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 just post you the question but not sure if you receive them since there are no send button.
Kind Regards,
Carina
Dear Dr. Sher,
I just turned 46, undergoing embryos banking:
1) First cycle at age 45: Short Protocol or Microflare, first 3 days (daily Menopur 300IU and Gonal F 450IU), 4th day (Menopur 150IU, Gonal F 450IU), 5th day (Menopur 150IU, Gonal F 400IU), 6th day (Menopur 150IU, Gonal F 350IU), 7th day (Menopur 150IU, Gonal F 300IU). On the 8th day, HCG injection and the estradiol was 1295 pg/mL and eggs sizes were 25mm, 23mm and 22mm. Manage to retrieve 2 eggs and lost the 25mm egg during retrieval. There were two embryos matured with grade B, waiting to undergo PGS.
Question: Do you think that the medication at the beginning with Menopur 300IU and Gonal F 450IU were too high and can destroy the quality of my eggs?
2) Second cycle at age 45: Short Protocol or Microflare, first 4 days (daily Menopur 225IU and Gonal F 450IU), 5th day (Menopur 225IU, Gonal F 400IU), 6th day (Menopur 150IU, Gonal F 350IU), On the 7th day, HCG injection and the estradiol was 1045 pg/mL and eggs sizes were 28mm, 25mm and 13mm. Manage to retrieve 1 egg and lost the two eggs deem to be empty follicles. However, the embryo arrested at 7 cells. Question: The medication was slightly reduced compared to first cycle, however why do we have empty two follicles and the embryo blastocyst stop growing at 7 cells?
3) Last cycle at beginning of age 46: Long Protocol or Down regulation, we kept consistent stimulation for 9 days (daily Menopur 150IU and Follistim 300IU). On the 10th day, HCG injection and the estradiol was only 496 pg/mL and eggs sizes were 23mm, 18mm and 13mm. Manage to retrieve 2 eggs but the two mature embryos did not fertilized properly.
Question: The medication is kept consistent with lower doses, however why does it failed? Is it important to wait for the estradiol to be above 1000 pg/mL before HCG injection although the lead egg size reached 23mm?
4) Should I go for mini IVF with even lower medication doses to improve my chance to get quality egg?
Please kindly advise the next step as we are not very keen to have donor eggs.
Kind Regards
Carina
Hi Carina,
Aside fro the fact that in my opinion your stimulation protocols would not have been my choice, you are fighting an insurmountable battle at 46Y, with what looks like severely diminished ovarian reserve (DOR). You are going to have to face the reality that using your own eggs (regardless of protocol) is no longer a viable option for you. You need IVF with egg donation…I am afraid.
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.
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF
•IVF Egg Donation: A Comprehensive Overview
I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
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
Hi Dr. Sher..
I am 29Y and turning 30 in a month. I have been taking infertility treatment from last 2.5 years. As I could not ovulate even after trying with different medication for 4 months my gynec suggested IVF. I had a failed IVF in November 2014. Doctor did not reveal the proper reason but left us with a doubt of endometriosis. Then we thought of having a second opinion.
I had undergone a laparoscopy with the new doctor in September 2015 and was told that I have moderate to severe endometriosis and thus having poor egg quality but uterus is good enough to get conceive. Later I was treated with the tablets Endofine & Veronica for 2 months to suppress the endometriosis and tried for natural conception. Even then I could not have ovulated. So doctor suggested IVF is the option.
In January 2016 we had gone for IVF again and got the 9 eggs and only two got fertilized but even those embryos could not reach up to the mark even after 5 days. So no transfer done. Doctor suggested to go for donor egg IVF. we have gone for donor egg. We got 4 good quality embryos and 2 blastocysts with the donor eggs out of which 2 embryos were transferred into my uterus on 8th February 2016 (which is 18th day of my menstrual cycle and my endometrial thickness was 10.23) and remaining were frozen. We did the beta hcg test on 22nd February which is negative. I got my period on 26th Feb. Doctor suggested to take the medicine Femilon in this cycle and in the next cycle she wants to transfer the 2 blastocysts.
Even with good quality of embryos and with good endometrial lining I could not conceive. Really day by day we losing our hopes. Sir can you please suggest what else we can do better. Is my problem that much critical that I cannot get pregnant at all ??
Whenever a patient fails to achieve a 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).
My answer to patients who ask me when is the time to stop undergoing IVF is ….Aside from the weight of the financial burden, the time to stop is when in spite of thorough and comprehensive evaluation, there is no remediable and treatable explanation for repeated failure.
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
•Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•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)
•The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
•Unexplained IVF Failure
•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)
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF
•The Role of Nutritional Supplements in Preparing for IVF
•Enndometriosis and Infertily
•Treating Ovarian Endometriomas with Sclerotherapy.
I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
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
Dear Dr Sher
First of all, I want to thank you for providing this invaluable service for people going through a very difficult time. I’d also like to apologise for the length of this post!
