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.
Good afternoon, dr. Sher!
My daughter underwent 7-8 unsuccessful IVF. She is 42 y old, used donor’s eggs, her husband’s sperm, but the number of NK cells was 24000.. and probably this is the reason for the recurrent implantation failure. The last IVF was a failure again. ..Her doctor offered her Intra Lipids infusion before the transfer an 2-3 infusions after.. Is there any other immunology treatment she can go for?
Hi Petinka,
The concentration of NK cells is not relevant. It is NK cell activity as measured by the K-562 target cell test that matters. This can only be done in a handful of reproductive immunology reference laboratories in the USA.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, you previously advised that older women tend to have increased LH and testosterone requiring individualised protocol. Can this be checked via LH and testosterone blood tests? And if the blood tests show normal levels of LH and testosterone can standard IVF protocols then be applied?
Unfortunately not Sheena. Increased LH activity will not necessarily show up on blood tests. The reason is that LH is released in a frequent pulsatile fashion with peaks and valleys. Before blood levels rise the valleys need to be filled in and thus by the time blood levels reflect a raise…it is often far gone. Also, the tests do not measure the biological activity of LH which increases with age and progressive DOR.
Also testosterone produced in the ovary dilutes in the peripheral blood and is much higher in the ovary than in the blood. And it is the concentration of testosterone reaching the ovarian follicles that matters.
Geoff Sher
I am currently 38 and am undergoing embryo banking (ivf/pgd) since March of 2015. My RE says I am in perimenopause. I have an AMH of .33 and FSH is 11.5. April 2016 I had my first cycle and we retrieved 5 eggs, 3 fertilized and 2 were frozen on day 6. We used no birth control. Since then I have had 3 canceled cycles, all which included birth control and/or Lupron, leading me to believe any suppression is bad in my case. My AFC is always 6. I also had one cycle where I ovulated in the waiting room before my egg retrieval. I’m very disheartened at this point. I’ve been told I have low estrogen (I test around a 7 each month on day 3) and every month for two weeks I have awful symptoms such as migraines, nausea, vomiting, vertigo, extreme irritability, etc. I asked my RE if I could do an EPP and he reluctantly agreed. I started the 0.1 Vivelle patch on CD 20 (Dec 16) but only started to lightly bleed this past Monday Jan 10. I’m not sure if it was a period or not. I went in for an ultrasound and bloodwork today. Estrogen is 250 and progesterone <1. He says he is not sure where I am in my cycle and that I can either stay on or go off the estrogen patch and he'll retest me in a week. He keeps telling me to stop treatment because ivf will no longer work for me. I have no idea what to do. I have 2 cycles left that have already been paid for. Can you please guide me in the right direction? Should I stay on the estrogen patch? Try a different protocol? I do not want to give up until I've exhausted all my options. I keep researching options because I feel alone in all of this. Thank you so much in advance for your kindness!
Are nk cells in the blood different from nk cells in the uterus? I have an elevated nk cell cd45 of 3630 and cd3 of 2496 and have had rpl after ivf….do you think I require further immunology testing?
The concentration in the blood is irrelevant. It is uterine NK cell activity as measured by the K-562 target cell test and/or uterine cytokine activity that matters. The K-562 test can in my bopinioin only be reliably measured at 4-6 Reproductive Immunology Reference Laboratories in the USA. I preferentially use Reproductive Immunology Associates (RIA) in Van Nuys, CA.
Geoff Sher
Hi Dr. Sher,
I hope you had a wonderful Christmas and a very happy 2017.
I am conducting a research on female infertility. I am trying to determine the usage of different diagnostic procedures that are prescribed for women with infertility. Kindly help me in completing my research work by taking part in the 10-minute survey.
Survey URL: https://goo.gl/forms/9mvEkolDb1xPIT812
Thank you for taking out time to participate in the survey. I truly value the information you have provided, and your contribution will be acknowledged in the research work.
Once again I appreciate your time.
Best Regards,
Deepti
I cant promise that I can comply as I am absolutely overloaded. I do however, wish you well!
Geoff Sher