility drugs that contain LH/hCG (e.g. Menopur) can have a negative effect on the development of the eggs of older women and those who have DOR and should be limited.
I try to avoid using such protocols/regimes (especially) in older women and those with DOR, favoring instead the use of the agonist/antagonist conversion protocol (A/ACP), a modified, long pituitary down-regulation regime, augmented by adding supplementary human growth hormone (HGH). I further recommend that such women be offered access to embryo banking of PGS (next generation gene sequencing/NGS)-selected normal blastocysts, the subsequent selective transfer of which by allowing them to to capitalize on whatever residual ovarian reserve and egg quality might still exist and thereby “make hay while the sun still shines” could significantly enhance the opportunity to achieve a viable pregnancy
Please visit my new Blog on this very site, http://www.DrGeoffreySherIVF.com, find the “search bar” and 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 Approach
•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 Design of Ovarian Stimulation Protocols for IVF.
• A Rational Basis for selecting Controlled Ovarian Stimulation (COS) protocols in women with Diminished Ovarian Reserve (DOR)
•Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
•Controlled Ovarian Stimulation (COS) in Older women and Women who have Diminished Ovarian Reserve (DOR): A Rational Basis for Selecting a Stimulation Protocol
•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
•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
•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
•Premature Luteinization (“the premature LH surge): Why it happens and how it can be prevented.
•IVF Egg Donation: A Comprehensive Overview•
. 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
I invite you to arrange to have a Skype or an in-person consultation with me to discuss your case in detail. If you are interested, please contact Julie Dahan, at:
Email: Julied@sherivf.com
OR
Phone: 702-533-2691
800-780-7437
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 ,
I just underwent IVF due to severe male factor . My husband had sperm extracted with TESE .he is not a carrier of cystic fibrosis and has one undescended testicle.
I have normal regular periods and I am 30 years . We got 18 eggs on retrieval and 15 were mature . 10 went to day 3 and only 2 made it to blastocyst. On Aug 17th I had one Frozen
blastocyst transfer but HCG 10 days later is 14 and is not doubling , doctor suspects a non viable pregnancy.
Can you please shed some light if there is any hope for us to have a kid . I have one more Frozen blastocyst,
Sadly this does not look very promising to me.
I am somewhat concerned about the relatively low yield of blastocysts.
Perhaps we should talk.
I invite you to arrange to have a Skype or an in-person consultation with me to discuss your case in detail. If you are interested, please contact Julie Dahan, at:
Email: Julied@sherivf.com
OR
Phone: 702-533-2691
800-780-7437
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, thank you for your wonderful blog! I would love to hear your opinion on my story. I have just had my 5th IVF failure with PGS tested embryos (3 chemical pregnancies & 2 negative cycles). We have some frozen PGS tested embryos waiting for us. My lining is always an issue on a FET cycle averaging around 7mm at the time I start progesterone and 8mm – 8.5mm at time of transfer so we know my lining is a part of the problem, however I don’t think it is the only problem. I recently had an endometrial biopsy which showed mildly elevated NK’s of 52% (reference range of 20%-50%) so for my last transfer I was on intralipids 12 days before transfer and on the morning of transfer, also I was on 5mg steroids from CD1 increasing to 20mg two days before transfer up until my beta and also daily Clexane, however even with the immune support, I had another chemical pregnancy. Since November I have been dealing with cysts on my ovaries which my doctor was sure was endometriosis so I had an MRI early this year which came back as haemorrhagic cysts, however when I went to have them aspirated last week the doctor drained 15ml of ‘chocolate’ fluid from the cyst on the left and she said in her opinion I had endometeriosis of the ovaries, she also said the cyst on the right was solid, I have now been referred to an endo specialist to have another lap (I had a lap 4 years ago which showed no signs of endo). I am preparing myself for endometriosis as my sister also has this condition. I am due to have the DQ Alpha test and the NK562 test through a lab in America in the next few weeks. My question is, taking it that I do in fact have endometeriosis and the fact my uterine NK’s were mildly elevated, do you think I need more immune support then I was on for my last transfer? Also if there anything you recommend to treat the endo as part of my next FET protocol? I really look forward to hearing from you, thank you 🙂
1. Chocolate cysts need to be removed laparoscopically or treated by sclerotherapy before doing IVF and the solid ovarian tumor will need also to be addressed.
2. The protocol used for ovarian stimulation will need to be reviewed or revised (see below)
3. The protocol and dosage of intralipid/steroid therapy also needs to be addressed.
4. the type of immunologic implantation problem must be determined because treatment of an alloimmune cause will differ from treatment of an autoimmune cause (which is the more likely of the two).
5. The uterine lining should ideally thicken on estrogen to >9,,. A lining of of <8mm is inadequate (in my opinion) and requires treatment with vaginal Viagra and estrogen...see below.
