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.
Hello Dr Sher. I am at a bit of an impasse in my treatment. I have had one round of IVF and responded very well – 7 PGS 5 day embryos frozen. I am 31 yrs old. Before I was able to have a FET I was recommended I have a hysteroscopy to remove some fibroids impacting the uterus cavity. I had this and we transferred 1 embryo under a fully natural cycle but I did not get pregnant. I then had progesterone (cyclogest) support for my second FET and achieved a positive test. things progressed until 7 weeks where it was discovered that the embryo had not grown since 6 weeks and I had a SCH. My clinic suggested that some of my lining was thin during the transfer, some was at 8mm and perhaps it was due to bad implantation. I subsequently had 2 further hysteroscopies to remove further fibroids – the uterus cavity is now completely clear, albeit I still have fibroids in the wall of my uterus but the view is that it is as good as we can get it. I have had one more FET, lining was at 8.6mm with support of oestrogen (progynova) and progesterone (cyclogest) support for luteal phase. Again I achieved a positive pregnancy test but at 4.5 weeks I started bleeding with a small SCH and at 6 weeks the embryo was not developing. I have subsequently had RPL tests and have no obvious blood clotting issues but do have the heterozygous MTHFR gene. I understand this is not so problematic but I have switched to 5 MTH folate rather than folic acid. The view is that next time I should be treated with clexane and maybe boost oestrogen/ progesterone drug levels. There is also view that immunotherapy with IL and steroids (prednisolone) could help. I have seen 2 doctors for their view on this, with one saying that he would treat me empirically with 1 IL before FET and at least 1 once I achieve a PGT. the other wouldn’t treat me without the NK cell and TH1/ TH2 tests. For my own curiosity I have conducted the tests and am waiting for the results. My question for you is how different is the outcome and medication you would use if you did not have the results of these tests? From y reading the IL seems to be the same but perhaps steroid levels can differ? additionally the one doctor who insists on the tests, says he also tests throughout the treatment cycle to ensure that the NK cell levels are sufficiently suppressed before a FET in order to allow a viable pregnancy to continue. what is you view on testing throughout treatment – I have read your blog and I think your view is that this isn’t necessary? From reading this would you believe that the issue could be immune? I should also say that before I had IVF I had 1 ectopic that failed naturally – I have never been able to get pregnant naturally thereafter and tried for 1.5 years. There is lots of contradicting views but I do believe that immunotherapy has a positive impact on IVF as many women have had babies using this treatment. Many Thanks
There are 2 issues here and both relate to implantation dysfunction. First there is the lining issue. I suggest you be treated on vaginal Viagra, prophylactically in the cycle. Second, there is the immunologic implantation dysfunction (IID) possibility. I do not agree with prophylactic treatment. You need a diagnosis , not only to identify an NK-cell cytokinopathy but if it is present, to distinguish between autoimmune and alloimmune causes. This requires that aside from the K-562 tare get cell test for NKa, antiphospholipid profile (APA) , antithyroid antibodies and immunophenotype, your and hubbub’s blood also be matched for DQ alpha/HLA genetic similarities. The reason is that treatment of alloimmune causes of IID will differ substantially from treatment of autoimmune IID….see below.
Name: (F) Brittany Cordova Age: 29
Partner: (M) Elias Mezquita Age: 31
Email Address: BRICOR87@GMAIL.COM
Contact Phone # 626) 993-4389
Dear Brittany,
I really enjoyed meeting and interacting with you. Thank you kindly for your interest in my opinion and in my services.
Below, please find a summary of our consultation for your records. Also, please know that you will be contacted by an office administrator to help you understand the financial options, as well as by a clinical coordinator who will discuss clinical aspects of treatment with me in Las Vegas.
I typically schedule my IVF cycles 6 months in advance, for specific dates. The cycles last about two weeks, and I do limit the number of cases in each batch in order to make sure I can personally monitor the cycles, and dedicate special attention to each patient. Given my very busy schedule, it is always advisable for you to schedule possible treatment for the earliest convenient date. Both, the financial and clinical coordinators will help you work out logistic issues, and assist you in finalizing the ideal dates for your treatment. We require that all patients make a modest non-refundable deposit to secure the date. This deposit is deducted from the cost of the cycle of treatment.
