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.
Dear Dr Sher
Do you have any thoughts about why an endometrium might reach a decent thickness, but then fail to shed properly as a menstrual bleed?
In my freeze-all cycle, my lining reached 11mm – but when my period came 14 days post egg retrieval, I didn’t get a bleed , just brown/black spotting. SHG showed the lining had thinned and was regular in outline, so appeared to have reabsorbed as it hadn’t shed as a menstrual bleed.
FET cycle my endometrium was difficult to stimulate, and took a mixture of Gonal-F, oestrogen tablets, vaginal viagra and G-CSF wash – but we reached the magic 9mm for transfer. Sadly this ended in a chemical pregnancy – however when I stopped progesterone, when my period came a few days later, yet again there was no menstrual bleed, just brown spotting. Ultrasound confirmed my lining had thinned and was regular in outline, so again appeared to have reabsorbed
Hysteroscopy showed a healthy looking endometrium with red blood, endometrial biopsy was normal.
A copper IUD was inserted, with a view to trying to get me to menstruate. First cycle on cyclogprogynova and pentoxyfylline and once again I didn’t get a menstrual bleed, just spotting.
There was no evidence of any Ashermans or damage to the endometrium or myometrium, and my lining has reached 11mm and 9mm, so is able to thicken
It just won’t shed properly as a menstrual bleed
Do you have any thoughts as to why this might be?
Kind regards and many thanks in advance
Katy
Every patient is different. I cannot however give you an explanation except to say that it is possible that a rapid but progressive involution does happen at times…although not commonly.
This having been said, I do not understand the combined Gonal-F/estogen endometrial preparation for FET.
Geoff Sher
Geoff Sher
Hi Dr Sher
I have had my first cycle of IVF cancelled. I have PCOS and high AMH (in the 60s) and was expected to over respond. I recruited about 20 follicles and they grew but my oestrogen on day 10 of stimulation was low (300 when it should have been 3000!). I was told the result meant the follicles were empty or had poor quality eggs. I stimulated on fostimon and cetrotide and was on the birth control pill for the previous cycle. I also took a myoinositol supplement. The clinic did not measure FSH or LH as I don’t have regular cycles so they thought this was not useful. Previous blood tests have shown I do have elevated FSH to LH (typical of PCOS). My question is what can be done drug wise to improve the situation? I am taking metformin again as this assisted in getting me ovulating on clomid briefly.
Many thanks 🙂
This is unusual, but it sometimes happens when the blood male hormone (testosterone/androstenedione/DHEAS) levels are high. It is necessary to determine if this is the case and whether this is related to a high LH or an adrenal factor. If it ois due to the former, then a few months of LH suppression on the BCP before starting the stimulation or the use of an anti-androgen like Aldactone or cyproterone might help. If there is an adrenal factor the DHEAS/17-OH progesterone might be elevated and in such a case, a few months of low dose steroids in advance of stimulation might be beneficial.
Geoff Sher
Does doing back-to-back stimulated IVF cycles or having only a short gap in-between helps with getting better eggs in the next cycle as the ovaries are already primed from the previous stimulation?
In my opinion it is always advisable to take a break of at least one full cycle (off all stim meds) between each treatment.
Geoff Sher
Hi, Dr Sher. I just had my first failed IVF cycle. My FSH is 11.8 and my AMH is 0.88. I have moderate/severe endometriosis. I have an endometrioma on my left ovary. My HSG was unremarkable except for mildly dilated tubes. I used an Androderm patch for 16 days before starting IVF and used the nuvaring before starting injections. My first round of IVF I was on the following protocol: 600IU of follistim (300am and 300pm), 75 units menopur, and 53units of omnitrope a day. I used ganirelix starting on day 9. I triggered with two syringes of ovridrel. I had 9 follicles, but only one ended up being mature (8 immature). The only mature egg did not
fertilize. My doctor is talking about doing 4-6 weeks of letrozol followed by a month of nuvaring and then using the micro dose lupron protocol. What do you think about this protocol and our chances of getting more mature eggs?
Hi Jolyn,
Very respectfully, there are two issues in my opinion: a) You have endometriosis with an endometrioma. The former is associated with an immunologic implantation dysfunction (IID) in 1/3 which needs to be evaluated and if present needs to be addressed through selective immunotherapy and the latter (the endometrioma), in my opinion needs to be surgically removed lest it compromise egg development (ovogenesis)….see below. b) You have DOR and thus in my view, the protocol used for ovarian stimulation needs to be drastically reviewed and revised. 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 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
•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 Immunologic Implantation Dysfunction (IID) and IVF
•Endometriosis and Infertility: Why IVF Rather than IUI or Surgery Should be the Treatment of Choice.
•Endometriosis and Infertility: The Influence of Age and Severity on Treatment Options
•Treating Ovarian Endometriomas with Sclerotherapy.
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.
Dear dr Geoffrey
I’m 48 had 2 children naturally and remarried to want to have a further child this was out one and only chance and chose a clinic in Cyprus with high success rates with the dr
We chose to have donor egg IMSI pgd gender selection Due to my age.
As far as I was told my womb was the correct thickness and all was good in preparation for our transfer.
On the day of transfer the director of the clinic told us we had out of our 10 embryos all 10 went to blastocyst.
He came back to inform us we had 4 boys and 4 girls but the enbryologist had said one of the boys was hatching and we had I implant it now we decided on also the 2 girls that were also best quality.
Unfortunately Unknown to me the rest who is the one with the success rates and is meant to as advertised be the only dr who treats you throughout you who journey whilst in Cyprus was not in the hospital I had some stranger a man who I knew nothing about did the transfer and spoke no English so I didn’t even know what was happening whilst I was lieing there petrified as not being even informed by the clinic the female dr was not on site.
The transfer happened and we returned to London. Waited the 2ww and had our hcg test to find it was negative.
I’m now unsure if the transfer failed due to this stranger doing the transfer and not implanting the embryos correctly or it was me.
After emailing the clinic for an answer as the female dr had sat and said to me you will get pregnant ! They responsed to say they can’t understand I had great embryos my womb was great and they say the teaser was good but obviously they won’t admit it wasn’t as she didn’t do the transfer and now can’t admit it failed as she didn’t do it.
Could there be a reason why they failed to implant.
I’m devastated
Thanks
Racquel
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).
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.
•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.
•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
•Advancing Age of the Woman and IVF: How Old is too old?
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.