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, i will be 42 in a few days. i had 3 IVF/ICSI cycles with own eggs and sperm of my husband, who is 56. at 40 and 1/2 i had a normal ovarian reserve (or so i have been told: fsh 8,41, amh 1,76, estradiol 50). my first IVF cycle ended with a m/MC at 7,5 weeks caused by a triploidy, the embryo was always measuring 10 days behind.
second IVF cycle failed, and third I am pregnant again, now 9 weeks. my embryos were always top quality.
since my two scans now gave again measurement few days behind (at 6+4 it was 6+1, at 7+6 it was 7+4, with good heartbeat though) i am worried of another miscarriage or an aneuploidy.
i think my odds are very high. what can i expect? is the measurement slightly behind a sign of increased odds of aneuploidy? is the age of the father also contributing, and how much? does the ovarian reserve give any hint on embryo odds of aneuploidy, besides age? thank you
The risk of aneuploidy is age-related. The few days lag in growth does not necessarily mean that the conceptus is aneuploid. Only time and testing through blood, CVS and/or amniocentesis will/can provide a definitive answer.
I wish I could be more specific but alas, I cannot!.
Good luck and G-d bless!
Geoff Sher
Good Day
Could you please help me, I am in South Africa and none of the doctors I have seen have been able to help me. Could you please give me any advise or suggestion please. I am 35, no tubes
Ivf 1 May 2014 – Zoladex, Menopur Cancelled D6 Oversurpression E2 44
Ivf 2 June 2014 – Antagonist Menopur, Cetrotide – M3 D2-D4, M2 D5, M3 D6-D9.
D8 ET 8.3mm E2 1498 LH 3.3 Prog 2.4. Left ovary only – 4 oocytes, 3 fertilised IVF, Transfer 8CG1 and 6CG2. Bleeding started 7 days after transfer
Ivf 3 September 2014 – Antagonist Pergoveris, Cetrotide, Utrogeston – P2 D2-D8
D9 ET 11.6 E2 2923 LH3.0 Prg 2.4. Left ovary only – 6 oocytes, 4 fertilised ivf, transfer 3AA and morula
Bleeding starts 7 days after transfer
Ivf 4 December 2014 – Antagonist Pergoveris, Cetrotide, Cycogest (double dosed) P2 D2-D8
I don’t have blood results. Left ovary only – 7 Oocytes, 6 fertilised Ivf, Transfer 3AA + 3AB froze 2 (early blast and a 2ab I think)
Bleeding starts 7 days post transfer
Fet 1 – Thaw unsuccessful
order test May 2015– Prolactin, S-TSH, Lupus, Protein C, Protein S, ATIII – All Negative except Cardiolipin Igm – 18 (Equivocal)
Ivf 5 March 2016 – Mini Cycle Menopur and Clomid – 6 oocytes from Left ovary only, IVF – zero fertilisation
Donor Egg Cycle – 21 Retrieved, 11 Mature, 10 Fertilised ICSI, Transfer 2 top quality blast + gestone and estrogen tablets – Beta Negative
3 Frozen
FET – 1 didn’t survive and 1 top quality transferred + gestone and estrogen – Beta negative
I still have 1 x fair quality blast frozen
I and my entire family just returned from a 3 week vacation in South Africa. Had a wonderful time. I had not been back for over a decade. The change was palpable and very impressive, especially as far as race relations is concerned.
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. Is it possible for an embryo to take it’s sweet time in completing the implantation process and thus causing to measure behind at a later ultrasound? I had 2 x blastocysts transferred and had an extremely faint positive home pregnancy test at 5dp5dt – but it remained faint for a week and then started darkening. My HCG blood tests reflected this as well: 9dt: 52 – 11dt: 56 – 13dt: 87 and then skyrocketed and proceeded to double every 30-35 hours. Jump forward to my ultrasound at 6 weeks 4 days and all we could see were two small circles, one of which was measuring 5mm (the other was not measured but looked the same). I’m assuming one or both is a gestational sac however my specialist did not explain what she was seeing and told me to await miscarriage. Blood was taken on this day and HCG measured 12,642 – still doubling within 35 hours.
Is it possible I could just be measuring behind due to the slow HCG start?
Hi Nicole…Anything is possible, but very frankly, this does not look very promising/encouraging. Give it a week and repeat the ultrasound. This should provide a definitive answer.
Geoff Sher
Hi Dr. Sher,
I am 29 years old and my husband 31. After going through testing, we found that both of my tubes were damaged, I have low AMH (.39) and my husband low morphology. I have been happy with my clinic, however am struggling with my results so far. This is our first cycle, and I was treated with a somewhat aggressive stim protocol due to my low AMH. I was not put on BCP, began with Lupron (20u) up until my cycle began, then reduced to 5u on CD3 and added in Menopur (3 vials in AM and 3 vials in PM). On only day 5 of beginning Menopur, my scan showed that my right ovary was responding too quickly. I had three lead follicles that were ready to be retrieved. The others were lagging behind quite a bit (I had four smaller ones on the left, and I believe 5 total on the right, but only the three ready to be retrieved). I was given the option to cancel or continue, but our doctor was suggesting we continue and try our luck since we are young. I have agreed to do so but am feeling discouraged by this. I was told that there wouldn’t be a huge change in protocol and that I run the risk of this happening again. We are definitely willing to see what this round brings us, however I am wondering if there is perhaps another protocol you think could yield better results. Thank you for your time!
Hi Dr. Sher, I am a 31 year old female with no fertility problems (we are dealing with male infertility) and we are planning on having a FET next month with a donor embryo. Since I have a very regular cycle and everything looked great in my internal ultrasound, we are planning a mostly natural transfer with just a trigger shot and progesterone after the transfer. To get me on the same cycle as my clinic, we are planning on me going on birth control for a week or so when I start my January cycle and then about 12 days after I go off birth control, I will have the trigger shot if all looks good. I’m a little nervous about this as I have never been on birth control. Do you think the birth control will affect my natural cycle in any negative ways that might affect the embryo’s chances? Thank you in advance for your reply!!
Very respectfully Hannah, I am very skeptical about such an approach. In my opinion, it is going to be extremely difficult to establish an ideal implantation base using such an approach and hard to pinpoint an ideal window of implantation, both critical to a successful cycle.. I would urge you to consider using a well orchestrated hormone replacement cycle.
Good luck!
Geoff Sher