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
Firstly, thank you for takirng the time to respond to me. I am 32 years old and my husband is 31. We both have normal karyotypes and in October 2015 I underwent a hysteroscopy which showed that everything was normal. I have PCOS and a history of rheumatoid arthritis, which went into remission in 2011. We attempted IVF with my own eggs on 3 occasions, but we always had a problem with fertilisation from the onset. Therefore, in April this year we moved on to donor eggs and got pregnant on our first try. I was treated with 20mg prednisone, aspirin, 0.2ml clexane, 2ml agolutin every third day, intralipids, 800mg utrogestan and 6mg progynova. I also had the endometrial scratch prior to transfer. Sadly, we experienced low HCG levels, a small gestational sac, slow heart rate, small baby and a subchorionic haemorrhage – and we had a missed miscarriage somewhere between 9 and 10 weeks. I had an ERPC in June this year and we have just completed a FET donor embryo cycle using one aCGH-tested embryo, which was a top quality hatching blastocyst. Both of the donors were proven and my lining was 9mm and triple layered. I was treated with exactly the same medications as mentioned above, but I did not undergo the endometrial scratch on this occasion. However, the cycle has been unsuccessful. I realise that not every embryo implants and that sometimes it is just a matter of luck, but I am struggling to accept that this is the case given that we thought we had increased our chances by using a donor embryo that was tested and all other factors seemed to be promising. In your opinion, do you consider that there may be more to play than just bad luck? Is there anything that you would suggest we should explore further, such as tests, medication, a different protocol? We are happy to continue with trying donor embryo cycles as the need for a genetic child has passed.
Many thanks for your time,
Natalie
I forgot to mention (although not sure if it makes any difference) that I am taking supplements – coenzyme Q10, vitamin D, folic acid and omega 3. I also take 25mg levothyroxine daily – not because I have a thyroid issue but because my thyroid level was considered to be suboptimal in terms of fertility. By taking this medication, I am now within normal fertility ranges.
I also took the BCP in the weeks leading up to my IVF cycle.
Thanks again,
Natalie
Hi Natalie,
I am very sorry about your failed cycles. Given you one early pregnancy using an egg donor, and have had PGS-normal (donor-derived) embryos transferfred with a negative outcome, I very strongly suspect an implantation dysfunction. And, given that your endometrial development seems OK (9mm lining), this is in my opinion very likely to be an immunologic implantation dysfunction (see 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).
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
•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!
•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
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.
Hello Dr. I want to know the validity of prolactin test result. meaning if it was normal 2 months back (on 1st September), what are the chances that it is not shoot up by now. Actually my periods are delayed by 10 days and one pregnancy test came negative. i just want to eliminate the fact that it is due to high prolactin. DO not want to spending much on the expensive blood tests.
I do not think it will be a problem once found to be normal….unless of course you are taking meds to control Prolactin. In such a case you need to monitor Prolactin.
Geoff Sher
Dear Dr. Sher,
About us: I am just 43 yo, I conceived naturally and very easily (after 4 months trying) my daughter 2 years ago. We started to try for the second one last May 2015. I got pregnant in July but we discovered T21 and during the following screens at around 15 weeks (we terminated the pregnancy in November). I had my first cycle in Jan this year and had a chemical pregnancy in April. In july we decided to go straight to IFV. My values:
LH: 9.5 (IU/l)
FSH: 9.4 IU/l
Prolactin basal: 246 mU/l
DHEA-Sulfat: 2.40 nmol/l
Testosteron: 0.2 (normal range 0.3-1.7) this was the value out of range
AMH: 15.5 pmol/l
At the baseline scan, they counted 8+7 follicles in total. The stimulation during IVF seems gave good results (Menopur injections): 9 eggs were retrieved and of those, 7 were fertilized (without ICSI). We were over the moon, since we had embryos for a fresh transfer plus few frozen for FET. We did transfer 3 of 2-days/4 cells good embryos. We were so thrilled about the test date but the result came as a shock: negative. We took one month break and then we moved into the next step: FET for 2 of 2-days/4 cells embryos (looking even better than the first ones). Today I got the call: negative!
