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. Sher,
Thank you for all the brilliant information you provide. I have your book The ART of making babies and feel it is an invaluable resource. My question for you is in relation to birth control (Desogen) used prior to frozen embryo transfer. I am 39, and had my first IVF where 24 eggs were retrieved which yielded 4 chromosomally normal embryos. Two will be transferred in November. I will be on Heparin, IVIG, and dexamethasone due to RPL and IID (4 losses at 6-8weeks, 2 chemical). I will of course also be but on estrogen and progesterone prior to transfer. The retrieval was in August, but I have to wait until November for the transfer because I am also doing LIT. My question is, I will be on Desogen for approximately 6 weeks prior to transfer (from Sep 7-Oct 18). I worry about being on birth control this long. How long is too long to be on BCP’s prior too transfer? I also was considering adding intralipids on top of the IV IG. What are your thoughts on that? In your book you mention this is rarely indicated, but I want to feel I am doing everything I can to increase my chances. This is our first IVF and FET and we do not have any live births. A bold question, but what are our chances with all these measures in place? Thank you again Dr. Sher for your reproductive immunology brilliance and generosity.
Hi Jessica,
In my oipinion, the length of time on BCP is not relevant and should not affect outcome.
There is no need to add Intralipid.
Good luck!
Geoff Sher
Hi Dr.
I am 36 yo recently diagnosed with Hashimoto. I have conceived a son naturally when I was 32 yo. Now TTC for 2.5 years and diagnosed with unknown infertility decided to do IVF. After two failed IVFs that ended up in chemical pregnancies Im starting to wonder that I could have immune disfunction. I did have NK Assay Full Panel and only one marker came out of range (%CD 19 at 17.9). Doctor did also laparoscopy, SIS, HSG and everything normal. What do you think? Other tests to rule out other issues? Do you agree on the immune disfunction possibility?
Since you have had a baby, I doubt that this is due to autoimmune hypothyroidism causing an immune issue. I would still like toook at the full immune panel of tests done so I can provide a more authoritative opinion. This having been said, the reason for your secondary infertility needs to be identified before treatment is initiated.
It is one thing for a woman who has never been able to conceive (primary infertility) to come to grips with undergoing In Vitro Fertilization. It is quite another matter for someone who has successfully achieved a pregnancy in the past having to come to terms with a subsequent inability to conceive (secondary infertility). When this happens, it raises issues of guilt, a declining sense of self-worth and ultimately self-recrimination. The ramifications often impact family relationships involving partners and siblings. The truth is that secondary infertility can be just as difficult for individuals and family to deal with as primary infertility.
There are many factors that contribute to the problem of secondary infertility. These include:
Social and marital factors: In this modern day and age where at least one in two marriages ends in divorce, it is not surprising that there would be an inevitable hiatus in childbearing. This often results in a considerable delay in re-initiating family building. Since the biological clock keeps on ticking in the interim, advancing age can, and often does, have a profound affect on a woman’s ability to subsequently conceive and successfully complete a pregnancy. In my experience, this is one of the most common reasons for secondary infertility. In addition, by the time a decision is made to enter a new relationship, many men and women will have undergone a prior sterilization procedure which now needs to be addressed. To make matters worse, many such men and women first opt for surgical reversal of their occlusive surgery, only to learn in the end that the procedures were not successful, and they now need to consider in vitro fertilization (IVF) in one form or another.
Financial factors: Here, the cost of raising a child often weighs heavily, especially in this present tough economic climate. This is becoming more of an issue as women playing an ever increasing role as a primary bread winner.
Career demands: There can be little doubt that when it comes to climbing the career ladder, women are considerably disadvantaged by the fact that pregnancy and the immediate demands of child rearing take away from their ability to compete with men. As such, many women choose to delay having another child until such time as they have been able to make up for prior lost opportunity.
Medical barriers to fertility: Certain common medical conditions, while not absolutely precluding pregnancy, make it much more difficult to conceive.
Endometriosis: It is not uncommon for women with endometriosis to achieve a pregnancy, but find difficulty in doing so again at a later date. The reason for this is that while most women with endometriosis have patent fallopian tubes, the environment surrounding their tubes is compromised due to pelvic toxins that are produced by the endometriotic implants. These toxins compromise egg fertilization potential, making it more difficult for sperm in the fallopian tube to fertilize the egg upon its arrival there. As such, endometriosis is one of the commonest causes of secondary infertility.
Tubal damage due to prior pelvic inflammatory disease: In first world countries, the early and often indiscriminate use of antibiotics for the slightest symptom has led to the point where an acute attack of pelvic inflammatory disease is often masked. As such, less than 30% of American women with tubal damage have knowledge that their tubes are compromised and that they might have subsequent difficulty in conceiving. Since, in many such cases the tubal damage will not have totally blocked both tubes, some of the women so affected might experience a pregnancy but have difficulty in conceiving again later down the line.