There is rarely a need for women undergoing controlled ovarian stimulation (COS) for IVF to begin serial monitoring by ultrasound and/or blood testing prior to the 7th day of stimulation. As such, the female partner is not needed to arrive in Las Vegas prior to the 7th day of fertility drug administration, All preliminary preparatory testing can thus be done at your home setting by your primary GP or OB/GYN, including (if needed) bloodwork and a baseline ultrasound examination with the start of the menstrual period that launches the cycle of ovarian stimulation. After treatment is completed, you can return home. We will follow up with you and/or your partner by phone or Skype communication. We will also interact as needed with your primary care OB/GYN to supervise post-treatment and early-pregnancy management.
While this process might at first glance seem somewhat complex, in reality with a dedicated Clinical Coordinator assisting you, we have developed over the past 30 years of providing infertility treatment to more than 70,000 patients a very easy, convenient, safe and effective method for treating local patients as well as those traveling to Las Vegas from out of state or from abroad.
I provide my cell phone number and email address (702) 281-7437 to all my patients and as such I invite you to call me if you have any questions or issues that need to be addressed. If I am not immediately available, leave your name and phone number and I will get back to you promptly.
Thank you again for your interest
–
CONSULTATION SUMMARY:
Date of Consultation: November 9th, 2016
Nature of The Reproductive Dysfunction:
Age: 29Y
•G P M E G 0
•Duration of infertility: 1Y
•Menstruation:
oRegularity irregular
oAmount/duration heavy
oPain moderate
•Pain with deep penetration during intercourse: yes
•Pain with ovulation: yes
•PAP Smears(2012): normal
•Previous pelvic inflammatory disease: no
•Prior abdominal-pelvic surgeries: cholecystectomy (2006) hysteroscopy (2016)
•Systemic History: possible PCOS/migraine/asthma/factor V Leiden
•Current Medications: none
•Allergic to: penicillin anaphylaxis
•Substances:
oSmoking: yes
oAlcohol: yes
•Family History: Diabetes
•Ovarian reserve: AMH=8.4ng/ml/FSH=8MIU/ml/LH=12MIU/ml
•Prior immune tests for IID: _
•Previous hysterosalpingogram: 5/24/16- normal
•Previous hysterosonogram (HSN):normal
•Hysteroscopy: Normal
•Male partner: Normal sperm parameters X1 (in a prior relationship)
oInitiated pregnancies in the past
oSemen analysisnormal (may 2016)
•Previous infertility treatments: clomiphene X 1 cycle (50mg) and Gonal-F, 75U X 1 cycle…cancelled NO IVF
SUMMATION: PCOS:
Failed clomiphene and 75U Could also have undiagnosed endometriosis/needs IID testing. Plan is to do L2c with IUI. Try 3 cycles and if no pregnancy…IVF.
PLAN:
1.Immune tests: NKa/APA/RIP
2.SA
3.BCP
4.L2C protocol with IUI X 3 tries and if no pregnancy…IVF . However, if NKa+ skip IU and proceed to IVF
5.CC/F consultation
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ADDITIONAL 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.
•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!
•Endometriosis and Infertily
•Endometriosis and Immunologic Implantation Dysfunction (IID) and IVF
•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!
•Micro-IVF: Often Preferable to Ovarian Stimulation with or Without IUI
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.
Geoff Sher
Dr Sher, I hope you can shed some light on our fertility issues and advice us of where to go from here. I was diagnosed with pcos back in 2010 and underwent two rounds of ovulation induction to conceive our daughter. We started trying to conceive a second child back in 2013 and did 9 rounds of ovulation induction with no sucess. Since then we have done 6 rounds of ivf, I seem to produce a good quantity of eggs due to my pcos but seem to loose a fair few through the icsi process and some don’t fertilse. In this last cycle we started out with 25 eggs 18 of which where mature but we only ended up with 8 fertilsed as we lost 4 through icsi and 5 never fertilised. Our embryos seem to start off on track with good grades until they reach day 4 when they slow down considerably and we usually dont get and morulas until day 5 and then as result if that we dont get blastocysts until day 6 or as in the case of this last cycle no blastocysts at all. Our fertility specialist is unclear of where our issue is he said it could either be an egg issue a sperm issue or maybe we just dont make chromosomally sound embryos. In the past we havd tested some of the blastocysts we have avhieved so have put back 2 PGD tested embryos but they both resulted in negative results. I wondered if you had any opinion as to where our issue is and iur best options from here. Our fertility specialist has suggested a cycle using 1/2 of my husbands sperm and half donor sperm, do you think this is our next best step?
