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 looking for some advice. I have a complicated case I’m 46 years old and have a history ofn7 years of trying to conceive when I first started I fell pregnant naturally very quickly one afternoon the other but would always miscarry within th first 6 weeks. I then went to a miscarriage clinic who offered me steroids and aspirin which I then had mor e miscarriages. I then went to another specialist and tested positive for v high Nk cells and blood clotting when pregnant. So then has a treatment plan of steroids, heparin, aspirin. I still miscarried I actually made it to a heartbeat on two occasions but never past 8 weeks..
I then took hydrocloxcloriquine on top of 4 humera shots. And the other drugs,,
I still continued to miscarry in total 11 miscarriages.. I then couldn’t convince for a year and a half so I did a superovulqtion programme and again didn’t conceive naturally for 2 years in total. Dust to this and my age we were advised to go fo egg donor in Spain which we have don 5 times twic with pgd eggs one of which was a chemical very low hcg at first time. and most recently two egg at once positive pregnancy test but again only 25 hcg which has dropp d so another chemical. .
I also have an under active thyroid which is maansged.
My question is it seems my body doesn’t want to accept any embryos even 5 day blastocysts that were almost perfect. Where do you recommend I go foto m here. We cannot afford any mor ivf. But are concerned to try naturally if in fact we can conceive now. Is there any point or will my body just not play ball?
Thank you in advanc.
This sounds like an under-treated alloimmune implantation dysfunction. If I am correct, I might be able to help you, but at 46Y you would need an egg donor.
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
•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
•Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
•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
•IVF Egg Donation: A Comprehensive Overview
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’m 5+4 weeks pregnant after IVF with pgs normal 2 blasts, I had 500 ml 20% Intralipid before FET, I’m also on plaquenil 400, progesterone injections, and clexcane 40. I did a CBC test 5 days ago and my White blood cells count was 13.3 and my Eosinophils was 24%, 4 days after this test I had my Intralipid infusion 200ml 20%, and today (2days later) my WBCs is 13.8 and my Eosinophils is 37%! I was able to see the gestational sac today and everything seemed ok except that I have light red spotting. Do I need prednisolone ? Or could it be an allergic reaction from any medication I’m on? Please note that my CBC test results were normal before pregnancy. Thanks
It is probably local cervical bleeding from vaginal inserts (suppositories or intercourse). Usually this is nothing to worry about!
Good luck!
Geoff Sher
Hi Dr. Sher,
My husband and I are about to do Ivf for our second child. First baby was conceived through Ivf as well. Just had my baseline testing done. Some of my hormone levels came back concerning. Fsh was 10.2 and e2 was 64.3. However, my AFC was 26 and my AMH was 3.56. My levels were all taken on day 5 (not day 3). I am 33 years old and we conceived our baby through Ivf 2 years ago. I did need to do 2 fresh cycles, and each time yielded 15 eggs. What do you make of the high fsh/e2? Should I be concerned considering my AFC and AMH are okay?
Thanks!!
If the AMH was 3.6 ng/ml and not 3.6 pmol/L then you would have normal ovarian reserve and that is good. If the latter then since the normal AMH is 15+pmol/L, this would signify severely diminished ovarian reserve (DOR). The FSH is slightly elevated. However I would need the information on the type of measurement of AMH to comment authoritatively.
Good luck!
Geoff sher
What causes ovary over stimulation and high level of HCG?
In very young women, women who do not ovulate at all or do so irregularly (e.g irregular or absent menstruation or polycystic ovarian syndrome-PCOS…etc) too many follicles (each of which produce estrogen) develop in response to fertility drugs, causing ovarian hyperstimulation syndrome after the hCG trigger shot. If too many eggs are released, multiple pregnancy can result in high hCG levels. Severe hyperstimulation can result in serious and even life-endangering complications and must be avoided whenever possible.
My approach in women who are at risk of developing severe ovarian hyperstimulation syndrome (OHSS) is
My approach is consistently to use a long pituitary DR protocol with an agonist, coming off 1-2 months on the BCP. The latter is intended to lower LH and thereby reduce stromal activation (hyperthecosis) in the hope of controlling ovarian androgen release. I then stimulate with low dosage FSHr to which I add a smidgeon of LH/hCG (Luveris/Menopur) from the 3rd day and watch for the # of follicles and [E2] starting on the 7th day of COS. If there are > 25 follicles, I keep stimulating (regardless of the [E2] until 50% of all follicles reach 14mm. Then, provided the [E2] is >2500pg/ml, I stop the agonist and the gonadotropin stimulation and follow the E2 (only) daily, without doing further US examinations. The [E2] will almost invariably climb and I watch it go up (regardless of how high the concentration of E2reaches) and track it coming down again. As soon as the [E2] drops below 2500pg/ml (and not before then ever), I administer 10,000U hCGu or hCGf (Ovidrel/Ovitrel-500mcg) as the “trigger” and perform an egg retrieval 36h later. ICSI is a MUST because “coasted” eggs usually have no cumulus oophoris and eggs without a cumulus will not readily fertilize on their own. All fertilized eggs are cultured to blastocyst (up to 6 days). And up to two (2) are transferred transvaginally under US guidance.
The success of this approach depends on precise timing of the initiation and conclusion of “prolonged coasting”. If you start too early, follicle growth will stop and the cycle will be lost. If you start too late, you will encounter too many post-mature/cystic follicles (>22mm) that usually harbor abnormally developed eggs.
Use of the above approach avoids unnecessary cycle cancellation, severe OHSS, and optimizes egg/embryo quality. The worst you will encounter is mild to moderate OHSS and this too is uncommon.
I do not use antagonists in high responders (e.g., PCOS) because it interferes with the assay of E2 (often causing the value to be understated), a valuable index in assessing risk for the development of severe/critical OHSS. I also do not believe in the agonist trigger to prevent OHSS. The reason is that the magnitude of the induced LH surge varies and if too little LH is released, meiosis can be compromised, thereby increasing the oocyte aneuploidy index.
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
•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?
•Understanding Polycystic Ovarian Syndrome (PCOS) and the Need to Customize Ovarian Stimulation Protocols.
•“Triggering” Egg Maturation in IVF: Comparing urine-derived hCG, Recombinant DNA-hCG and GnRH-agonist:
•The “Lupron Trigger” to Prevent Severe OHSS: What are the Pro’s and Con’s?
•Intrauterine Insemination (IUI): Who Needs it & who Does Not: Pro’s & Con’s!
•
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 asked a question the other day but I couldn’t stay off Dr. Google. 🙁 I have twins from our first IVF + PGS cycle. We were interested in transferring 1 blastocyst in the future. (All our remaining blastocysts are PGS normal). I have been reading stories of women not even getting pregnant with 1 PGS normal embryo. I just don’t want to through away 3K for a FET cycle that won’t work with 1 blastocyst. What are your thoughts? Does having a set of twins increase your chances of a second set? Our next blastocysts are graded 3BB. My twin pregnancy went very well. No complications. Induction at 38.5 weeks due to my physician just wanting them out due to mortality rates post 38 weeks. Babies born healthy 6lbs each. Thank you for the time.
I would do single blastocyst FET transfers. In the right hands, the success is at least as high as with fresh embryo transfer and perhaps even better.
Good luck!
Geoff Sher