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,
In November, I had two uterine polyps removed. The Dr. used a MyoSure Lite tool to remove the polyps. When my period came back in January, it was much shorter in duration than it has ever been- about 3 days. It has now increased to about 5 days of bleeding, but I used to have 7 full days. When should I expect my period to return to it’s normal length? In researching why my periods are shorter and lighter, I came across Asherman’s Syndrome. I’ve been told that you think that has more to do with if there was an infection from a D&C due to miscarriage, but my concern is related to my belief that the Myosure lite is an oscillating tool and what I read about “Unstuck Ashermans”. Do you think I could get Asherman’s Syndrome if they went too far/deep into my endometrium with the MyoSure lite? My husband and I have also been trying to conceive since January unsuccessfully. I appreciate and thank you for any advice you have for me!
Forgive me, I should have also mentioned that in addition to the uterine polyps, the Dr. removed some scar tissue in my uterus they believed was from my emergent c-section from Aug 2014. I had a placenta abruption during the birth of my first (and only) child. Ok, thank you!
I do not believe that the procedure increased the risk of Asherman syndrome. Also, the length of the period would not be an indicator of an insufficient endometrium.
Geoff Sher
Hi Dr Sher,
I had my egg collection and they gave me a progesterone injection after and said I should expect my period in 2 weeks. Ten days later I got my period and it sennet pretty normal. About 5 days after my period finished I’ve had pink discharge/spotting for a couple of days now… Just wondering what this is?
Not significant in my opinion.
Geoff Sher
Hi Dr. Sher,
My husband and I are 29 years old. I just had my laparoscopy surgery in April 2017 to remove Stage III Endometriosis. I was told they found endometriosis on both my ovaries and top of uterus. They said my tube was stuck with the uterus with Endo adhesions and they unstuck it during the surgery. In my RE’s words I was “endometriosis free” after the surgery.
He is still recommending we go for IUI or IVF directly. What would you recommend? Will IUI be waste of time and money given I had stage III endometriosis? Is IVF our best case scenario?
Thank you,
Respectfully, IUI is not an ideal treatment for women with endometriosis in my opinion…see below.
It is hard for me to believe that more than three decades have flown by since I first introduced intrauterine insemination into the clinical arena (Journal of Fertility & Sterility, April, 1984). At that time and for more than 2 decades thereafter, I held the strong belief that IUI would provide a less expensive, safe and equally successful alternative to IVF in cases where the woman had at least one (1) patent Fallopian tube…. How wrong I was! In my defense however, let me say that in the 1980’s and 90’s the reported National IVF success rate was under 15% while y IVF success rates are now often 4 or even 5 times higher.
Today I believe that IUI is being over-used, is not nearly as beneficial as I once thought and that there are (often ignored) serious down-sides to its use. Here is one important example: Women who fail to ovulate or ovulate dysfunctionally, often respond to controlled ovarian stimulation (COS) by the releasing (ovulating) of several eggs at a time. Since unless IVF is used, it is not possible to control/regulate the number of embryos reaching the uterus, the risk of high-order multiple pregnancies (triplets or greater) is far greater with IUI. And, multiple pregnancies (especially triplets or greater) carry a very high maternal and neonatal risk.
Here are a few of the misperceptions about the use of IUI:
1)IUI is a “cost saver”. However, given the fact that IVF is at least 3-4 times more likely to be successful, when one looks at cost per baby (rather than cost per procedure) this turns out to be a fallacy. But cost also comes in the form of emotional currency and this needs to be measured in terms of the much lower chance of success with IUI.
2)”IUI is less invasive than IVF”… ….True! However aside from the surgical egg retrieval (which is a very safe procedure in the right hands/setting), IUI with gonadotropins requires largely the same drugs, preparation and monitoring as does IVF and the success rate is several fold lower than IVF.
3)The use of oral Clomiphene Citrate for IUI- COS provides the same success rates as does Gonadotropin-IUI. This is absolutely incorrect. In fact the IUI success rate with clomiphene is about 30% lower than when gonadotropins are used.
4)Natural cycle IUI has benefit: This is only true when frozen donor sperm is used for inseminations and in the isolated cases where there is non-immunologic cervical hostility to sperm. In all other cases, COS is needed to improve success.
5)IUI can be used in cases of Embryo Implantation Dysfunction: Given the complexity of treatment is in cases where a thin uterine lining, significant uterine anatomical disease or immunologic implantation dysfunction (IID) prevents a healthy pregnancy, it is my opinion that IVF is the preferred primary approach.
