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 am experiencing extreme migraines during my 8th week of pregnancy following FET. I have always suffered hormonal migraines & this is exactly the same. They are debilitating & last anywhere from 2 to 5 days with migraine aura & vision disturbance etc. I’m worried it will carry on & I won’t cope with the severity of them. I have been to my ER and they just gave me maxilon & paracetamol. I have been using codeine to treat the migraines, which I have read is safe. What is your recommendation for treatment of migraines during pregnancy? My FS is not helpful with this type of thing amongst others which is why I am turning to you. Desperate for help! What medications are safe?
Migraines can be exacerbated by estrogen, the blood concentration of which can be 200 times higher in the pregnant state than when non-pregnant. It is indeed sometimes very hard to treat but it can be so debilitating that it MUST be reversed. Since standard approaches are clearly not working, my advice would be to visit with a neurologist and have him/her advise you on treatment.
Good luck!
Geoff Sher
Dear Dr. Sher,
Here is a background of my case:
2013- 9 eggs retrieved and 1 got fertilized ( morula at grade4). It was a failed ivf due to poor embryo quality according to the doctor.
May 2016- 3 eggs retrieved and 1 fertilized into a grade 3 morula.
July 2016- decided to have another retrieval but was cancelled because the follicles did not respond to the stimulation medicines. RE said to try the next cycle as follicle quality and quantity vary from cycle to cycle.
August 2016- 4eggs retrieved. 3 fertilized into 1 -grade 2 morula and 2 grade 1 blastocysts.
September 2016- natural transfer attempt on cd21 was cancelled due to low progesterone at 3.44 even if RE started me on oral and suppository progesterone from cd17 to cd21. But lining was already at 13mm on cd15. RE said, it might be due to the not so good quality of the corpus luteum.
October 2016- 2nd transfer attempt. Uterine lining was at 11mm on cd10. progesterone was at 1.13 on cd13. RE had me on oral and suppository progesterone from cd14 to cd18. Progesterone was at 5.24 on that day hence, cycle was cancelled again.
Now waiting for the next cycle as we will have an HRT transfer this time. Two previous transfer attempts were both natural transfer.
Do you think HRT transfer is appropriate for my case? What blood test should I do to check if my body is prepared and will be towards good receptivity to the forthcoming transfer cycle?
My sincerest thanks in advance.
Yes! I do believe it is worth a try. However, before trying, please read 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).
Hope this helps!
Geoff Sher
Dear Dr. Sher
In 2015 I became pregnant naturally but unfortunately had a pregnancy loss due to severe hydrops and turner’s syndrome at 15 weeks. At the time I got pregnant my amh level was 0.2. I have taken clomid and femara and a mixed cycle with clomid/menopur without success since. In April of this year my amh was retested and it came back almost undetectable at 0.03. I’ve made some diet changes and alternative healing medicine (acupuncture and herbs) to help. In September my amh came back at 0.16 and fsh at 7.5 mlU/mL, and estradiol was 58 pg/mL. My afc was 12. I’m 35 years old and the doctors are saying my best route is donor eggs through IVF. I don’t want to give up on my own eggs yet, do you think an IVF protocol adjusted for DOR might be an option? What would be such protocol for someone like me?
It worth a try with own eggs, if you are willing to do embryo banking.
Women who (regardless of age) have DOR have a reduced potential for IVF success. Much of this is due to the fact that such women tend to have increased production of LH biological activity which can result in excessive LH-induced ovarian male hormone (predominantly testosterone) production which in turn can have a deleterious effect on egg/embryo “competency”.
While it is presently not possible by any means, to reverse the effect of DOR, certain ovarian stimulation regimes, by promoting excessive LH production (e.g. short agonist/Lupron- “flare” protocols, clomiphene and Letrozole), can in my opinion, make matters worse. Similarly, the amount/dosage of certain fertility drugs that contain LH/hCG (e.g. Menopur) can have a negative effect on the development of the eggs of older women and those who have DOR and should be limited.
I try to avoid using such protocols/regimes (especially) in women with DOR, favoring instead the use of the agonist/antagonist conversion protocol (A/ACP), a modified, long pituitary down-regulation regime, augmented by adding supplementary human growth hormone (HGH). I further recommend that such women be offered access to embryo banking of PGS (next generation gene sequencing/NGS)-selected normal blastocysts, the subsequent selective transfer of which by allowing them to capitalize on whatever residual ovarian reserve and egg quality might still exist and thereby “make hay while the sun still shines” could significantly enhance the opportunity to achieve a viable pregnancy
Please visit my new Blog on this very site, http://www.DrGeoffreySherIVF.com, find the “search bar” and 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 Approach
•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
•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
•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.
•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
•Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
•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
•Premature Luteinization (“the premature LH surge): Why it happens and how it can be prevented.
•IVF Egg Donation: A Comprehensive Overview
I invite you to arrange to have a Skype or an in-person consultation with me to discuss your case in detail. If you are interested, please contact Julie Dahan, at:
Email: Julied@sherivf.com
OR
Phone: 702-533-2691
800-780-7437
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 evening doctor…this my 3rd attempt on IVF ,the 1st 2 attempts failed and my doctor suggested we go for frozen embryoso which I had 6 embryos transfered on the 24th of October …but I have been experiencing internal heat at day 4 of my transfer,pls doctor Could it be that there is any problem cos I still have 12days to my pregnancy test..thank you very much
I understand your angst Fatima, but I feel strongly that you should wait to determine the outcome of this treatment cycle. If you do not conceive then please reach out and I will rrespond promptly.
Geoff Sher
Hello Dr. Sher,
Thank you very much for taking time to read and reply to so many questions. We are all grateful. At age 44, I had 9 Natural IVF cycles, 6 embryos made it to five day blasts and were transferred, one per month. Only one implantation–chemical pregnancy. I then moved on to donor eggs. Donor is 30. We had three PGS ‘normal’ embryos frozen. One was transferred in October. It failed. I was on .5 Dexamethasone nightly, aspirin, .5 injectable Estradiol twice a week and nightly 1.5 progesterone injections. The HCG measured below 1 at a blood test done 14 days after transfer. There was no blood work done the day of transfer (or ultrasound) so I do not have that information to help guides us forward. We have two PGS ‘normal’ embryos left and are looking for help of what to do. How can I address whatever issue I have as to not waste our last two embryos? So so grateful for your advice!