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.
Dear Dr Sher,
I got tested for APA, RIP AND NK cells.
AntiPhosEth IgM came back high 26 U/mL 0-15
and NK cell 12.1 H <10
I have a FET scheduled for next month. My Dr recommends doing IVIG, I have heard of intralipids and other treatments like the ones you mentioned here but she says because of my results this will be the only one that would work. Do you recommend the same? Also, they said I should do it the day of the transfer which I think may get me nervous but they don't want to do it earlier without confirming the embryo quality. Please advise. Thanks in advance
Hi Lauren, I respectfully submit that in this day and age, IL is as effective as IVIG. It certainly sounds as if you have an immunologic implantation dysfunction . perhaps we should talk.
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.
•Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
•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
•Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas
•Should IVF Treatment Cycles be provided uninterrupted or be Conducted in 7-12 Pre-scheduled “Batches” per Year
•A personalized, stepwise approach to 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.
Dr Sher
I found out today that my fouth FET was negative. I had grade A embryos this time around. First time I had a BFP was in a clinic in India where they transferred two day three’s and also a day 5 all in one fresh cycle. This cycle caused hyperstimulation and at 6 weeks I miscarried. Second time around we did a transfer of two 5 day embryos in a natural and frozen cycle which were negative results.
So with these negative results how do I proceed? Is there a problem with my endometrium. Or progesterone levels. Not sure where to go from here so lost and frustrated.
Hi Dr Sher,
I am somewhat of a “seasoned IVFer” as I have been through 8 embryo transfers – 2 fresh and 6 frozen.
I have high AMH (13.1) though no other signs of PCOS besides high antral follicle count, and a history of severe OHSS (37 eggs retrieved my first cycle). The 3 FETs from that first cycle resulted in no babies.
But my second IVF cycle (long lupron with low and very closely monitored puregon/menopur – decreasing the puregon later in the cycle and increasing menopur totalling 15 days – max E2 of 4,500) gave me 17 mature eggs which all fertilized and my two daughters (full term) (through a fresh cycle and subsequent frozen cycle with a failed frozen cycle between them).
I just came out of my third full cycle with a new RE who put me on an antagonist protocol and kept my dosage consistently at 75 gonal f/75 menopur for 11 days. I didn’t end up with OHSS as there were far fewer mature eggs (8/15 retrieved) even though my E2 hit 6,000. 7 of the 8 fertilized but only 3 embryos became blasts 4bb, 4bb and 4bc, and after two transfers (1 fresh 1 frozen) I have no babies from that cycle – the FET ended in a chemical pregnancy with a beta of 19.
Does this suggest that the protocol was not correct for me? Should I try again with a long lupron protocol? Or do we just make poor embryos? Should we consider PGD/PGS? To me, the fact that our second cycle was so successful tells me we should be able to have another, but my history of 6/8 transfers with no success makes me think maybe we have a quality issue?
I don’t know what to consider from here.
PS- I am 32 with a BMI of 20 and our initial issues were/are my husband’s antibodies post vasectomy reversal. We have used icsi in every cycle.
PS – we used 10,000 units of hcg to trigger in all 3 cycles.
It certainly sounds like a protocol issue to me. I even suspect that you were either triggered with an agonist such as Lupron or buserelin or you were given 250mcg Ovidrel or 5,000U hCG. In women who overstimulate there is also often a tendency to trigger too early to arrest the stimulation before it becomes pathological. That too can adversely affect egg quality. Either way, the most important determinant of egg/embryo quality is age, ovarian reserve and the protocol used for ovarian stimulation.
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.
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.
•Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
•Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas
•Should IVF Treatment Cycles be provided uninterrupted or be Conducted in 7-12 Pre-scheduled “Batches” per Year
•Preventing Severe Ovarian Hyperstimulation Syndrome (OHSS) with “Prolonged Coasting”
•Understanding Polycystic Ovarian Syndrome (PCOS) and the Need to Customize Ovarian Stimulation Protocols.
•“Triggering” Egg Maturation in IVF: Comparing urine-derived hCG, Recombinant DNA-hCG and GnRH-agonist:
•The “Lupron Trigger” to Prevent Severe OHSS: What are the Pro’s and Con’s?
•Intrauterine Insemination (IUI): Who Needs it & who Does Not: Pro’s & Con’s!
•Micro-IVF: Often Preferable to Ovarian Stimulation with or Without IUI
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.
Hello,
I have had 4 total failed fertilization ICSI cycles (including AOA) and the doctors now believe it may be an oocyte cytoplasmic maturation issue rather than a sperm issue. Can this be overcome naturally? I just turned 32 and all tests have come back normal for me.
Thanks
Hi Nelly!
I would need a great deal ,of information to answer your question authoritatively. However, I can tell you that, depending on circumstances, the protocol used for ovarian stimulation can play a huge role in dictating egg competency.
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.
•Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in 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.
Also in am not underweight infact if anything i have put on significant weight 5’7″and 164lbs. So is it still likrly to be hypothalamic amenorrhea?
It could be PCOS but given the information you provided in your post, it is in my opinion possibly hypothalamic.
Geoff Sher