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.
I should add I have had an endometrium biopsy, after the first two surgeries that said my uterus is receptive. However I have had 2 more hsyteroscopies since then. Thank you 🙂
Hi Dr. Sher,
I am writing this in hopes you can give me some guidance. I have had a laparoscopy and 3 hysteroscopies to remove a full uterine septum. A brief breakdown: After the first 2 surgeries, I had 3 IUI cycles (1 chemical), followed by my first IVF round, fresh transfer (chemical), 1st frozen= negative. THEN followed by 2 more hsyteroscopies to remove residual septum. I did a 2nd IVF round, have just had 2 more failed frozen transfers. My doctor says the septum is gone and there isn’t any scar tissue. I really don’t know where to go from here and neither does my doctor. (I am already on my 4th doctor + clinic) I have made it quite clear that I have an extremely light period cycle now. Could this still be the cause? During my FET cycles, with heavy estrogen I am able to get my uterine lining up to 10mm. But naturally it is quite thin. Do you think my uterine lining has been so severly damaged from the surgeries that an embryo can’t implant? Have you ever seen this before? Any advice would be greatly appreciated. I am very active and a healthy bmi. I eat healthy and have tried everything to thicken my lining. I appreciate you taking the time to read this.
Hi Kathleen,
This is precisely why I (with a few exceptions) do not recommend septectomies for infertility. While a septum can result in mid-trimester losses and premature labor, it does not in my opinion cause infertility. This having been said, if you are indeed able to develop a .9mm estrogen-induced lining and a follow-up hysteroscopy or sonohysterogram has excluded scarring and other uterine lesions, then you probably have an unrelated cause for your IVF failures.
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
ANNOUNCEMENTS:
1. About my Retirement by mid-2018:
After > 30 years in the field of Assisted Reproduction (AR), the time has finally come for me to plan on retiring from full-time clinical medicine within a year. If you are interested in my medical services prior to my retirement, I urge you to contact my concierge, Julie Dahan ASAP to set up a Skype or an in-person consultation with me. You can also contact Julie by phone or via email at 702-533-2691/ Julied@sherivf.com. You can also apply online at http://www.SherIVF.com.
2. The 4th edition of my newest book ,
“In Vitro Fertilization, the ART of Making Babies” is now available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoffrey Sher MD
5320 S. Rainbow Blvd. Suite 302. | Las Vegas, NV 89118 |office: 702-478-1024
www. sherivf.com| Facebook | Twitter | Instagram | LinkedIn | Dr. Sher’s Blog
“Believe…In a Successful Journey from Infertility to Family”
I contacted you via this blog on 23rd March 2016 after a cycle of IVF for gender selection (we are trying for a girl after 3 healthy boys).
Despite responsing well to the medication (Gonal F), our embryos came back as follows and sadly, we didn’t make it to embryo transfer:
1 – Complex abnormal – unknown sex
2 – Abnormal +10 FEMALE
3 – Abnormal -16 FEMALE
4 – Normal MALE
5 – Normal MALE
6 – Abnormal +4, -9, +13, -21 FEMALE
7 – Normal MALE
8 – Abnormal -18 MALE
The embryologist suggested at the time that we may never be able to conceive a ‘normal’ daughter and of course we were very disappointed, however, you diagreed strongly with this and even suggested that one of the females (-16) may have autocorreced in the uterus?
We decided to try again and in March this year, we started a cycle on a slightly higher dosage of Gonal F (300 iu) in order to get more eggs, however, devastatingly, I failed to respond to the drugs and only developed one follicle that looked like it would release a decent egg. This was most strange, however, the consultant had used a drug called Medroxyprogesterone acetate to delay my period to accomodate travel plans, and since this is the only thing we did differently this time, I wonder if it may have contributed to the cycle being cancelled? He also instructed me to start the Gonal F on day 4 as opposed to day 2 as we did last year. This was due to the fact that they could not fit me in for the initial day 2 scan! He saw me on day 3, then advised me to start injections on day 4.
We have decided to try again using Menopur and my period is due next week. I am keen to hear your thoughts and am even considering getting on a plane and coming to you in Vegas if you think you can help! I am almost 38 and I understand my egg reserve to be low 🙁 My AMH in March 2016 (one year ago) was 1.82.
Financially, it has taken us a year to save and this may be our last chance.
Is there any hope for us? I would love the opportunity to be able to skype if possible?
I very much look forward to hearing from you.
Hi Diane,
I stand by my assertion that you can indeed produce female embryos with your husband…in fact you did so. It was very unfortunate that all the female embryos were aneuploid..but that was simply bad luck. Your subsequent responses to stimulation were in my my mind very possibly a function of preparation for the cycle of stimulation and the protocol applied and implemented.
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
•A personalized, stepwise approach to IVF
ANNOUNCEMENTS:
1.About my Retirement by mid-2018:
After > 30 years in the field of Assisted Reproduction (AR), the time has finally come for me to plan on retiring from full-time clinical medicine within a year. If you are interested in my medical services prior to my retirement, I urge you to contact my concierge, Julie Dahan ASAP to set up a Skype or an in-person consultation with me. You can also contact Julie by phone or via email at 702-533-2691/ Julied@sherivf.com. You can also apply online at http://www.SherIVF.com.
2.The 4th edition of my newest book ,
“In Vitro Fertilization, the ART of Making Babies” is now available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Dr Sher,
If doing 300 of Gonal F do you still only recommend using 75 of Menopur? Would the ratio of FSH:LH be too low?
Yes I would so recommend!
Geoff Sher
Can you be over suppressed by an immune protocol such that it could DIMINISH your chances of success? I think my immune results are somewhat inconclusive, but I have had 4 chemical pregnancies, 3 of them with PGS tested embryos, so my doctor is prescribing prednisone & IVIG. Besides the cost and side effects (both of which I understand), are there any DOWNSIDES from a success rate standpoint of taking these if it’s not clear they’re NECESSARY. can they only help, not hurt is the question?
I do not believe it would jeopardize in any way!
Geoff Sher