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.
Hello Dr Sher,
I have been trying to concieve for over a year now. I have a daughter that is seven now and when I concieve her it was simple. I am now 34 and I have been on birth control for 6 years. I stop taking bc hoping to become pregnant and it didn’t happen in fact for the 1st 3 months after stopping my bc my menstrual came then it has stop!! I went to the GYN I was put on progrestone to make my cycle come and it did then I found out that I’m not ovulating so I was put on Clomid 50mg that didn’t work so that dose of Clomid was upped to 100 mg and again no pregnancy because that didn’t work so recently I was put on 150mg of Clomid I got to give blood work in a couple of day and hopefully it works . My GYN is telling me my body is basically screwed up because I’ve been on birth control for so long . If this round of Clomid doesn’t work she would like for my to see a fertility Dr. My question to you is do u think my body will ever return back to Normal with a menstrual cycle monthly with ovulation so this pregnancy can happen? My fear is that I will be too old to concieve at least two more children!! Please HELLPPP!!
It could return to normal ovulation but it could take time. I would follow the advice of your doctor and see a fertility specialist because you might need injectable gonadotropin fertility drugs with or without intrauterine insemination.
Good luck!
Geoff Sher
Hi Dr Sher, I have written here before and have been grateful for your advice and recommendations. I am a physician in Sydney, Australia currently in the IVF process.
Just to repeat our background: I am 34, husband is 40. Our only diagnosis which led to IVF was MFI. Husband had a vasectomy reversal in December 2014. Initially his count rose to about 8 million but subsequently dropped and has remained about 1-2 million with very low motility. DNA fragmentation test was within normal ranges.
All of our IVF cycles have been antagonist cycles:
July 2016- ICSI- 13 eggs collected, 11 mature however only 3 fertilised. 2 were on track on Day 3 but then all arrested and transfer was cancelled. In retrospect the only issue identified was that my LH dropped to almost 0 with introduction of antagonist.
September 2016- ICSI- we reduced the gonal f and antagonist doses and supplemented with LH. 14 eggs retrieved, 10 fertilised, most on track on day 3. By day 5 we had 2 early blasts of top grade. 1 transferred but resulted in chemical pregnancy. 1 frozen
October 2016- planned for natural FET. Unfortunately embryo did not survive the thaw process and transfer was cancelled.
Your advice at this stage was to double my trigger to 500 (my specialist had also recommended this). My specialist also made the decision to trial a new growth medium.
November 2016- ICSI- same doses of gonal and antagonist, plus LH supplementation, then Ovidrel 500 trigger. 19 eggs collected- all mature, 13 fertilised. 5 considered on track and good grade on Day 3 (another 2 were considered too fast growing as 9A and 10A). We transferred two 8 cell A grade embryos on day 3 (there were some concerns that I had mild to mod OHSS but the transfer proceeded). Result was negative. 3 early blastocysts, all grade A were frozen.
January 2017- Natural FET (no meds/supplements at all), transferred 1 blastocyst. It survived the thaw, was still grade A and was expanding up until transfer. At time of transfer they said it was pulsating which was indicating that it was getting ready to hatch. Unfortunately this also resulted in a negative.
We now have 2 early blastocysts grade A left in the freezer.
My questions are:
-What do you think the chance of these 2 blastocysts resulting in a live pregnancy, given the lack of success with 3 other embryos from that batch?
-Our third cycle with the double trigger seems to have provided the best result so far, and I asked my specialist if that is likely due to the double trigger. He seemed to think that it is all completely chance and that we were just lucky to get a better batch of eggs that time? Do you agree?
-My husband and I are starting to struggle with the process and I think would like to transfer the 2 blasts together (if they both survive thaw) rather than go through 2 more cycles. If that is unsuccessful we will go through with a 4th cycle. Do you think there is anything else we should consider changing for the 4th cycle? Should we think about changing clinics?
-With natural FET do you think we should have had progesterone supplementation?
Thank you for your time and advice, it is greatly appreciated.
Your relatively young age is certainly not an issue, your ovarian reserve is clearly adequate, and I do not think thatb your husbands sperm is an issue (provided ICSI is done. In my opinion, it is far more likely that your woes are (at least in part) attributable to either the protocol used for ovarian stimulation, its implementation or the timing of the hCG (Ovidrel-500) trigger. By way of but a few examples, if you are launching a late antagonist suppression cycle coming off a BCP….this in my opinion could be problematic (see below.”..use of the BCP in IVF”) and if because of the fear of OHSS developing you are deliberately being “triggered” early to avoid overstimulation,…… it is quite possible that your follicles/eggs are underdeveloped and not ready for the trigger. These are but a few possible flaws to be aware of.