My husband and I received the news yesterday that our second IVF cycle was unsuccessful. We are both 33, and have been trying to conceive our first child for four years. In that time, I have never seen a positive pregnancy test. Our official diagnosis (or non-diagnosis) is ‘unexplained infertility’, but I think one positive that has emerged from two failed IVFs is that we are closer to understanding what’s going on – in both cycles, our embryos failed to become blastocysts.
As far as we know, there is nothing wrong on my husband’s side – his semen analyses have all come back normal. After our previous failed cycle, we also tested for sperm DNA fragmentation, which was low. Again after our previous cycle, we both underwent karyotype analysis, which came back normal.
Now to me – I have what looks on paper like a fairly mild form of ovarian dysfunction/ hormone imbalance, which seems to be having a catastrophic effect on both my natural fertility and IVF outcomes. Different doctors have described my ovaries (as seen via ultrasound) as either ‘mildly polycystic’ or ‘multicystic/ multifollicular’, which I’m given to understand are different things.
I have fairly regular cycles of about 26/27 days, although in the time I have been keeping track, I have experienced longer (31 days) and shorter (19 days) cycles, so I wouldn’t say they are like clockwork. I ovulate on my own, which has been confirmed by day 21 progesterone and ultrasound, where a corpus luteum could be seen.
Regarding other symptoms of PCOS, I could probably lose a few pounds, but my BMI of 23 is within the healthy range. I experience mild breakouts on my chin, and also have to pluck the occasional hair from the same area. But these symptoms don’t seem any more severe than those experienced by friends who have had children. And I have met people with far more obvious symptoms in the waiting room of my fertility clinic (I’m sorry if this isn’t all relevant, I’m just trying to give as full a picture of our situation as possible).
When I had bloodwork done for PCOS about 18 months ago, my fasting blood glucose and insulin levels were normal (I have not had a glucose tolerance test). My LH/FSH ratio was slightly off, but the doctor I was seeing at the time felt this was not significant, as he would expect to see a greater disparity in typical PCOS. My androgen levels were very slightly raised. Again, my doctor didn’t feel the levels were high enough to be concerned about.
As far as know, my FSH and AMH levels are within normal ranges. I feel I should mention that some of my other hormone values have been slightly off as we have gone through this process – my first ever (and subsequent) day 21 progesterone came back as indicating ovulation, but apparently below the threshold for establishing/maintaining pregnancy. And before starting our recent IVF, apparently my progesterone was higher than it should be. I’m sorry I can’t provide specific values. I have had so. many. blood. tests. that I don’t have all the relevant results to hand.
During our first IVF in February/March 2015, I was put on what I assume was a standard low dose long protocol. I downregulated with Suprefact (Buserelin) nasal spray, then started on 75u Gonal F and 75u Merional for 8 days. I was also taking Zomacton (growth hormone) every other day. On day 8 my estradiol was 3714, and my LH 2.4. On day 9 I injected 75 Gonal F and 37.5 Merional. On day 10 my estradiol was 10014 and my LH 3.2, and I injected 37.5 Merional only. I triggered with Pregnyl on day 11 having taking no further stimulation medication that day.
Of the 19 eggs retrieved, 4 were immature, and 4 fertilised abnormally (nothing was mentioned at the time about the significance of this), which left us with 11 embryos. On day 2, the majority were growing more quickly than they should, which I now understand to be an early sign of abnormality. I believe embryos at this stage should have 2-4 cells – ours were as follows: 5,7,5,3,3,8,5,7,6,8,5. On day 3, they all seemed to have levelled out, and the embryologist called me with the “amazing news” that we had 8 ‘top quality’ and 3 ‘good quality’ embryos, that they were going to continue to culture to blast. Cell numbers were as follows: 10,8,10,12,10,10,8,12,10,8,12, with little or no signs of fragmentation. Then came the devastating news on day five that none of our embryos had progressed as expected. They were left in culture for another day, and I had what the lab described as a ‘pre-morula’ and 16 cell transferred on day 6.
We decided to do our second IVF at a famous London clinic known for its intensive monitoring (2 blood tests per day during the second half of stimulation) and tailored treatment. Although this cycle failed, I still feel that it was significantly better than our first. This time I downregulated with 1×0.5ml Suprefact injection per day. On day 2/3 of this cycle, my LH level was too high to start stimulation. I continued to downregulate for another week, during which my dose was increased to 2×0.5ml Suprefact injections per day. I had my LH tested a total of 4 times before being given the green light to start stimulation. I was very happy about this, as I had read your blog about the deleterious effect of too much LH on egg quality, particularly in women with PCOS. My previous clinic didn’t check my LH until day 8 of stimulation, so I have no idea if I was properly down regulated in the first place with that cycle.
I feel that the stimulation phase of this cycle was better than our last, with my doses of Fostimon and Merional adjusted on a daily basis based on my hormone levels and scans. I don’t have the specific dosages to hand, but my protocol seemed to favour Fostimon whilst being relatively sparing with the Merional. I stimulated for 14 days (although I took no stimulation medication on day 13, I presume because my estradiol was high again), and triggered with Pregnyl having had a final 37.5 dose of Merional on the same day.
