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 Doctor Sher,
I was advised by a FS after I had one early miscarriage (7wks – natural pregnancy) last year at age 36 to have an endometrial biopsy for any possible implantation issues. At the time I was due have a hysteroscopy for other reasons by a different doctor & did not have the biopsy. I am now undergoing IVF and will have my first transfer very soon. Do you think I really needed to have that biopsy? I’m kind of regretting not asking the other doctor to do the biopsy while he was in there. Is hysteroscopy the only way to do an endometrial biopsy?
Ideally you need a hysteroscopy or sonohysterogram to confirm regularity of the uterine cavity and then blood tested for an immunologic implantation dysfunction (NK cell activation by the K-562 target cell test, and antiphospholipid antibody panel (ASPA) and an immunophenotype. I personally do not advocate endometrial biopsy.
Geoff Sher
Hello Doctor Sher,
Next month I am about to begin banking embryos, and I am 37 so I want to do as many cycles as I can before my eggs disappear! My question to you is: How long should I leave between cycles? And how many cycles do you suggest to get enough before I start transferring? I also do not have access to PGD testing unfortunately.
Thanks in advance! G
Hi Gabrielle,
Remember, the most important part of the process is the selection of the ideal protocol for ovaizn stimulation.
The number of cycles will depend on the number of expanded blastocysts propagated per cycle. Ideally you need a total of 6 or more and there should be at least 1 full month off treatment between each cycle.
Geoff Sher
Hello, just curious what your thoughts are. We suffer feel make factor infertility due to obstructive azospermia. Husband had TESE done and we have 4 vials of sperm. Our first IVF cycle was in July. I was on Menopur, Gonal-F, & Cetrotide. I was on stims for 11 days. They anticipated 10-12 follicles for retrieval however they retrieved 8 and only 2 were mature. The 2 that were mature fertilized however when we went for embryo transfer they had fragmented. Our doctor said it was probably an egg issue. I’m 26, husband is 38. We had a chromosome analysis completed on my husband and that came back normal. I’m now on the Long- Lupron protocol. I’ve done 18 days of 20 units Lupron and I started my stims tonight. Now I take 5 units Lupron, 75 Menopur, & 120 Gonal-F. Curious to see what you think success rate would be for us. Our RE was extremely shocked that our 1st round failed. I have no medical problems. I seemed to have responded to the meds appropriately during our first cycle. Are success rates generally better with Long Lupron protocol? I’m also taking Co- Q 10, vitamin D, prenatal, and Omega 3.
Hi Angie,
In my opinion it is highly unlikely that at 26y with normal ovarian reserve you will have an intrinsic egg problem. Most likely this is about the protocol used for ovarian stimulation whuch probably needs to be thoroughly reviewed and revised …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?
•Blastocyst Embryo Transfers Should be the Standard of Care in IVF
•Why did my IVF Fail
•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.
•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
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.
Good day dr.sher..i have seen your videos and read some about you and your heartfelt help for those who wants to be a parents..i have some concerns about having a baby.i am 30 y.o. ..have regular menstrual cycle and havent been experience to any conception.I am current engaged with my 54y.o british fianceé .Having a baby is one of our dreams in the future.But the problem is,my fiancee had a vasectomy about 10 yrs ago.Is there any way that we can have a baby..in any means.?hope you can help me with my queries.thank you so much.
Men with no sperm in their ejaculates (azoospermia) whether due to non-obstructive or obstructive (usually post-vasectomy) causes, can have their sperm accessed surgically and still propagate pregnancies. There are 2 methods by which this can be achieved. : 1) TESE (testicular sperm extraction), where a biopsy of the testis is done or, 2) TESA (testicular sperm aspiration), which involves introducing a needle into the testis and aspirating fluid and tissue. Both methods can be conducted under local anesthesia and both will provide sperm-containing tissue and fluid for immediate processing and fertilization (using ICSI) or cryostorage for future use. However, the question is: Which method yields better results. An Israeli study performed on men with non-obstructive azoospermia, conducted about a decade ago, compared the results of TESE with those from TESA in the same patients and found TESE to be the preferred approach.
