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 Doctor,
I am devastated. This Monday I have received negative results for my 5th IVF. I live in Georgia, which is poor country in east Europe. My husband and I are fighting infertility for 8 years already. I am 38, husband 33. He has a child from his ex-girlfriend.
My history: I have autoimmune skin disease, Vitiligo, gastritis and slight to anemia, though for the moment my blood tests are normal. I have history of hypothyroidism, which was due to lack of iodine (Georgia is iodine deficit country) and in 2005-2007 I’ve been receiving L-thyroxin, now I receive only iodine supplements and regularly check my thyroid status, which is fine, normally my TSH is between 1-2, which is ideal for the pregnancy. Since I am visiting reproduction specialists, I have been diagnosed with hyperprolactinemia and take dostinex every week for over 4 years already. Did my MRI scan and my pituitary gland is fine. I take 1/4 tablet of dostynex, sometimes, 1/2, depending on levels of prolactin. My FSH was bouncing before I started regularly taking dostynex, now they are always below 12, between 7-10. My progesterone was always good or bit high, estradiol levels closer to a lower range. My cycle is regular, though duration is 26-28 days, flow has decreased and is 2-3 days. My tubes were checked through x-ray and they were open. My husband has slight oligospermia, he is HCV positive, though his liver is fine, constantly checked and we are waiting for new medications to be cheaper to start treatment, for the moment, we cannot afford treatment and are not eligible for programs which are available in the country an at this stage they target F3 level patients (my husband is H 0-1), we still have some time.
After 4 IUIs, using stimulated cycle, no pregnancies achieved, I had my first ivf in 2013, with folistim (or fostimon?) and orgalutran stimulation. Started on 2nd day of my cycle, on Day 11 of the cycle, 11 follicles were retrieved, 5 were fertilized and 3 good embryos were developed. 2 were transferred on day 3, 1 did not survive to blastocyst stage, therefore we had nothing to freeze. On day 9 from transfer I started bleeding and had cramps. On day 11 we made HCG test and result was positive, though very low (12), after 3 days it was 45 and after 48 hours 135 and +48 hours over 500. After 3 days bleeding stopped and my HCG levels were raising normally. After transfer I was receiving endometrine (progesterone) 3 times a day, methylprednisole 4 mg, once a day and cardyomagnyle (low dose aspirin) 75 mg once a day. At the end of week 5 I had mild cramps and 2 drops of blood, went to my RE, she checked on ultrasound and found a sack, but she said it was too small and has checked on ultrasound one week after and sac was no longer there. My HSG levels started dropping, she discontinued medicines and few days my period started, therefore I had miscarriage.
Next IVF we did after 8 months. I changed clinic, they checked my AMH levels and it came very low, 0,39. Protocol was similar, Menopur started on day 2 and after several days added Orgalutran, length of stimulation was 8 days. When they checked my estradiol-progesterone levels before HCG administration, my estradiol levels were good, but progesterone was very high, 5. Doctor said that they had to remove follicles ASAP and told me that they would not do transfer and offered to freeze embies. 8 were retrieved, don’t remember how many were fertilized, but only 1 embryo was good enough to freeze.
In September 2014 we started 3rd cycle. Doctor changed protocol and started with Femara (Lupron) and added Menopur on day 7, low dose, + orgalutran. She used minimum stimulation so that my progesterone levels did not raise. They retrieved only 4 eggs and made 2 good embies. My progesterone still was over 1,5 (1,7) and she did not transfer. In November they transferred all 3 embryos (of July and September) in natural cycle + used hormones for uterine thickness (estradiol Gel) and utrogestane (200 mg 3 times a day, vaginally) + methylprednisole 4 mg and Clexan 0,2 mg, which is the same as Heparine. Clexan and prednisole they started one day after my HCG shot. On day 12 my HCG blood test was positive, 124, though my estradiol levels were bit low and she added estradiol tablets. After few days I started spotting and ended up with ectopic pregnancy and had laparoscopic surgery. They removed my right tube and checked left one, which was healthy. Doctor said that I had scar tissues on my right tube from my appendicitis operation, which I had in my childhood.
I march 2015 I started one more cycle, this time doctor changed medications, cycle was modified again, started in natural cycle, on Day 7 she added Pergovaries, 150 IUI, +Orgalutran, on day 13 collected 5 follicles, all oocytes were fertilized and 4 embryos (2 good, 2 medium) were frozen because of my slightly high progesterone again. We did transfer in June, doctor did scratching of my uterus on day 2 of the cycle, as my lining was not thick enough due to my not so good blood E2 levels, from Day 8 they added estradiol gel, after transfer HCG shot added progesterone (Crynone gel 2 times a day) progesterone injections 2,5 mg, once a day, methylprednisole 4mg once a day. After transfer she added Clexane, which is lowmollecular heparin, 0,4 ML, once a day. On day 12 of FET my HCG test was negative.