6)IUI can supplant or replace IVF in all cases where there is patency of at least 1 Fallopian tube. However, contrary to popular belief, there is no evidence that IUI improves pregnancy potential in cases of:
a.Moderate or severe male factor infertility
b.Endometriosis with patent Fallopian tubes. Since inseminating sperm does not overcome the main impediment to fertility, i.e., a “toxic” peritoneal factor that compromises sperm penetrating the egg envelopment).
c.Older women (over 40y) where the IUI pregnancy yield is only about 2% per treatment cycle.
Upon Honest Reflection:
Unfortunately, too many physicians who should (and alas often do) know better, still liberally recommend IUI preferentially in cases of moderate or severe male infertility, older infertile women or those with diminished ovarian reserve (DOR), cases of endometriosis or where there is clear evidence of an anatomical r immunologic implantation issue. Such women would be much better advised to go directly to IVF but find themselves attracted to what they erroneously consider to be a much lower cost alternative.
Then there is the fact that many infertile patients, erroneously believing that IUI is less risky that IVF, provides an equivalent chance of success, and comes at a much lower price tag, put undue pressure on their physicians to first try the former several times before resorting to the latter.
To make matters worse, many misguided insurance providers (purely for economic reasons) demand that their female clients who have at least 1 patent Fallopian tube, first undergo several unsuccessful attempts at IUI before becoming eligible for IVF. And they often take this position regardless of cast iron indications that IVF should be the primary treatment of choice.
In summary, it is my opinion that IUI is presently an over-prescribed treatment. As such, we as physicians need to rethink the basis upon which we recommend IUI and educate our patients appropriately
Geoff Sher
800-780-7437
Hi Dr. Sher,
I am a 40 year old female living in Toronto and trying to get pregnant for the first time using ivf. My AMH is 7. my doctor says I might get around two embryos and he suggests, because of my age, to do
PGS testing on the embryos. I have heard, however, that there are drawbacks to PGS testing, in that it might decrease the quality of the embryo. Since I might get very few embryos to begin with, I am concerned about destroying the embryos. I was wondering what you think about it? Does the negative outweigh the positives of PGS testing in this case? As mentioned I live in Toronto and my clinic is good, but I have no way of knowing how experienced the embryologist will be, nor if the technology is good enough these days.
Please advise.
Thank you,
Sherri
Hi Sherri,
I agree with your doctor.
In my opinion, the protocol used for ovarian stimulation, against the backdrop of age, and ovarian reserve are the drivers of egg quality and egg quality is the most important factor affecting embryo “competency”.
Older women as well as those who (regardless of age) have diminished ovarian reserve (DOR) tend to produce fewer and less “competent” eggs, the main reason for reduced IVF success in such cases. The compromised outcome is largely due to the fact that such women tend to have increased LH biological activity which often results in excessive LH-induced ovarian testosterone production which in turn can have a deleterious effect on egg/embryo “competency”.
Certain ovarian stimulation regimes either promote excessive LH production (e.g. short agonist/Lupron- “flare” protocols, clomiphene and Letrozole), augment LH/hCG delivered through additional administration (e.g. high dosage menotropins such as Menopur), or fail to protect against body’s own/self-produced LH (e.g. late antagonist protocols where drugs such as Ganirelix/Cetrotide/Orgalutron that are first administered 6-7 days after ovarian stimulation has commenced).
I try to avoid using such protocols/regimes (especially) in older women and those with DOR, favoring instead the use of a modified, long pituitary down-regulation protocol (the agonist/antagonist conversion protocol-A/ACP) augmented by adding supplementary human growth hormone (HGH). I further recommend Staggered IVF with embryo banking of PGS (next generation gene sequencing/NGS)-normal blastocysts in such cases. This type of approach will in my opinion, optimize the chance of a viable pregnancy per embryo transfer procedure and provide an opportunity to capitalize on whatever residual ovarian reserve and egg quality still exists, allowing the chance to “make hay while the sun still shines”.
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.
•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 Aproach
•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)
•Controlled Ovarian Stimulation (COS) in Older women and Women who have Diminished Ovarian Reserve (DOR): A Rational Basis for Selecting a Stimulation Protocol
•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?
•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 Testing (PGS) in IVF: It Should be Used Selectively and NOT be Routine.
•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
•Implications of “Empty Follicle Syndrome and “Premature Luteinization”
•Premature Luteinization (“the premature LH surge): Why it happens and how it can be prevented.
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.
Geoff Sher
What is the rate of miscarriage in identical twins at 10 weeks? Heartbeats seen and strong. So far pregnancy is going well. Hard time finding an answer on this. Thank you, Dr. Sher!!
Probably < 10%. Geoff Sher