TSE/TESA is the preferred method for accessing sperm in men with azoospermia. By far the commonest indication for using this approach is post-vasectomy obstructive azoospermia where the use of TESE/TESA is far more successful and uncomplicated than is the alternative of having the man undergo surgical reversal. In fact, TESE/TESA yields a comparable IVF birth rate as for controls where normal sperm derived through masturbation is used. The approach is simple, relatively low-cost, and safe. In most cases, it is relatively painless and has a low complication rate. Moreover, in post-vasectomy men, it avoids the need for riskier and painful surgery designed to reconnect sperm ducts (vasa deferentia) while enabling the man to retain his chosen method of contraception after having propagated another pregnancy. In addition surgical vasectomy often fails to successfully reestablished duct patency and even when successful it often results in the subsequent reocclusion of the sperm ducts due to scar tissue formation. Moreover, in a large percentage of cases where vasectomy reversal was performed > 5 years after the vasectomy antisperm antibodies develop and this will almost always preclude subsequent natural conception even in cases where surgery had reestablished duct patency.
While in some cases of non-obstructive azoospermia, TESA/TESE will yield sperm capable of achieving fertilization through ICSI and also subsequent viable pregnancies, success rates are low. However, in such cases, this approach yields the only possibility of the male partner participating genetically in propagating pregnancy.
I hope this helps!
If you would like to discuss in detail with me,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.
Geoff Sher
Hi Dr. Sher,
I have a quick question that I was hoping you could answer for me please. I am 37 years old and my husband is 38 years old. We have been trying to conceive for 3 years now. We turned to IVF last year and through all the pretesting it was determined that we have “unexplained infertility.” My AMH was tested in June 2015 and it was really good at 3.10.
We proceeded with IVF. My results were the following:
Cycle #1 July 2015 – Antagon Freeze Protocol with ICSI
23 follicles tracked before egg retrieval
31 eggs retrieved
17 mature
12 fertilized
2 embryos at Day 6 for CCS testing
Both embryos came back normal on CCS testing
Transferred first frozen embryo in September – result was negative
Transferred last frozen embryo in November – result was positive, but resulted in a chemical pregnancy
Cycle #2 July 2016 – Micro Dose Lupron Protocol with ICSI
18 follicles tracked before egg retrieval
15 eggs retrieved
9 mature
3 fertilized
1 embryo at Day 6 for CCS testing
Embryo was abnormal on CCS testing – nothing to freeze or transfer
I should also mention that I have the MTHFR gene 2 copies C6777T Homozygous.
I also have elevated NK assay <1/5 and Th1/2 cytokine ration 2/5. The scale my doctor uses is 0 to 5, with 0 normal and 5 is high immunity.
I am also on supplements including CoQ10, Vitamin D, fish oil, etc.
Bottom line….
After both failed cycles my doctor finally told me that the lab noted (different embryologists each time) that my eggs have cytoplasma that is dark and heavily granulated. He also said both times there were fragments between the yolk and the shell of the egg. Oddly, though…I had 2 perfect CCS tested embryos in cycle one to transfer, but neither one materialized.
My doctor told me that because of this it makes the eggs harder to fertilize and therefore lowers my chance at success. He said that this may only be fixable using donor eggs and said that if I was to do another stimulation with my own eggs we would probably again see this egg factor issue with lower fertilization rates. He recommended that I move to donor eggs.
What I am wondering from you is your opinion on the cytoplasma being dark and granular and the fragmentation. I have read that the protocol/stimulation method can have a direct effect on how the eggs look/quality at retrieval. Are my egg factor issues noted above fixable and if so how? What is the cause of my egg issues stated above? Is this a direct result of the stimulation/protocol? Would my eggs look this way under a microscope even if no IVF was performed? Any information would be helpful please. I really do not want to use a donor egg unless there is no chance we can solve this egg factor issue either through supplements and/or protocol, etc.
Thanks so much for your help! I appreciate it!
In my opinion there are 2 central issues: 1) likely immunologic implantation dysfunction and how this was treated in your transfer cycle of PGS normal blastocysts and 2) the protocol used for ovarian stimulation because this is in my opinion, the most likely factor that contributes to egg/embryo quality.
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.
•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
•How Many Embryos should be transferred: A Critical Decision in IVF.
•The Role of Nutritional Supplements in Preparing for 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.
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).
My answer to patients who ask me when is the time to stop undergoing IVF is ….Aside from the weight of the financial burden, the time to stop is when in spite of thorough and comprehensive evaluation, there is no remediable and treatable explanation for repeated failure.