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,
Thank you so much for your blog – it has been invaluable to me!
I am a healthy 31 year-old woman. After struggling to get pregnant for 2 years, I have now had 2 recurrent miscarriages (both natural cycles, the last mc was September 2015). I have been tracking my cycles for almost 3 years now, and they are very regular (always the same length, I always ovulate on the same day, but my luteal phase is only ever 7 days long). There is no male-factor infertility, but I have a low amh of 0.8 (fsh is 7). My mid-luteal progesterone (which for me is not as much mid-luteal as it is the day before my period) is low at 8 ng/ml.
I am now pregnant again after my first IUI cycle (medicated). I started progesterone supplementation (200mg Prometrium as a vaginal suppository once/day) 2 days after IUI. At 4wks 1 d my hcg was 138 and progesterone was 7.4. I was given an injection of 100mg progesterone in oil IM, and my Prometrium was doubled to 400mg (vaginal suppository) once/day. At 4 wks 3d my hcg was 442, and at 5 wks my hcg was 3052, progesterone 11.7. I am now 5wks 4d, and am starting PIO injections, 100mg IM every other day (in addition to the 400mg Prometrium daily). Does this seem like an excessive amount of progesterone supplementation? I am very concerned that I will miscarry again. I am also on levothyroxine sodium (TSH was 2.9 right before becoming pregnant) and aspirin (81mg/day). Thank you so much for your help!
Your doctor seems to have taken appropriate measures and at present there is probably no more that can be done. You have to wait it out. An ultrasound about 1 week from now followed by serial weekly repeat examinations should help evaluate what is happening. I am guardedly optimistic for you!
Geoff Sher
My wife and have gone through 4 Ivf cycles and one preg out of those 4 which ended up with a loss at 20 weeks prior to 2014. We never were givena reason why or what was wrong with us. I never got tested other than low sperm count.every cycle he just does a 3 day cycle and no results. We decided to leave our RE and switch to someone who has more known success hoping for results.so we did our 5th cycle in 2016 of January. We performed a TESE with a male fertility DR on me to extract better semen, he said my DFI was around 35 I think. I was excited thiking it was me the whole time causing the infertility so the tese would fix our issue. she ended up with 13 follicles, 6 eggs and only 2 matured. In the end none of them fertilized and we didn’t end up putting them inside her, because we had paid for genetic testing. Our whole cycle we paid for covers up to two tries/cycles
We still have one more to try, not sure what we want to do. In our hearts we want our child but would donor egg be a better option?
Just feels like we spent more of our 20s saving and trying..we are 30s now and have nothing but a 20 week loss to show for it. Our RE says our problem is maturity of the eggs and he can fix it by pushing her 1 or 2 more days. This past cycle we did Stims for 13 days. Is this something that RE normally do in these situations? Our history of IVF we have done 5,8,9,10,13 days on stims and all has resulted in immature eggs according to our our first RE and second RE.
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).
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?
•Frozen Embryo Transfer (FET): A Rational Approach to Hormonal Preparation and How new Methodology is Impacting IVF.
•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
•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
It’s ridiculous. I am 45 (46 in June). I have two beautiful girls I conceived with no troubles at 35 and 37. In a hormone-fueled third trimester, I made the horrible decision to tie my tubes after a cesarean delivery. I regretted it while still in the delivery room.
At 44, I started pursuing IVF. But, after a family tragedy in March last year, I put the treatment on hold. At that time, I had an AMH of .21 and 7 follicles. My cycle is still relatively consistent with a short or long cycle occasionally.
The incredible yearning to have another child has not waned. Now, I want to pick up where I left off; I’m sure my outlook is much worse.
I have read stories (albeit, few) of women my age having success with IVF and mini IVF. Is Mini IVF a viable option? Is IVF in general a futile attempt to have a third child? What will it take? Donor eggs are not a good fit for our family. Finances are limited.
Thank you for any encouraging advice.
Hi Juliana,
IVF at 45y with own eggs is a very long shot. This is because of the inevitable age-related decline in egg chromosomal integrity. At 36Y about 1: 4 eggs can be expected to be competent while at 45 only about 1:20 are normal. Then there is the likelihood that with advancing age the number of available eggs left in your ovaries will have declined leading ro diminished ovarian reserve and poor response to fertility drugs. Mini-IVF is not in my opinion an answer .It will only reduce the low chance even further.
If you insist on using own eggs, then time is a big issue. a delay of even 1 additional month would significantly reduce your chances even further. As long as you recognize these facts, I would be prepared to try. This would require IVF with embryo banking of PGS normal blastocysts to improve the efficiency of the process. Stimulation would involve a robust, modified long pituitary down-regulation protocol (an Agonist-antagonist conversion protocol) with human growth hormone (HGH) augmentation…see below.
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?
•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 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
•Traveling for IVF from Out of State/Country–
•A personalized, stepwise approach to IVF
•The Role of Nutritional Supplements in Preparing for IVF
•Measuring and Interpreting Blood hCG to Assess Pregnancy Viability Following ART Treatments.