This time, 24 eggs were retrieved. We were not given any information about their maturity. The embryologist suggested we try spilt IVF/ICSI, as in their experience some cases of unexplained infertility may be caused by an undetected sperm issue that only shows up as ICSI embryos growing “beautifully” in comparison to their IVF counterparts. This is where the first sign of a problem showed up. Of the 11 embryos ‘stripped’ in preparation for ICSI, 3 showed enlarged polar bodies. I believe this indicates that the eggs have failed to split their genetic information evenly during meiosis. The following day, we were told that 5/11 ICSI and 6/13 IVF embryos had fertilised – so we were back to the same situation we had before of having 11 embryos.
On day 2, the situation was looking better. 4 of our embryos had 5 cells, but the rest had between 2 and 4, and none showed 6, 7 or 8 like last time! I was really hopeful that the tailored stimulation protocol this time around had made a difference. Because of our history of poor embryo development after day 3, the clinic suggested a split transfer. So I had an 8 cell, grade 4 (top quality) embryo transferred at day 3 (I suspect this was ultimately pointless because it looks like this batch of embryos was again aneuploid/ chromosomally abnormal). As before, the rest of our day 3 embryos all looked good, with the right numbers of cells and little or no fragmentation.
On day 5, the situation was better than last time, but not great. Over half of our embryos were compacting, and two were showing signs of cavitation – so they had progressed further than last time, just not far enough. I had the best cavitating morula transferred. Apparently our IVF embryos fared better than the ICSI ones (so we know to stick with IVF in the future), but none of the remaining embryos had progressed enough to freeze by day 6.
It seems to me that there may be nothing wrong with my eggs per se, the problem seems to lie in their maturation. And the fact that our embryos were better this time shows that they’re influenced by treatment. I truly believe successful IVF will be achieved by getting the stimulation protocol right.
I would be extremely grateful if you would be able to provide any insight into our particular brand of infertility (I feel like we have become a special/difficult case, and I have yet to come across anyone in a similar situation!) And if you could provide any suggestions regarding changing/improving our stimulation protocol to increase the number of chromosomally normal eggs and resulting embryos.
Many thanks in advance for your help.
Katie
Hi Katie,
Well, the problem (s) you are confronting are almost certainly egg quality related. What cannot be stated with any certainty at this stage is whether this is related to the protocols used for ovarian stimulation (the most likely) or whether it is due to an inherent egg defect (less likely).I believe that you likely do have a variety of PCOS which does complicate the stimulation process. My approach (were I to treat you) would be to put you on to a monophasic BCP (such as Marvelon) for 2-3 months in advance of ovarian stimulation. I would then overlap the last 3 days on the BCP with Superfact. Assoon as the period started, I would again supplement with HGH and after confirming that the base-line E2 was <200pmol/L, would lower the dosage of Superfact and start stimulating with a (FSH-recombinant)-dominant stimulation protocol, adding no more that 75U Menopur or Merional from day 3. I would continue the low dosage Suprfact until the 10,000U hCG trigger. The stimulation with gonadotropins should ideally not be less than 8 days in duration and the follicles...no larger than 22mm in mean diameter.If signs of overstimulation occured, I would implement "prolonged coasting" but the timing of the latter is crucial to success.
Once harvested and fertilized (ICSI only), I would allow to develop on and do PGSusing next generation gene sequencing (NGS).... see below.
If this did not work out, you are probably dealing with an inherrent egg defect and would need to consider egg donation...in my opinion.
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
•Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•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.
•The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
•Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
•Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
•IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
•Unexplained IVF Failure
•Why did my IVF Fail
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF
•The Role of Nutritional Supplements in Preparing for IVF
•Preventing Severe Ovarian Hyperstimulation Syndrome (OHSS) with “Prolonged Coasting”
•Understanding Polycystic Ovarian Syndrome (PCOS) and the Need to Customize Ovarian Stimulation Protocols.
I invite you to call 702-699-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
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
I’ve had 3 rounds of IVF with ICSI (2 fresh 1 frozen) all 3 cycles went perfect responded well got good numbers from retrieval and good embryos to transfer. Great one for our first fresh transfer and two good ones for our frozen and another good one for our last fresh one. All 3 of these cycles have ended as a biochemical pregnancy. All low hcg numbers never above 50. I have got another frozen cycle to go but my clinic won’t do any investigating to see why I keep having theses early losses. They said my hcg numbers have been too low to call it a loss. What can I do? I want to go ahead with my next cycle but scared the same will happen again. Feel like I’m wasting my embryos.
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).
My answer to patients who ask me when is the time to stop undergoing IVF is ….Aside from the weight of the financial burden, the time to stop is when in spite of thorough and comprehensive evaluation, there is no remediable and treatable explanation for repeated failure.
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
•Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•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)
•The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
•Unexplained IVF Failure
•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)
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF
•The Role of Nutritional Supplements in Preparing for IVF
I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
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