In July I had conversation with my doctor, who is one of the best specialists in this country and she told me that we could try one more time, but if no success, she would recommend to use donor eggs as she thought that reason of a failure was the quality of my oocytes and age ( was already 37). Next month she did full protocol, started on day 3 of my cycle with 3 Menopurs every day (75 IU each), increased the dose up to 5. She told me that it was important to retrieve as many oocytes as possible. They retrieved 10 oocytes, froze 3 on day 2. I had several GV oocytes and embryologist managed to grow one of GV oocytes to blastocyst stage.
In October we transferred 3 day 2 embies, in natural cycle + estradiol gel from day 7 and additional progesterone when I had ovulation. This time I had no HCG shot as ovulated spontaneously. Doctor added progesterone shot once a day, Crynone twice + Clexane 0,4 ml shot from da day of transfer and methylprednisole. Result was negative again. I still had one frozen blastocyst.
My doctor canceled several cycles, in November because she did not like Uterine thickness, In December because of follicular cysts, In February because my progesterone jumped high again, without stimulations during the follicular phase. She prescribed me Methylprednisole and told me to come back in next cycle and they transferred my last blastocyst on 5th of March, this year. I was on Methylprednisole for about 3 weeks on day of transfer, she added estradiol from day 8, as my uterine thickness was not good enough. Anyway, I had HCG shot on day 12 of the cycle, my progesterone was 0,6, but LH was bit low. She told me to do HCG shot in the evening of day 12 and start progesterone the day after. She added estradiol tablets vaginally. The thickness of endometrium was about 9 mm the day I had HCG shot. They transferred blastocyst on day 19 of the cycle. Embryologist said that blastocyst was of very good quality. On day 9 from FET, my beta was negative again.
This result is devastating for me. My doctor tells me that now I have to use donor eggs.
Do not know if this is helpful to me. I have autoimmune factors, which I think are bit overlooked in Georgia. Last autumn I had pains in my fingers, over the stomach, at the chest bone and I went to rheumatologist in early December. I did several tests and some of tests came positive:
LA (Lupus Anticoagulant) screening: result 54,1 (norm is 31”-44”)
LA confirm: 38,7 (norm is 30”-38”)
LA ratio: 1,4 (norm is 0,8-1,2)
Antophospholypid Antibodies IgG IM.6.1.2a: 2,8 (norm is <10 GPL)
Antophospholypid Antibodies IgM IM.6.1.2b: 1,8 (norm is <10 GML)
Antinuclear factor (ANA-HEp-2): 1:<80- (norm is 1:<80)
Antinuclear Antibodies ANA IM.6.3 : 1,5 (norm <1)
Anti-dsDNA antibodies IM.6.7 :9,1 (norm is <20)
My c-reactive protein levels were also bit high 37, maximum normal level is 15 in this country. Though My ANA is elevated and I am LA positive.
Based on results, I was diagnosed of reactive arthritis in early January 2016 and idiopathic antiphospholypid syndrome. I was prescribed of 10 days of antibiotics + nonsteroid anti-inflammatory drugs for 30 days. I did this treatment in January. I informed my RE doctor about my autoimmune status. She told me that she was taking this into account anyway as I have Vitiligo and she was adding to my treatment methylprednisole and low molecular Heparin anyway. They never did embryo quality check, PDG, as this practice is not available in this country and we have to send material to Turkey and this is a cost which is very high. My doctor has never proposed it anyway.
Doctor Sher, I described a very long story. Maybe my English is not very good, but I think that you will understand my history. As you can see, 4 IUIs, 5 ivfs, 1 miscarriage, then ectopic and 3 negative results. I don’t even know if it does make sense to try donor eggs because of my autoimmune status, I have been spending all of my income on my infertility treatment for last 7 years, I work hard to pay all my medical costs, but results are devastating me. I feel demoralized and hopeless. I have not had vacations for last 5 years, because I cannot afford them and I work on 2 jobs to pay my medical bills as insurance does not cover them in this country. I even sold some property to cover costs, as my husband is unemployed for almost 2 years already. I had even taken a loan from the bank because my income is not enough for everything.
Now my doctor proposes me to use donor eggs. I will work hard for few months to collect enough money to cover these costs and take out another loan; cost of treatment in this country is lower than in Europe or US, but still are extremely high, as wages are low. I am afraid of another failure. I just can’t take another negative result. Please, advise what to do. Do I have to do additional blood tests? Which tests? Don’t even know a RE specialist in this country who is experienced enough to manage my autoimmune status properly.
