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,
I’m 35 yo and have undergone IVF 4x – 2x at a small center in NYC (was blindly triggered too early and had zero transfers both times and was told I needed egg donation) and 2x at CRM in NYC. I’ve never been pregnant and have unexplained infertility. I’m responding well to my protocol at CRM. 1st cycle in Feb ’16 resulted in 18 eggs but the majority were immature. Two quality embryos were transferred on day 3, neither took. During this 2nd cycle in Sept I had relatively even growth and got 27 eggs, 8 were mature and 5 fertilized with good quality. I put back 3 on day 3 (no success) and 1 made it to blast, which I froze.
My last protocol was:
14 days – 8/26/16 shots start. Duel trigger on 9/8/16 with Lupron and HCG (E2 was 3968 at trigger). 9/10 was retrieval. 9/13/16 was transfer.
Estrogen patch leading into cycle
Started injections with 300 Follistim // 150 Menopur and got down to 100 Follisitm // 75 Menopur + 7 days with Ganirelix.
My RE is saying he believes I can create a baby with my own eggs. At this point having put back a total of 5 good/high quality without them sticking he wanted me to repeat a hysteroscopy which I did on 10/3/16 (1st one was done 1.5 yrs ago and they found a polyp) and he also did a laparoscopy (removed one of my fallopian tubes because it was inflamed), cleaned out a mild case of endometriosis and did a DNC ‘scratch’.
My RE is suggesting to repeat the same protocol but with lower doses and potentially push me for a day or two more to try to get more mature eggs. Freeze on Day 1. Let my body return to baseline for 2 months and transfer back in 3rd month to mimic a natural cycle.
Based on this information, is there anything that stands out to you- that I should be asking or doing differently? Thank you, in advance, for your thoughts on my case – I really appreciate it! This has been a long journey of over 5 years and we are really anxious for some good news soon!!!
Hi Tyler,
In my opinion, a great deal of your aberrant response to stimulation could have to do with the protocols used for ovarian stimulation and their implementation. I think I can help here, but do so would require that we interact one-on-one (see below).
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.
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?
•Blastocyst Embryo Transfers Should be the Standard of Care in IVF
•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.
In your professional opinion, could a silent miscarriage occur (when a heartbeat was already detected) when progesterone is stopped, possible prematurely, at 7 weeks, 4 days, rather than the recommended 10 week period?
It would be a very unlikely happening…but possible.
Geoff Sher
Hello, I am 27 with fsh of 10, my cycles are pretty regular and I ovulated on day 14-16, this cycle I am ovulating on day 21 which isn’t normal for me, can this just be an off month and can I expect it to go back to normal next cycle or a sign of what’s to come with my elevated fsh?
It likely will return to normal, but keep a watchful I to make sure it does.
Also with an AMH of 10 at your age, I would definitely have my AMH measured to make sure that you are not prematurely developing diminished ovarian reserve.
Good luck!
Geoff Sher
Hi. I had an embryo transfer yesterday after my first ivf. We got only 5 eggs but all eggs feetilized and resulted in 5 high quality 3 day embryos.one was 9 celled 1 8celled and 3 7 celled.nobody mentioned to uw 5 day transfer as blastocysts.i am 36 and my hausband 35. What i am worried about is what are our chances fow success?and were these chances higher with a blastocyst transfer?thank you im advance
Hi Zenia,
It is not about the chances of a baby being greater with blastocyst transfer. The overall chance of babies would be the same were these embryos to be transferred on day 3 as would be the case were only resulting blastocysts to be transferred. Embryos that fail to reach blastocyst are almost always incompetent and non-viable and would not have been able to propagate a viable conceptus had they been transferred earlier, anyway. By allowing them to go to blastocyst, many of the “incompetent” embryos are culled out, such that those that reach blastocyst are much more likely to propagate a viable pregnancy. By confining youirself to selectivel only transfer blastocysts, the transfer 1 or 2 embryos (blastocysts) at a time optimizes success and at the same time reduces the risk of multiple pregnancies.
Good luck!
Geoff Sher
Hello Dr Sher,
I wanted to seek your advice on whether PGS is a recommended option in my situation-
I’m 34 and have had a molar pregnancy earlier. My recent tests have shown indications of DOR with FSH between 8-15 in different months, and AMH 1.3-1.5, and AFC ranging 5-8 count. We have decided to use ICSI as part of IVF treatment , but unsure about PGS.
We were thinking of PGS but are concerned if it will adversely affect chances of live birth, given my age and DOR (reference some research papers)
Would you still recommend PGS in our case.
Thank you for reading through my note.
The chance of a repeat molar pregnancy is 1: 1000. If PGS is being considered, it should in my opinion, not be to try and prevent another molar pregnancy. Rather it should be done because of your DOR and in ordrer to bank “competent” (euploid) embryos for subsequent tranfer so as to improve the chance of success.
Geoff Sher