•IVF Egg Donation: A Comprehensive Overview
•Human Growth Hormone (HGH) Administration in IVF: Does it Enhance Egg/Embryo Quality and Outcome?
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
I implanted 2 five day blasts during my first IVF cycle on Feb 18th. Several days after and ever since I had very minimal spotting and cramps. Today was my beta HCG at 2 weeks later. About 8 days ago I had dark red notable blood and assumed my period was starting but it hasn’t. My hcg result was 8 which seems relatively low from what I’ve been reading. I’m on progesterone injections daily through the entire process. Could the embryo have implanted later than normal explaining the low rate. Should I be concerned?
Hello Dr. Sher! I have a question regarding NK killer cells. I had a frozen transfer with 2 5 day blasts. Lucky for us it was successful and I am now 4 weeks and 3 days. Unfortunately I am very ill. I had the intralipids before the transfer and have had the second infusion since the positive pregnancy test. I also take .075 dexamethason daily. Is this just good old fashioned morning sicknesses, which really lasts all day, or is there a possible connection with my immune system trying to fight against me?
Hi kelly,
I of course have no way of knowing for sure , but this sounds like morning sickness. However, if you are vomitting profusely, you need to be unde medical treatment because it can be dangerous.
Good luck and G-d bless!
Geoff Sher
Dear dr. Sher,
I am Dutch so maybe some medications are named differently here, I hope you understand.
I have an extreme form of PCOS (29 years old, AMH of 30, no ovulation, lean, lots of follicles, normal hormone levels) so ovulation induction and IUI didn’t work for me because there was no growth or too much growth.
Last year I started with IVF and the first round was ended before the egg retrieval because of overstimulation. The second attempt was short protocol but growth was really slow (I used gonal f for 23 days before egg retrieval, after a week combined with Orgalutran).
At egg retrieval there were about 20 big follicles (>18mm) and a lot of small ones but the outcome was not as expected: only 4 eggs and only 1 of them was mature enough. This didn’t result in a pregnancy so I am now starting with my next attempt.
I am taking Metformin for about 3 weeks now and yesterday I started with Menopur instead of gonal F because of low LH levels last round (which is strange in women with PCOS right?). Do you think this can be the right method for me or do you have any tips I can offer to my gynaecologist?
Thanks so much!
It would be presumptuous of me to offer any tips to your personal RE. This can be very tough to treat. There is an ever present risk of OHSS and also if you reach egg retrieval, a very increased risk of egg aneuploidy. The low yield of eggs, in spite of numerous follicles, is due to the fact that often, very severe and complex egg aneuploidy prevents eggs from releasing at the time of egg retrieval (see the article below on “empty follicle syndrome”). In my opinion, cases like yours require a very individualized approach to ovarian stimulation which included the timely implementation of “prolonged coasting”.
My approach is consistently to use a long pituitary DR protocol with an agonist, coming off 1-2 months on the BCP. The latter is intended to lower LH and thereby reduce stromal activation (hyperthecosis) in the hope of controlling ovarian androgen release. I then stimulate with low dosage FSHr to which I add a smidgeon of LH/hCG (Luveris/Menopur) from the 3rd day and watch for the # of follicles and [E2] starting on the 7th day of COS. If there are > 25 follicles, I keep stimulating (regardless of the [E2] until 50% of all follicles reach 14mm. Then, provided the [E2] is >2500pg/ml, I stop the agonist and the gonadotropin stimulation and follow the E2 (only) daily, without doing further US examinations. The [E2] will almost invariably climb and I watch it go up (regardless of how high the concentration of E2reaches) and track it coming down again. As soon as the [E2] drops below 2500pg/ml (and not before then ever), I administer 10,000U hCGu or hCGf (Ovidrel/Ovitrel-500mcg) as the “trigger” and perform an egg retrieval 36h later. ICSI is a MUST because “coasted” eggs usually have no cumulus oophoris and eggs without a cumulus will not readily fertilize on their own. All fertilized eggs are cultured to blastocyst (up to 6 days). And up to two (2) are transferred transvaginally under US guidance.
The success of this approach depends on precise timing of the initiation and conclusion of “prolonged coasting”. If you start too early, follicle growth will stop and the cycle will be lost. If you start too late, you will encounter too many post-mature/cystic follicles (>22mm) that usually harbor abnormally developed eggs.
Use of the above approach avoids unnecessary cycle cancellation, severe OHSS, and optimizes egg/embryo quality. The worst you will encounter is mild to moderate OHSS and this too is uncommon.
I do not use antagonists in high responders (e.g., PCOS) because it interferes with the assay of E2 (often causing the value to be understated), a valuable index in assessing risk for the development of severe/critical OHSS. I also do not believe in the agonist trigger to prevent OHSS. The reason is that the magnitude of the induced LH surge varies and if too little LH is released, meiosis can be compromised, thereby increasing the oocyte aneuploidy index.
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)
•Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
•The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
•Frozen Embryo Transfer (FET): A Rational Approach to Hormonal Preparation and How new Methodology is Impacting IVF.
•Implications of “Empty Follicle Syndrome and “Premature Luteinization”
•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