Dysfunctional ovulation: Since ovulation as well as normal hormonal support of the early implanting embryo are both essential for a healthy pregnancy to occur, it follows that women with irregular or dysfunctional ovulation (e.g., polycystic ovarian syndrome – PCOS, persistent follicular luteal phase deficiencies or post birth control pill ovulatory problems) might sporadically conceive and thereupon find it difficult to do achieve another pregnancy later on.
Immunologic Implantation Dysfunction (IID): has become ever more apparent that immunologic factors play an important role in achieving healthy implantation. Women with endometriosis (regardless of its severity), those with a personal or family history of autoimmune diseases such as lupus erythematosus, rheumatoid arthritis and thyroid autoimmunity (TAI), and some cases where the man and the woman share certain genetic similarities (alloimmune implantation dysfunction), will have activated CTL/NK cells that can inhibit or compromise healthy implantation. This is an often overlooked cause of secondary infertility. Most such autoimmune/alloimmune cases require selective immunotherapy and IVF.
Antisperm Antibodies: Although infrequent, some cases of secondary infertility might also be caused by the woman harboring antisperm antibodies. In such cases IVF is mandated.
Previous post-pregnancy uterine infection: Retention of products of conception after the birth of a child, miscarriage, or abortion can so damage the uterine lining as to result in subsequent implantation failure. Unless specifically looked for, this will usually be unknown to the patient, who will simply present with secondary infertility. Treatment is often difficult because such patients might not respond adequately to surgical removal of intrauterine scar tissue or to hormonal or Viagra therapy
Male immunologic factors: Most men who have undergone a previous vasectomy more than 10 years earlier, will have antisperm antibodies that will interfere with fertilization. Such cases require IVF with intracytoplasmic sperm injection (ICSI). Here we offer a few words of caution to men who are considering undergoing surgical reversal of vasectomy. Always first have a test done to exclude the presence of circulating antisperm antibodies, because in such cases, even if the reversal is successfully performed, they will not be able to initiate a pregnancy without IVF/ICSI.
Whatever the cause, secondary infertility often affects older couples disproportionately, creating a sense of urgency and even desperation in achieving a viable pregnancy before time runs out. It is for this reason that IVF becomes the treatment of choice in such cases. However, even IVF becomes progressively less successful with advancing age of the woman (whose eggs are being fertilized). In such cases it is important for the couple to be realistic with regard to their expectations. Here, options that include embryo banking and egg donation should be carefully considered.
Another important point is that whenever a regularly ovulating younger woman (under 36 years of age) with patent fallopian tubes is diagnosed with secondary infertility, it is essential to consider underlying endometriosis or non-obstructive tubal disease as a possible cause. In such cases, IVF is again the treatment of choice.
If interested, 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 am finding the fertility treatment process to be very stressful. Every doctor we go to or talk to repeatedly says “this is not a his or her problem, this is a couples problem.” And yes, I would agree, but then for many procedures that have to take place on very intimate parts of the body, my husband and I are often separated. It gives us both incredible anxiety. Why can’t my husband be in the procedure room with me for an egg retrieval? Why can’t I be in the room for a sperm abstraction? Men scrub up all the time to go with women in to the OR for a C section, to me, trying to create life is just as important as birthing it. I want us to be able to be there for one another and not have some nurse or doctor be the only person in the room with me or my husband to comfort us through a very stressful and sometimes disappointing journey or experience.
I can understand your position. However, protocol differs from one program to another. If this is an important consideration for you, I suggest you discuss this upfront with the program you aproach and allow their policy to influence your decision of where to seek treatment.
Good luck!
Geoff Sher
Hi Dr Sher, do you think there ine one type of progesterone support that is better for people with immune issues? I have been prescribed Duphaston 10mg twice per day and Cyclogest 400mg once per day. I would love to hear your advice. Regards Rebecca
I prefer intramuscular progesterone but the type should not play a role in any underlying immune issue being treated.
Geoff Sher
Dr. Sher – I’m 42, first menses @age 9, never on bcp, never cysts, normal cycle, cycle length 25 days . FSH 6.91, AMH 0.408, Prolactin 21.36, TSH 1.29, Estradiol 46.16. I just did my first IVF cycle and it resulted on retrieval: 7 eggs, 4 fertilized, 1 blastocyst frozen (after biopsy, awaiting PGS results). Your protocol article is very useful. Would you have any recommendations for my next cycle? Is there anything in particular that you would recommend for women past 40? Thanks so much! Protocol used: Natural cycle-Estradiol 2MG PO 7 days before menstruation, continued until CD4. CD2-CD9:Follistin 450, HCG 20u//CD10-CD13: Follistin 375, Generic HCG 20u, Cetrotride 0.25mg//CD14:Follistin 300,Gen HCG 20u, Cetrotride 0.25mg/CD15: Ovidrel250mcg (E2:2245, P4:0.923).