After 4 years struggling with infertility we are coming to the end of our journey and need to make a very considered decision from here.
Thankyou for any opinions you can offer
As you probably are aware, PCOS notoriously is associated with a higher percentage of aneuploid (chromosomally abnormal) eggs/embryos. Notwithstanding, I do not believe that all your eggs are abnormal since you have had a baby and you have propagated euploid (PGS-normal) blastocysts. In my opinion, this could be a stimulation protocol issue and thus the most important and for this reason the protocol used for ovarian stimulation MUST be very carefully and strategically individualized and implemented…see below. Second, you need to be tested for an implantation dysfunction,(anatomical/endometrial thickness and immunologic). If there is an immunologic implantation dysfunction, it could be alloimmune, which commonly results in secondary infertility (inability to conceive after having had a child)….see below.
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 Approach
•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.
•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
•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!
•Micro-IVF: Often Preferable to Ovarian Stimulation with or Without IUI
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.
Thankyou for your reply in regards to our fertility issues. Do you definitely believe that we are dealing with an egg quality issue then? Our fertility specialist has said as the embryos slow down at day 4 this could prove to be a sperm issue as this is when the sperm takes over. As for the immune issues I have very slightly raised NK cells which my specialist is treating through intralipds clexane 60mg and prednisone 25mg.
Dr. Sher,
I had a 5 day FET on October 12th with two pgs tested embryos. I’m currently 6 weeks 5 days pregnant with one embryo. I had an ultra sound today. They said they saw a gestational sac, yolk sac, and heart beat of 124 . They said I’m measuring 6 weeks 2 days even though I should be 6 weeks 5 days in reality. My progesterone levels for the last few weeks were as follows: 24.2, 36.2, 40.4, and today it is 29.3 . Should I be worried about this drop in progesterone? I’m on daily pio injections of 1 ml, estrogen patches every 3 days, and estrogen pills daily. I have had three miscarriages around this time previously with ivf. Every single time I have noticed a drop in progesterone before the miscarriage happens . Should I be worried?
Also they saw another questionable gestational sac with a questionable yolk sac measuring 5 weeks 2 days. They weren’t sure if it is the second embryo or a sub choronic hemorrhage. They said they will keep monitoring this. Couple of months ago I had an fet and lost baby after a bleed was discovered. They said this had nothing to do with the miscarriage and told me this time around not to take the baby aspirin jus to be sure.
I’m worried about my progesterone dropping and what this finding on the u/s could be? What causes a sub chronic hemorrhage. Is there anything I can do ?
ot be it is imperative to keep an eye on tghe possible 2nd sac vsone week should be more definitive.
Good luck!
Geoff Sher
Dr. Sher,
I recently did ivf. My beta is doubling well. Today the ultrasound tech said I’m measuring 6 weeks but I’m only 5 weeks and 4 days preggo. Too early to see a heartbeat yet. What does this mean?
Give it another week and repeat the US.
Geoff Sher
Hi,
I failed an IVF cycle yesterday, due to “empty follicles”. Investigating the matter, I found you blog, and following is my question. It’s my belief that my protocol was completely wrong for my medical condition. I was hoping for your take on it. I was diagnosed with Mosaic Turner’s into my early twenties when my regular menstrual cycle vanished. My husband and I decided to pursue IVF several years thereafter. I was on Megace due to endometrial hyperplasia, which has since been reversed. One week after completing Megace I began a protocol of 25 Gonal-F and 5 units Lupron in the AM followed by 3 vials of menopur and 5 units Lupron in the PM. This resulted in 2 follicles, one at 20mm and one at 15mm. Neither yielded any eggs. I was triggered with 100,000 HCG. Prior to starting this IVF cycle my AMH was 0.16, FSH 2.8. LH 5.4. My menstrual cycle did not return. I am physically and emotionally drained, and heart broken. We received the bad news yesterday. Any advice or guidance would be greatly appreciated. God bless you!
You clearly have severely diminished ovarian reserve.
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, https://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.
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