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.
Dr. Sher,
I’m currently 13 weeks pregnant and I’m taking intralipid 10% every two weeks until week 20. Since I have Thrombophilia and NK bodies and Protein C issue, do you think I should continue intralipid till I give birth? Thank you
No …that is not necessary.
Geoff Sher
Hello Dr,
We had our 1st IUI in June 2015 which resulted in miscarriage at 6.5 weeks with no fetal heart beat. Then we had our 2nd IUI in Nov 2015 which resulted in chemical pregnancy . In Jan 2016 we had our 1st IVF (embryos were not tested) this resulted in miscarriage at 4.5 weeks. Changed RE with the same fertility clinic, ivf medication increased where 27 eggs were retrieved out of which only 2 embryos made it. Due to the increase in fertility meds I suffered OHSS . We had FET with PGS tested normal embryo in June 2016, became pregnant and had a fetal heart beat 117 at 6 weeks. Started spotting and miscarried after few days. I have thyroid problem and currently I am on 112 mg dosage. Done the RPL workup where Anti Phosphatidylethanolamine IGM and Thyroid peroxidase came back positive. RE mentioned this will not cause miscarriage like in my case. I consulted with another RE and he suggested endometrium biopsy ,NK cell and TH1:TH2 testing. Would you recommend any other tests? We only have 2 embryos left and I want to have enough ground covered before we plan for our next transfer.
Appreciate your response
A: Preventing Severe Ovarian Hyperstimulation Syndrome
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.
B: Why IVF Fails:
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).
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 interested in Mini/low dose IVF and would like to know what do you think. I have been trying to get pregnant for 3.5 years. After 2.5 years, I got pregnant with twins on 50 mg of Clomid but the pregnancy turned out to be ectopic. I had a salpingectomy and my right tube removed after. I’d like to know if you offer this service and your thoughts. Much appreciated. TIA
Mini-IVF yields very poor results..less than 10% fer ER…especially in women 35y and/or those with DOR. Far better is Micro-IVF.
Micro-IVF differs from “conventional IVF” in that when performed on younger women (<36Y) who have normal ovarian reserve (AMH=>2.0ng/ml and basal FSH= <9.0MIU/ml) it requires less effort/time/human resources to conduct, This allows for a significant reduction in cost. The beauty is that success rates with Micro-IVF do not differ significantly from that which is reported for, using “conventional IVF”. It thus provides qualifying candidates with an opportunity to receive treatment at a reduced cost, without compromising outcome.
It is important to realize that the cost of infertility treatment is simply a function of the cost of any procedure. Rather it comprises the cost of having a baby. Moreover, in addition to the financial component, there is also an emotional cost. Since the success rate with Micro- IVF is several fold greater than when fertility drugs are used ( with or without intrauterine insemination-IUI), it is my opinion that if there are any associated factors that could lower the chance of success using non-IVF alternatives, IVF should be considered preferentially. The following are examples of where Micro-, should in my opinion, be considered preferentially:
•Absent or irregular ovulation (e.g. Polycystic ovarian syndrome (PCOS) and hypothalamic amenorrhea) where multiple ovulations cannot be regulated and there is a substantial risk of high order multiple pregnancies i.e. triplets or greater (-around 10-15%). Moreover, such women are highly susceptible to the development of severe ovarian hyperstimulation syndrome (OHSS), a life endangering condition that is best avoided/controlled in the IVF setting.
•Male Infertility: IUI is all too often recommended by physicians in cases of moderately severe cases of male infertility. This in my opinion is ill-advised because without resorting to IVF/ICSI in such cases, the chance of success is no greater than when no treatment is provided at all. Here Micro-IVF, by limiting the number of embryos transferred, reduces this risk substantially.
•Mild to moderately sever endometriosis: Here, a toxic pelvic environment that is invariably present and through which the egg must pass to reach the Fallopian tube for fertilization, can reduce fertilization potential by several fold. This occurs regardless of the severity of the endometriosis and can only be averted through retrieving eggs before they are exposed to such pelvic toxins, fertilizing them outside the body and then transferring the embryos directly to the uterus. An additional consideration is that approximately 1/3 of women with endometriosis, regardless of its severity have an immunologic implantation dysfunction (IID) linked to activation of uterine natural killer cells (NKa). Such IID is most effectively treated in the IVF setting.
•Pelvic adhesions: Regardless of whether the adhesions were surgically removed and/or whether the Fallopian tubes are patent, non-IVF alternatives are associated with reduced pregnancy potential.
•Immunologic Implantation Dysfunction (IID) linked to NKa: When NKa is detected, regardless of the cause, IVF provides a more controlled environment in which to successfully administer selective Immunotherapy than does the non-IVF setting.
Micro-IVF was devised to serve some women who otherwise might be regarded as candidates for fertility drugs (with or without)IUI . At a success rate of about 40% per Micro-IVF treatment and a cost of about $9,000.00 (which includes monitoring, egg retrieval, fertilization, embryo transfer and embryo freezing but excludes medications, long term embryo banking and PGS testing, and testicular sperm extractions Micro-IVF is significantly less expensive than is conventional IVF.
Please contact me at 702-699-7437 or 800-780-7437 if you need more information.
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.
•Ectopic (Tubal) Pregnancy and 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.
I know they say not to do a HPT after a transfer.. but I had my 3 day frozen embryo transfer on 10/20.. My first beta is on 10/31.. When would be an okay time to take an hpt that would be accurate before my beta?
Probably not before 11/2 anyway.
Geoff Sher
Dr Sher is it normal or ok to experience flu like symptoms during early pregnancy? I have strong nausea & extreme exhaustion and every few days along with it are flu-like symptoms such as a creepy crawly sensation to my skin, a heavy hangover feeling, a feeling like a fever (I don’t actually have a fever) and sensitivity to temperature change, particularly cold. I am almost 8wks pregnant following a day 5 FET. Other symptoms include an intensely strong sense of smell, heavy heartbeat/pulse, spacey headed/dizzy. Does this sound normal?
Pregnancy symptoms can be diverse and non-specific in some cases. Have yourself checked on by your primary physician to make sure.
Geoff Sher