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,
I have been recently following your live videos and blogs and they are so informative thank you.
My story is as follows
End of 2010 I had my first miscarriage, got pregnant the first month of trying. I did some bloods and found out I had positive anticardiolipins
In 2012 I had my daughter having taken steroids, clexane, aspirin and prog to 12 weeks. She had a small birth defect – universal right sided choanal atresia which was repaired at 2 years of age.
I tried to have a second child from October 2013 to no avail. I had my AMH tested in May 2014 and found out it was 5. I did TSI and got pregnant the same month but miscarried at 10 weeks in October 2014. I tried TSI again and got pregnant in December and miscarried at 10 weeks (down syndrome and a boy). I also had thyroid antibodies so took 25mg eltroxin, selenium and also vit d3 as it was low.
I decided I could not face any more loss and did IVF with PGS in Prague (I live in Ireland). We had 2 day 5 embryos, one came back abnormal, the second inconclusive and was retested. Implanted successfully. Did intralipids 7 days before transfer and around positive test. At 21 weeks we found out our son had CDH, right sided. he also developed hydrops and was born at 34 weeks and lived for 7 hours. His lungs had not developed.
Im now 42. My heart says give up, but I feel that something must be wrong (besides DOR) and I would love your opinion
Emma
I am so sorry for all the problems you have had.
Older women as well as those who (regardless of age) have diminished ovarian reserve (DOR) tend to produce fewer and less “competent” eggs, the main reason for reduced IVF success in such cases. The compromised outcome is largely due to the fact that such women tend to have increased LH biological activity which often results in excessive LH-induced ovarian testosterone production which in turn can have a deleterious effect on egg/embryo “competency”.
Certain ovarian stimulation regimes either promote excessive LH production (e.g. short agonist/Lupron- “flare” protocols, clomiphene and Letrozole), augment LH/hCG delivered through additional administration (e.g. high dosage menotropins such as Menopur), or fail to protect against body’s own/self-produced LH (e.g. late antagonist protocols where drugs such as Ganirelix/Cetrotide/Orgalutron that are first administered 6-7 days after ovarian stimulation has commenced).
I try to avoid using such protocols/regimes (especially) in older women and those with DOR, favoring instead the use of a modified, long pituitary down-regulation protocol (the agonist/antagonist conversion protocol-A/ACP) augmented by adding supplementary human growth hormone (HGH). I further recommend Staggered IVF with embryo banking of PGS (next generation gene sequencing/NGS)-normal blastocysts in such cases. This type of approach will in my opinion, optimize the chance of a viable pregnancy per embryo transfer procedure and provide an opportunity to capitalize on whatever residual ovarian reserve and egg quality still exists, allowing the chance to “make hay while the sun still shines”.
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
•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.
•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?
•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
•Implications of “Empty Follicle Syndrome and “Premature Luteinization”
•Premature Luteinization (“the premature LH surge): Why it happens and how it can be prevented.
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.
Geoff Sher
Hello Dr. Sher,
Today I received some blood test results and I’m worried that I’m not a good IVF candidate. I would really appreciate your honest opinion.
I’m 30 years old
FSH: 3.3 u/l
LH: 3.9 u/l
LH/FSH ratio: 1.18
E2 Roche E170=282 ng/l
AMH: 1.71
SHBG: 181 nmol/l
FAI: 1.28
DHEA sulfat Roche E170=3012 ug/l
Testosterone: 0.67 ug/l
Thank you very much.
Not so! In fact with your AMH tipping downward (suggesting BL ovarian reserve), I would suggest you not delay unnecessarily.
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.
•Premature Birth and 2nd Trimester Recurrent Pregnancy Loss (RPL)
•Hereditary Clotting Defects (Thrombophilia)
•Blastocyst Embryo Transfers Done 5-6 Days Following Fertilization are Fast Replacing Earlier day 2-3 Transfers of Cleaved Embryos.
•Frozen Embryo Transfer (FET) versus “Fresh” ET: How to Make the Decision
•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
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 have 2 children, both from prior successful FET. In between my first and second child, we thawed and did trophodecterm biopsy for CGH testing on my frozen blasts. My first transfer when trying the second time was a chemical pregnancy, and my second transfer resulted in a pregnancy/live birth. Now I am trying again with my CGH normal frozen blasts, and I just had a chemical pregnancy. Obviously I had 2 live births before, so I am confused whether there’s any reason to think there’s an implantation failure issue, or whether it’s just dumb luck & statistics that CGH normal embryos don’t always achieve pregnancies? 2/6 of my IVF transfers have resulted in live births, 3/6 in chemical pregnancies, and 1/6 I had no implantation at all. Do these statistics concern you or should I just keep trying with my frozen blasts as planned????