Please, advise what to do, shall I try egg donation or do something else? If additional tests are required, we have couple of labs which send blood to Germany, so if I need additional tests, will try to use this option and do additional autoimmune research. But please help. I know that your service is expensive. I cannot arrive to the US, but if needed can pay for a visit and have consultation through skype or other media. Please, give advice as I have no hope left and after of trying so much and having always negative result, have even lost interest in other things and feel very depressed and unhappy. I have been searching a lot on internet and found your blog, which is little hope for me. Pease, help.
I certainly concur that you should be considering egg donation at this stage. However, your autoimmune state, concerns me. It is important to exclude an immunologic implantation dysfunction associated with natural killer cell activation, in my opinion. If tthe NK test (K-562 target cell test is positive, you would need Intralipid therapy starting 10-14 days prior to ET. This should be combined with corticosteroids and because of your LA you would need Clexane as well.(see articles below).
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).
My answer to patients who ask me when is the time to stop undergoing IVF is ….Aside from the weight of the financial burden, the time to stop is when in spite of thorough and comprehensive evaluation, there is no remediable and treatable explanation for repeated failure.
Please visit my new Blog on this very site, http://www.DrGeoffreySherIVF.com, find the “search bar” and 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.
•Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
•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)
•IVF Egg Donation: A Comprehensive Overview
•IVF-Gestational Surrogacy: An Overview
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.
Good luck and G-d bless!
Geoff Sher
I have done 3 collections and all cycles have come up with limited egg number cycle one – 9 follicles – 3 eggs- 2 blasts. Collection 2 – 11 follicles -4 eggs- 1 blast, collection 3- 8 follicles -1 egg- 1 blast. I am 28 and pcos, I have also had 2 miscarriages from these embryos. I don’t understand why we can’t get better egg numbers.
Your response to stimulation was quite blunted. This is not typical of patients who have PCOS, who tend to hyper-respond. In addition, it seems that many of the follicles you developed did not yield their eggs almost certainly was because of poor egg quality, possibly due to the choice and/or the implementation of the protocols used. Central to your having an improved response s the protocol used for ovarian stimulation.
In my opinion. you need You need a modified long pituitary down-regulation protocol. I would use an agonist/antagonist conversion protocol with human growth hormone (HGH) augmentation and would recommend Staggered IVF with embryo banking of PGS (next generation gene sequencing)-normal blastocysts, to make hay while the sun still shines.
Please visit my new Blog at o to http://goo.gl/4hvjoP , find the “search bar” and 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.
•Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
•Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
•IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
•Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
•The “Biological Clock” and how it should Influence the Selection and Design of Ovarian Stimulation Protocols for IVF.
•Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
•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?
•Frozen Embryo Transfer (FET): A Rational Approach to Hormonal Preparation and How new Methodology is Impacting IVF.
•Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
•Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
•Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
•IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
•Why did my IVF Fail
•Traveling for IVF from Out of State/Country–
•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
I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
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.
Geoff Sher
I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
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.
Geoff Sher
I recently went through an ICSI cycle, but none of my 5 embryos made it to blasts by day 6. We ended up with 3 morulas which were discarded. Is there any chance that those morulas could have implanted? How rare is it to have no embryos make it to blastocysts?
Embryos that do not reach the expanded blastocyst stage are almost invariably abnormal and would not have propagated a baby even if transferred earlier.
The likelihood of blastocysts developing is, among other factors, dependent on age,ovarian reserve, method of ovarian stimulation, male factor and the number of mature eggs harvested.
Geoff Sher
My A1c test came back 5.1 (normal), my fasting glucose level is 104 and my fasting insulin level is 5.7.
My question to you – do you see a problem with my current levels listed above? If so, what would you advise? Medication?
As stated below, we need to talk and discuss these detais via Skype. Call 800-780-7437 or 702-699-7437.
Geoff Sher
Dr Sher, I am a 34 year old who was hoping to start a family this year. As a precaution, I had my bloods checked. I am devastated with the results. My AMH level is 12.2, apparently this should be 15-20. My day 3 FSH came back @14 U/L. My day 21 results are as follows: Progesterone level is 41.8 nmol/L , FSH 10.7 U/L, LH 8.6U/L, Oestradiol 331 pmol/L. I’m wondering if I’m even ovulating? I would really appreciate some advice on what to do next. Thanks
Hi Rozanne,
Your FSH is elevated but your AMH is still reasonably OK, but clearly, you need to be proactive because it is just below normal and you could be on the way to developing DOR.
I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.
Geoff Sher