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.
Hi Dr Sher, I am now into my 6 weeks pregnancy via IVF ET. Yesterday, there was a brown stain in my vagina and today, I have brown and dark red blood spottings. It is not flowing out as I am taking a lot of bed rest. I took a pregnancy test kit and it showed that it was positive still. Is this a sign of an early miscarriage if the next few days I am bleeding more? I do not have extreme menstrual pain cramp like I usually do before I am pregnant when the spotting began yesterday.
Vaginal bleeding occurs in about 25% of all pregnancies. When it happens, it almost invariably raises the concern of pregnancy loss (miscarriage). Bleeding can also be a sign of a tubal (ectopic) pregnancy, and in cases where the distended Fallopian tube ruptures it can precipitate a life-threatening crises. However, a small amount of painless vaginal bleeding can also be the result of normal embryo implantation (i.e. implantation bleeding) or it can result a local erosion of the vagina or cervix and/or trauma during intercourse.
Notwithstanding, in virtually all cases the occurrence of early pregnancy vaginal bleeding congers concerns or even alarm regarding the possibility of miscarriage. And when this happens to women who conceived following infertility treatment, the alarm often turns into panic. However, the truth is that in most such cases the bleeding soon stops and the pregnancy proceeds unabated to the birth of a healthy baby. However, because some do progress and end in miscarriage, and in most cases, only time will tell how things will ultimately turn out, we use the term “threatened miscarriage” to describe such early bleeding. The term “inevitable miscarriage” is used once symptoms and signs confirm a miscarriage is in progress. The term “complete miscarriage” is used if all products of conception are passed, leaving the uterus “empty”. An “incomplete miscarriage” refers to cases where some products remain retained in the uterus.
Miscarriage: Mild painless vaginal bleeding (often referred to as “spotting”) is usually due to hormonally induced eversion of the glandular cells that line the inner cervical canal, such that erosion develops on the outer part of the cervix that protrudes onto the vagina. The everted glandular tissue is fragile and susceptible to contact trauma, brought about sexual penetration or the insertion of vaginal suppositories. Since such local bleeding does not involve the developing conceptus located inside the uterus it is almost always innocuous. The diagnosis of a local cause of bleeding requires visual inspection of the vagina and cervical inlet a speculum examination. Thereupon, provided that the pregnancy has advanced beyond 5-6 weeks, a concomitant sonogram could confirm the presence of an unaffected pregnancy. Patients are advised to be more careful in inserting vaginal suppositories and to avoid sexual penetration until the bleeding has stopped for at least 1 week.
Sometimes bleeding occurs behind the conceptus inside the uterus (retrochorionic bleeding). Some blood will usually track down through the cervix and into the vagina. A speculum examination will often reveal blood tracking into the vagina through the cervical canal and a sonogram will reveal the presence of a retrochorionic blood clot. Although such retrochorionic bleeding can become an inevitable miscarriage, it often abates and over time the blood clot in the uterus absorbs, and the pregnancy continues normally. Treatment involves careful observation, avoidance of aspirin and other non-steroidal anti-inflammatory medications, bed rest and avoidance of vaginal penetration until the condition stabilizes, is essential.
While mild painless vaginal bleeding is usually innocuous, bright red bleeding that increases in amount and is accompanied by escalating pain is another matter altogether. It often suggests an impending inevitable miscarriage.
Before the 7th week of pregnancy a normally rising blood hCG (pregnancy hormone) titers is a comforting indicator that the pregnancy is more than likely progressing normally. Likewise, the detection of a normal heartbeat detected by ultrasound examination done after the 7th week of pregnancy is a very reassuring finding. However, even such findings by no means exclude the possibility of an inevitable miscarriage.
The causes of a miscarriage are multiple and diverse. However in most cases it is due to the developing conceptus being chromosomally/genetically abnormal. However, early miscarriages that reoccur more than twice in a row (Recurrent Pregnancy Loss-RPL) often suggest of an underlying implantation problem that could be due to a poorly developed uterine lining (endometrium) or immunologic dysfunction involving activated immune cells known as uterine natural killer (NK) and/or T-cells. Treatment requires an accurate diagnosis of the cause and selective therapy.
An ectopic pregnancy must be excluded: .Bleeding in the first 2-3 months of pregnancy especially if associated with the sudden onset of acute abdominal pain that is aggravated by movement and is accompanied by right shoulder tip pain, and light headedness or fainting could point to a bleeding ectopic pregnancy (one that is located in a Fallopian tube, outside the uterus) . The condition can be life endangering and warrants an immediate trip to the hospital as it often requires emergency surgery.
Molar pregnancy: Molar pregnancies are due to rapid overgrowth of the trophoblastic tissue that forms the placenta. Although infrequent they can cause early vaginal bleeding in pregnancy. Bleeding from molar pregnancies is often present with typical bleeding which resembles “red currents floating in a red jelly”. Bleeding from a molar pregnancy can either painful or painless. The condition is often associated with severe vomiting in early pregnancy, disproportionate enlargement of the uterus, and very elevated blood levels of hCG. Ultrasound evaluation, often reveals a rather characteristic snow-storm like image.