No I do not think with 2 babies that this is an implantation issue. I do however not believe that it is a good idea to thaw frozen blastocysts for biopsy only to freeze them again while awaiting rfesults and then having to thaw them again for transfer. In my opinion it is too traumatic for the embryos.
Geoff Sher
Hi Dr. Sher. My husband and I are thinking of doing a FET next Fall 2017. Embryos are PGS normal. We will be using a 3BB day 5 blastocyst as well as a 4AB day 6 blastocyst. Could this potentially be a twin pregnancy? Am I wrong to think it’ll end in just 1 baby? Thank you for the time, Dr. Sher!
The chance of twins if you transfer 2 PGS-normal blastocysts could be around 40%
Good luck!
Geoff Sher
Hi Dr Sher
My husband and I have been trying to conceive for 2 years. I am 34 and my husband is 28. A little bit of background on me. In 2012 I was diagnosed and had removed by cranitomy a craniopharyngioma (a benign pituitary tumour). While the operation was successful removing the large majority of the tumour, it has unfortunately impacted my pituitary function resulting in hypopituitarism. In particular, my sex hormones has been significantly depressed meaning that I do not ovulate on my own. I also suffer from hypothyroidism and diabetes insipidus (a rare disorder that affects my body’s ability to control its water balance). My growth hormone production is also lower than what would be expected for someone my age.
Given my history, I was always aware that I would need to take fertility medication in order to conceive. Starting in Nov 2014, I started taking 150 IU Gonal F injections with a 10,000 IU Pregnal trigger combined with timed intercourse. We tried 5 cycles of this and had one chemical pregnancy followed by another pregnancy that sadly miscarriage at 8 weeks. We have also tried IUI, where I took 150 IU Gonal F with Pregnal trigger. This was unsuccessful.
We have now proceeded to IVF and have just completed our first round, which was unsuccessful. The IVF protocol prescribed by my fertility specialist was HA-ICSI, where I took the following medication:
– Puregon 300IU injection daily until follicles reach desired size
– Pergoveris 150IU injection daily until follicles reach desired size
– Orgalutran 250g daily when advised (once follicles were close to desired size)
– Pregnyl 10,000 IU once follicles were at desired size
– Luteal support in the form of Endometrin 100mg 3x daily
I have also been diagnosed with increased Natural Killer cells so I was prescribed 10 mg of prednisolone from start of cycle and a daily injection of clexane after egg collection.
During this cycle we collected 28 eggs, 14 of which were mature. Following this, 8 went on to fertilise (using ICSI). By day 3, we had 7 embryos. However, by day 5 none had reached blastocyst. We ended up transferring the most advanced embryo and waited to see if any of the remaining embryos would be suitable for PGD and freezing on day 6. Unfortunately, none were suitable. While I have not had the full debrief with my fertility specialist, according to one of the embryologist, our remaining embryos were slow growing and showed fragmentation issues.
My question for you is have you ever treated someone who has a similar medical history to me (i.e. craniopharyngioma/pituitary tumour/disorder). If so, is there anything in particular you would recommend should be included/done as part of an IVF protocol? For example, I have read that treatment with human growth hormone may be beneficial for women who have a similar medical history to me?
Thanks so much!
My question
Obviously this is not a common problem. However, it is treatable. In my opinion, there are 2 issues: The 1st (and most important) is the embryo “competency” issue. Embryos that fail to reach blastocyst are almost invariably chromosomally abnormal and are not worthy of being transferred. Here the problem usually resides in the protocol chosen for ovarian stimulation and its implementation (see below) and this has no direct link to your panhypopituitrism. The 2nd has to do with your NK cell activation causing an immunologic implantation dysfunction. Unfortunately steroid therapy alone is in my opinion insufficient and will not solve such an issue. I hold that it will also be important to test further in order to differentiate between an alloimmune and autoimmune cause because treatment differs but either way this will require intralipid + steroid therapy…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.
•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
•Why did my IVF Fail
•Blastocyst Embryo Transfers Done 5-6 Days Following Fertilization are Fast Replacing Earlier day 2-3 Transfers of Cleaved Embryos.
•Frozen Embryo Transfer (FET) versus “Fresh” ET: How to Make the Decision
•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
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.