Finally, in my view, you should not ignore the possibility of there being an implantation dysfunction. This should be carefully assessed before you go any futher. And if you do another fresh IVF cycle, you should include PGS in the process.
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
•Use of GnRH Antagonists (Ganirelix/Cetrotide/Orgalutron) in IVF-Ovarian Stimulation Protocols.
•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
•Preimplantation Genetic Testing (PGS) in IVF: It should be Used Selectively and NOT be Routine.
•IVF: Selecting the Best Quality Embryos to Transfer
•Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
•PGS in IVF: Are Some Chromosomally abnormal Embryos Capable of Resulting in Normal Babies and Being Wrongly Discarded?
•PGS and Assessment of Egg/Embryo “competency”: How Method, Timing and Methodology Could Affect Reliability
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.
Doctor in the AACP the gonadotropins and cetrotide stims begin the day menstruation begins even if is brown first spotting or wait to the second day with blood Flow to start stims?
It wont matter whether you start immediately with spotting or with full flow, provided that an ultrasound is done and shows that there are no ovarian cysts and that your blood estradiol level is <70pg/ml or 200pmol/L.
Geoff Sher
Dr Sher,
Thank you for your responses, they are invaluable. I have two questions for you:
1. For FET, what is the progesterone cut off for cancelling transfer? My RE says if it goes above 2.7 she will cancel.
2. I’m 5′ tall and 105 lbs, would transferring two embryos be too risky given how petite I am?
Thank you again!
1.. For FET, what is the progesterone cut off for cancelling transfer? My RE says if it goes above 2.7 she will cancel.
A: That should not really apply with FET because in my opinion the raised progesterone in my opinion is more an indicator of premature luteinization affecting egg/embryo quality than of the effect on the endometrium.
2. I’m 5′ tall and 105 lbs, would transferring two embryos be too risky given how petite I am?.
A: I personally transfer up to 2 embryos at a time …but not more. I do not thin height is the determinant of an ability to carry twins. But transferring 1 embryo at a time, while reducing the chance of success per ET will not affect the overall chance of any embryo from implanting and the cumulative chance of success will likely be the same.
Geoff Sher
2. I’m 5′ tall and 105 lbs, would transferring two embryos be too risky given how petite I am?
Hi, I wonder if you could tell me whether you think it is worth doing microsort for gender selection?
No! In my opinion it will not improve gender bias in IVF.
Couples have for centuries sought to influence the gender of their offspring. More than seven centuries ago the ancient Chinese developed a birth calendar said to be able to predict gender on the basis of when conception occurred. Later, the ancient Greeks suggested that by lying on her right side during intercourse, a woman could improve the likelihood of having a male child. And 300 years ago, the French suggested that placing a ligature around the right testicle would improve the chance of having a male child.
More recently in the U.S., methods such as timing intercourse, assuming different positions during sex, and (relatively recently) employing rapid sperm centrifugation in an attempt to separate male chromosome-bearing sperm from female sperm prior to artificial insemination were proposed. The fact is that none of these (as well as many other) such anecdotal assertions have been shown to have any real validity.
Currently, in spite of several well described medical approaches, the indisputable fact has emerged that it is only by way of IVF that reliable sex selection can be achieved. This allows for embryos to be screened for gender through preimplantation genetic diagnosis prior to transferring the embryo(s) of the desired gender to the uterus.
Nevertheless, it is an inescapable reality that the very idea of medical sex selection challenges moral and ethical beliefs at their very foundation. Many hold that the growing popularity of gender selection solely for the convenience of altering a family’s gender balance represents an unwanted example of how assisted reproductive technology is subject to abuse…and thus it should be outlawed. They also see it as an example of a disturbing trend towards “designer babies” where genetic engineering could be used to manipulate the intellect, body configuration, build, height, and the talents of future offspring. This assertion is commonly followed by the tantalizing question as to where all this would end and whether we as a society “would really want to live in such a world.”
There is, however, one clear exception to the apparent across-the-board opposition to sex selection that is well worthy of mention. This applies in cases where sex selection is used to avoid the occurrence of a serious medical disorder that selectively affects one gender or the other (e.g., Hemophilia, a life threatening bleeding disorder that selectively affects male offspring).