Patients with vaginal bleeding are often told to stay in bed. While this might reduce visible blood loss, there is no tangible evidence that it will prevent a miscarriage. Unfortunately, there is no definite treatment for this kind of bleeding in the early stages of pregnancy. Alas, in most cases only time will provide the answer.
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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.
•The IVF Journey: The importance of “Planning the Trip” Before Taking the Ride”
•Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•Recurrent Pregnancy Loss (RPL): Why do I keep losing my Pregnancies
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 am 39 years old patient at Sher NY and I have immune related problem.
We had two unsuccessful fresh 3day embryo transfer last year at facility C, and recently had two egg retrieval at Sher and we were able to freeze 3 normal (PGD tested) expanded blastocyst.
Prior to the transfer, we had immune test since I had two unsuccessful transfer in the past, and recently received a shocking news.
“Your immune tests show that you have:
1. Borderline elevated NK cell activity (13.5%) Normal is less than 10%; 11 to 14% is borderline)
2. A partial DQ-alpha match with your husband (You both have one type 4.2 but are different regarding the other one)”
After I received this result, I read
the article of your Blog about NK cell and DQa match. The more I know about it, the more I become hopeless.
Our transfer is scheduled in the end of January, and we are planing to treat it with prednisone 20mg daily and intralipids every 3 weeks until 16 weeks pregnancy. Hopefully it will work but it’s difficult to stay positive.
Would you kindly give me an advise, anything I can do to increase the possibility?
Thank you for your kind help in advance.
I think the articles on my blog say it all. Based on the above you do have an alloimmune , partial DQa match with NK cell activation. You need IL 20% dilueted in 500cc NS infused 10-14 days prior to ET and repeated every 2-4 weeks until the 20th week of pregnancy. In my opinion it is not likely to be successful with this treatment UNLESS it is combined with prednisone 10mg daily starting at the same time and tailed off after the 8th week of pregnancy and also provided only 1 embryo is transferred at a time (see below)…not 2.
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.
•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!
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
Iam 28 years old .This is our first IVF cycle.My egg retrival happened on (DEC 9 2016). 21 eggs were retrieved .Most of them were matured .Finally we got 11 embryos on day 6 .Dr told me we are going to 5 days transfer but we did it on 6th day because of embryo’s slow growth.So embroyo transfer happened on dec 15 2016 .2 embroyos were transfered remaning were freezed .Today (dec 21 2016) is my first beta after embryo transfer. I got my HCG level less than 2 my dr told me it supposed to be above 5 but he told me to repeat the test after 2 days . Right now it is technically negative will it become positive in second blood test ?If it is continued in negative what are all the possible reasons for this ?During the process he mentioned about my “Thin Uterine Lining” but my estrogen level were around 3000 before egg retrieval .If it is negative we have to try “Frozen Embryo Transfer” my question is what is the percentage of success in second cycle?
Thanks
Bavi
This does not look promising. I cannot predict how second transfer will do without knowing MUCH more about your case.
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.
•The IVF Journey: The importance of “Planning the Trip” Before Taking the Ride”
•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
•IVF: How Many Attempts should be considered before Stopping?
•“Unexplained” Infertility: Often a matter of the Diagnosis Being Overlooked!
•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.
Hi Dr Sher,
I am 33 Yrs old. I tried 3 IUI’s all failed. We tried IVF this cycle. We took a total of 900+900IU Gonal F and Menopour. Eventually i produced only 4-5 Follicles. out of that only 1 survived till day 5. We transferred and had implantation but now we have low HCG Day 9 – 28…48…78. The doctor advised us to stop progesteron and estrogen so that it will be chemical pregnancy. During egg retrival the doctor mentioned that he saw blood in one follicle and it was empty and mentioned that it could be endomitrosis. Could that be the reason for low HCG? What could we do next? one mor IVF or treat endometriosis?
Hi Dr Sher,
1 ) is it possible to miss a period if you don’t ovulate one month?
2) if you don’t ovulate one month and don’t get a period, will the chances of pregnancy be reduced in the following month, because you still have the old lining?
3) should you induce a period if you miss your period one month, or just wait until it appears naturally?
This is the first time this happened to me, and I am concerned why I don’t get my period (I had a negative hpt). I had an endometrial scratch cd22 this month but would assume this has nothing to do with a delayed period.
1 ) is it possible to miss a period if you don’t ovulate one month?
A: Yes indeed!
2) if you don’t ovulate one month and don’t get a period, will the chances of pregnancy be reduced in the following month, because you still have the old lining?
A: It is less likely that you will conceive if you do not menstruate about 2 weeks prior to ovulation
3) should you induce a period if you miss your period one month, or just wait until it appears naturally?
A: I would wait a while but if no period occurs after about 8 weeks, I would induce a bleed with progesterone and then take ovulation induction agents…discuss with your RE.
Geoff Sher