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
•Endometriosis and Infertily
•Endometriosis and Infertility: Why IVF Rather than IUI or Surgery Should be the Treatment of Choice.
•Endometriosis and Infertility: The Influence of Age and Severity on Treatment Options
•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.
3. Surface lesions
Than you for your reply! I will be having a laparoscopy in a few weeks to investigate the endometriosis. My doc has suggested for my next FET to do down regulation with a low dose stim (my lining responds a little better this way) adding in 2mg vaginal estrogen from CD6, do you think this is a good protocol for endometriosis and to help a thinner lining? Do you suggest any other immune tests apart from the DQ Alpha & NK562? I want to make sure I cover everything before we transfer another one of our embryos. Thank you again for responding, it’s so very kind of you to give your time to answering everyone’s questions 🙂
Dear Dr. Sher,
Could you please help me answer some doubts I have regarding my recent (second) failed IVF? I had a first IVF 4 months ago and even though it didn’t work, my egg collection went very well, most of my follicles had eggs and only one didn’t fertilise. Back then I was asked to take one Ovidrel injection exactly 36 hours before retrieval.
This time my doctor was on a holiday, and another doctor followed up my IVF. This doctor prescribed 2 injections of Ovidrel 250 µg (instead of one) 37 hours (instead of 36) before egg retrieval. I followed up the new instructions, but when I went to my egg retrieval appointment I was told that I had already ovulated and only one egg could be retrieved (flushed) from one of the smaller follicles. The first time everything went very well from this point of view, and this time I can’t stop wondering if this happened because I had 2 trigger injections instead of one and the time was delayed by one hour.
Thank you so much.
No Ana, the problem started before the Ovidrel shot. It sounds like it was due to premature luteinization and this cvould be the result of the protocol used for stimulation which needs to be reviewed and possibly revised. By the way, vials of Ovidrel is the correct dosage. In my opinion 1 vial is insufficient.
The older a woman becomes, the more likely it is that her eggs will be chromosomally/genetically “incompetent” (not have the potential upon being fertilized and transferred, to result in a viable pregnancy). That is why, the likelihood of failure to conceive, miscarrying and of giving birth to a chromosomally defective child (e.g. with Down Syndrome) increases with the woman’s advancing age. In addition, as women age beyond 35Y there is commonly a progressive diminution in the number of eggs left in the ovaries, i.e. diminished ovarian reserve (DOR). So it is that older women as well as those who (regardless of age) have DOR have a reduced potential for IVF success. Much of this is due to the fact that such women tend to have increased production of LH biological activity which can result in excessive LH-induced ovarian male hormone (predominantly testosterone) production which in turn can have a deleterious effect on egg/embryo “competency”.
While it is presently not possible by any means, to reverse the age-related effect on the woman’s “biological clock, certain ovarian stimulation regimes, by promoting excessive LH production (e.g. short agonist/Lupron- “flare” protocols, clomiphene and Letrozole), can make matters worse. Similarly, the amount/dosage of certain fertility drugs that contain LH/hCG (e.g. Menopur) can have a negative effect on the development of the eggs of older women and those who have DOR and should be limited.
I try to avoid using such protocols/regimes (especially) in older women and those with DOR, favoring instead the use of the agonist/antagonist conversion protocol (A/ACP), a modified, long pituitary down-regulation regime, augmented by adding supplementary human growth hormone (HGH).
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 Design of Ovarian Stimulation Protocols for IVF.
• A Rational Basis for selecting Controlled Ovarian Stimulation (COS) protocols in women with Diminished Ovarian Reserve (DOR)
•Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
•Controlled Ovarian Stimulation (COS) in Older women and Women who have Diminished Ovarian Reserve (DOR): A Rational Basis for Selecting a Stimulation Protocol
•Optimizing Response to Ovarian Stimulation in Women who Have Compromised Ovarian Response to Ovarian Stimulation in Women who Have Compromised Ovarian Reserve: A Personal Approach.
•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?
•Implications of “Empty Follicle Syndrome and “Premature Luteinization”
•Premature Luteinization (“the premature LH surge): Why it happens and how it can be prevented.
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
I am currently undergoing IVF for a second time. I did get pregnant the first time I got pregnant but it resulted in a miscarriage. I have stage four endometriosis and bad egg quality. I am writing this the night before my egg retrieval procedure. I took my trigger shot the previous day so there is a one day space in between.
The problem is I have been on clexane for the past two weeks and accidently took a clexane shot today when I was supposed to have taken the last shot yesterday along with the trigger shot.
Will this in any way create problems with my egg retrieval procedure or quality of the eggs collected?
I am freaking out right now so any help will be greatly apprecaited.
It will probably make no difference…Do not worry!
Geoff Sher