EVALUATING CURRENTLY USED METHODS FOR SEX SELECTION
SPERM GRADIENT METODOLOGY (discredited because of a lack of reliability)
This is one of the simplest methods that still (unfortunately) remains in widespread use. Here sperm is rapidly spun down (centrifuged) in the hope of separating the male sperm (those with Y-chromosomes) from the female sperm (those with X-chromosomes). It relies on the assumption that the X chromosome makes sperm heavier, allowing for separation of male from female chromosome-bearing sperm. Though this method is often touted as a low cost method for sex selection, the truth is that it simply does not work!
LOW CYTOMETRIC TESTING BY THE MICROSORT METHOD (discredited because of a lack of reliability)
This method which is now somewhat discredited by the FDA employedthe use of a fluorescent dye that adheres to genetic material within the sperm. It was based on the premise that because X-bearing sperm contain more genetic material, these sperm were supposed to pick up more dye than Y-bearing sperm. Thereupon, X and Y bearing sperm are then separated into two groups and used for intrauterine insemination (IUI) or IVF. This method was touted as yielding a 60% to 70% accuracy rate with IUI. This has not been adequately confirmed and in my personal experience its reliability in the IVF setting has been questionable to say the least. The Microsort technique is to my knowledge not presently being offered in the United States.
IVF using PREIMPLANTATION GENETIC DIAGNOSIS (PGD)
Preimplantation Genetic Diagnosis (PGD) involves the removal of one or more cells from an embryo, for chromosomal or genetic analysis. The most widely used and he most reliable PGD method for gender selection is fluorescence in-situ-hybridization (FISH). However, this technique does not identify all 23 pairs of chromosomes in the embryo’s cells. At best it can well identify 12. Thus, while FISH provides an excellent method for gender selection and for identification of structural chromosomal aberrations, it is not a reliable method for diagnosing embryo aneuploidy (“competency”). Conversely, another PGD method, next generation gene sequencing (NGS) which does assess all the embryo’s chromosomes can be used for both detecting all the embryo’s chromosomes and thus can determine embryo “competency” reliably. It also reliably identifies gender. However, while NGS is very bit as reliable as FISH for gender selection, FISH can be done in fresh cycles (i.e. the ET is done in the same cycle as that in which the ER is done), while NGS requires time for testing that requires Staggered IVF (St-IVF) in which the embryos are biopsied on day 3 or day 5-6 (post-fertilization) and the blastocysts are ultrarapidly frozen (vitrified) and allowed to proceed in culture to blastocysts whereupon they are ultra-rapidly frozen (vitrified) and are then held for transfer in a subsequent cycle.
Upon completion of FISH, which takes about 24-36 hours, the couple can select which embryo(s) they will transfer to the uterus. If pregnancy results, there is almost a 100% chance it will result in the desired gender. If NGS is used, the degree of accuracy in diagnosing gender, is as reliable as is FISH but in addition, NGS provides information on the entire karyotype (all 23 pairs of chromosomes) which is extremely beneficial because it assesses embryo “competency, while FISH does not.
A PERSONAL OPINION:
Sex selection done purely for family balancing is somewhat controversial, raising concern that if widely accessible and freely available, such practice could distort the natural sex ratio, leading to a population gender imbalance. However, for this to happen, there would have to be a significant population preference for sex selection. In reality, the contrary seems to apply, since studies conducted in western societies discount these concerns. In fact, the relatively high cost of IVF with the added cost of gender selection in the United States makes it unlikely that the demand would ever become large enough to impact overall population gender balance. In addition, several studies done in Western countries have shown that the majority of people do not seem to be concerned about the gender of their offspring, and that with a few notable exceptions, gender preference does not appear to be slanted in the direction of either male or female. Thus, from a practical standpoint, such concerns are overstated.
Given that in the United States most couples do not care about the gender of their offspring, and only a minority are interested in selecting the sex of their children there is currently no risk that IVF sex-selection will impact the population gender balance. Thus, in my opinion by and large, freedom of choice should prevail and a service for sex selection should be freely available
So, in my personal practice, I absolutely do offer gender selection in the following circumstances.
•Medical Indications for Gender Selection:
oFor cases associated with
?sex-linked genetic disorders or,
?serious genetic disorders that are more likely to occur in one gender or the other.
•Non-Medical Family balancing
o For couples who have at least one child of the opposite gender to that which they choose for their IVF embryo transfer and,
oFor those women who do not have any children at all but prefer to have a child of one or the other gender.
Good luck!
Geoff Sher