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.
Dr Sher,
What are your thoughts on Menopur vs Luveris? Luveris doesn’t have the HCG and may be more consistent in LH dose because it’s recombinant.
It is an excellent replacement. Only it is not available in the U.S.A…That is why I use Menopur.
Geoff Sher
Hi Dr. Sher,
I am at quite a loss so would greatly appreciate any advice.
First off, I’m in South Africa so there is no testing for NK cells or an ERA.
Background info and suspected reason for infertility is in 2012, stage 4 endometriosis was removed by an inexperienced Dr, which resulted in a bowel perforation. A hernia repair was required a few weeks later. And finally in 2014 a subphrenic abscess removed, not endo. Fortunately have found an endo specialist, who given my history, feels a laparotomy is not warranted. I am now 35 years old and hubby is 46 years old but as per genetic testing, I doubt there is an issue with embryo quality.
Aug 2016, fresh transfer with untested embryo = negative.
October 2016 – changed to PIO, had a scratch and embryo glue, added immunoglobulin = negative.
Jan 2017, second retrieval with embryos sent for PGS and 6 out of 8 normal.
Feb 2017, hysteroscopy – myoma removed and superficial adenomyosis discovered.
March 2017 – FET as above with 2 tested embryos = negative.
Current FS ran further testing on antibodies which came back clear but he recommends adding intralipids and Clexane next time.
Went for a second opinion and new Dr recommends having the HSG x ray to determine whether or not my tubes are blocked and possibly causing trapped fluid. Also sees adeno on my US and, depending on dye test, suggests Lucrin to reduce adeno and endo before transferring again.
Thank you!
This sounds highly suspicious of an immunologic implantation dysfunction linked to your endometriosis.
You can have the testing done at ReproSource in Boston, MA. This is essential before proceeding any further.
More than half of women who have endometriosis harbor antiphospholipid antibodies (APA) that can compromise development of the embryo’s root system (trophoblast). In addition and far more serious, is the fact that in about one third of cases endometriosis, regardless of its severity is associated with NKa and cytotoxic uterine lymphocytes (CTL) which can seriously jeopardize implantation. This immunologic implantation dysfunction (IID) is diagnosed by testing the woman’s blood for APA, for NKa (using the K-562 target cell test or by endometrial biopsy for cytokine activity) and, for CTL (by a blood immunophenotype). Activated NK cells attack the invading trophoblast cells (developing “root system” of the embryo/early conceptus) as soon as it tries to gain attachment to the uterine wall. In most cases, this results in rejection of the embryo even before the pregnancy is diagnosed and sometimes, in a chemical pregnancy or an early miscarriage. As such, many women with endometriosis, rather than being infertile, in the strict sense of the word, often actually experience repeated undetected “mini-miscarriages”.
Women who harbor APA’s often experience improved IVF birth rates when heparinoids (Clexane/Lovenox) are administered from the onset of ovarian stimulation with gonadotropins until the 10th week of pregnancy. NKa is treated with a combination of Intralipid (IL) and steroid therapy: Intralipid (IL) is a solution of small lipid droplets suspended in water. When administered intravenously, IL provides essential fatty acids, linoleic acid (LA), an omega-6 fatty acid, alpha-linolenic acid (ALA), an omega-3 fatty acid.IL is made up of 20% soybean oil/fatty acids (comprising linoleic acid, oleic acid, palmitic acid, linolenic acid and stearic acid) , 1.2% egg yolk phospholipids (1.2%), glycerin (2.25%) and water (76.5%).IL exerts a modulating effect on certain immune cellular mechanisms largely by down-regulating NKa.
The therapeutic effect of IL/steroid therapy is likely due to an ability to suppress pro-inflammatory cellular (Type-1) cytokines such as interferon gamma and TNF-alpha. IL/steroids down-regulates NKa within 2-3 weeks of treatment the vast majority of women experiencing immunologic implantation dysfunction. In this regard IL is just as effective as Intravenous Gamma globulin (IVIg) but at a fraction of the cost and with a far lower incidence of side-effects. Its effect lasts for 4-9 weeks when administered in early pregnancy.
The toxic pelvic environment caused by endometriosis, profoundly reduces natural fertilization potential. As a result normally ovulating infertile women with endometriosis and patent Fallopian tubes are much less likely to conceive naturally, or by using fertility agents alone (with or without intrauterine (IUI) insemination. The only effective way to bypass this adverse pelvic environment is through IVF. I am not suggesting here that all women who have endometriosis require IVF! Rather, I am saying that in cases where the condition is further compromised by an IID associated with NKa and/or for older women(over 35y) who have diminished ovarian reserve (DOR) where time is of the essence, it is my opinion that IVF is the treatment of choice.
I hope this helps!
Geoff Sher
P.S. I am from South Africa too!
Dr Sher,
Do you ever do low dose dexamethasone during stims to decrease adrenal contribution to elevate progesterone which may cause premature luteinization?
I always use low dosage dexamethasone but not for that reason. Rather to immunomodulate the uterine environment and optimize implantation.
Geoff Sher
Dr Sher,
I had my ER a couple of days ago. (1ST cycle). On day of trigger my progesterone was too high, so needed a freeze all. I had about 16 large follicles. (Largest 17-21mm). Only 7 eggs retrieved. On day 1 only 3 fertilized. They said my egg quality wasn’t too good. I was taking ubiquionol 600mg, Aspirin, synthroid and multiv with folic acid in preparation. I am under unexplained infertility and 36 years old. I was on antagonist protocol with Gonal F 225and Luveris75 with cetrotide later and HCG trigger. Stimmed for 11 days. What went wrong?
Hi Melissa,
In my opinion, the most important possibility is that the protocol used for ovarian stimulation was not optimal (see below).
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.
•Why did my IVF Fail
•Unexplained IVF Failure
•My Retirement in the Year Ahead: A letter of Thanks From me to You!
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
Hi Doctor, our last IVF cycle failed due to poor egg quality. The oocytes were brown and small oococytes with poor quality. What causes brown oocytes and is there anything which I can be doing to improve them for my next cycle? Can eggs go from poor quality small and brown to normal?
I’m 33 years old, my day three FSH is 4, LH 4 but my estradiol was quite high at 147.
During that IVF was on the antagonist protocol, where I had 225 of gonal F for 14 days and I triggered using cetrotide due to risk of OHSS. I had 22 eggs, 17 at M2 and 14 fertilised via ICSI. Only had 3 blastocysts, of which 2 were below average and only 1 was average. I had aFET which resulted in a biochemical pregnancy.
Later, my doc did a B12 and Vit D TEST. B12 was normal, but Vit D was 17.88, a bit on the low side. I’ve started taking multivitamins and 200mg daily of ubinquinol.
I really want to try and improve my eggs for the next cycle. Is there anything which I can do?
Your young age, should be associated with good quality eggs. In my opinion, the most important possibility is that the protocol used for ovarian stimulation was not optimal (see below).
I strongly recommend that you visit https://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.
• Why did my IVF Fail
• Unexplained IVF Failure
• My Retirement in the Year Ahead: A letter of Thanks From me to You!
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