I am fully aware how my age indicates bad or low quality eggs / embryos, while issues with my uterus seem unlike to be the cause of the failure. I have the chance of the next FET of the 2 remaining embryos but I feel defeated and somehow I expect not different results (of course I hope for the best but maybe prepared for the worse). I am not sure what to expect or to plan after. I am not ready to give up or to consider the donor egg option now.
My questions: we would like to try for a second fresh cycle and if we could get the same amount of fertilized eggs, we wish we could be able to have genetic testing so to see if we have good embryos (genetically normal) and transfer only the ones –if any- that are good. For this I should anyway move into another country since in Switzerland PGD testing is new and not fully implemented. Does this make sense to you? Would this be a good approach? I am honestly discouraged to transfer embryos which potentially could be bad (not viable). Even though the embryologist was saying that transferring at day 2, we give them more chances to survive inside the maternal body. What would be your suggestions here?
Also, is there any meaning beyond my low testosterone? I also have a lot of hair-loss during all months of the year. They told me it is not important for IVF/FET. However, I still think there is something wrong due to this hair loss I have since my daughter was born (I initially thought it was just due to the pregnancy but never really stopped).
If we go for a second cycle, should I try any supplements that are supposed (even though without real clinical studies to back up such info) improve egg quality – like ubiquinol or DHEA? Is there any risk to take them?
Any guidance on how to move on would be really appreciated – we are lost and devastated but still a very strong and happy couple.
Thank you
Maria
I forgot to mention: we are both very healthy. The only drugs I ever taken in my life, are the ones for IVF/FET. His sperm check was also excelent.
I do agree with your strategy, but would suggest you avoid using DHEA. Also bear in mind that your peripheral blood testosterone level is not an indicator of ovarian testosterone which can be several times higher.
The older a woman becomes, the more likely it is that her eggs will be chromosomally/genetically “incompetent” (not have the potential upon being fertilized and transferred, to result in a viable pregnancy). That is why, the likelihood of failure to conceive, miscarrying and of giving birth to a chromosomally defective child (e.g. with Down Syndrome) increases with the woman’s advancing age. In addition, as women age beyond 35Y there is commonly a progressive diminution in the number of eggs left in the ovaries, i.e. diminished ovarian reserve (DOR). So it is that older women as well as those 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 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 age-related effect on the woman’s “biological clock, certain ovarian stimulation regimes, by promoting excessive LH production (e.g. short agonist/Lupron- “flare” protocols, clomiphene and Letrozole), can 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 older women and those 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 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.
Hi Dr.
I am age 36, living in London. At the moment I am doing my first IVF. I was on buserelin from 21st day of my last cycle for a total of 3 weeks. In my first scan on Gonal F 300ui only 2 follicles were more than 10 mm. They upped the gonal f to 450. Today, there were 5 follicles more than 10 mm. I was afraid to use buserelin so long (more than 10 days after my period started). Do you think it has an effect on the growth of the eggs? Also, will it effect the egg quality.
Thank you!
In my opinion, if it was used for 3 weeks before starting the simulation, it could slow down follicle development.
Geoff Sher
Your article on the recurrent implantation failure was interesting. I myself have undergone one IVF procedure and one ICSI procedure- both ending in a negative test.
Although age is against me, i don’t feel that it is the main issue. My embryos have been of average- to good quality so I feel that the NKa you mentioned, as a result of endometriosis is my issue.
I live in the UK and the 2 treatment cycles have been provided by the nhs. I have no say in extra testing for NKa or a means to genetically test healthy embryos.
My main question is: What was the treatment provides for this couple which resulted in the live birth? It is not clear in the article what was done once the NKa were identified.
I would greatly appreciate your counsel as time is ticking on and I need someone who knows what they are talking about the give good, straight advice.
Many Thanks
Sarah
Hi Sarah,
I am not sure which article you are referring to and whether this is in this new blog or in my old one (www.IVFauthority.com).
Geoff Sher.
If you could direct me and then re-post this question for reference, I will address the issue.
Geoff Sher