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.
I have just discovered this forum and I found it very helpful. It makes one know he’s not alone,other has same problem. Please doctor I am 50 years old with secondary infertility, I have just lost the only child of the family. This necessitate going for ivf with donor’s egg. I had 5 failed ivf already. I have been diagnosed of ashermar syndrome as a result of previous surgeries. Then I had hysteroscopy with balloon catheter placed on it for a week after the removal IUD is inserted and placed on estradiol tablet twice a day for 8 weeks. Please sir can I go for another ivf immediately after the removal of the IUD and the withdrawal bleeding same month?
Thank you sir.
Th
Hi Kamil,
Unfortunately you might have an intractably damaged endometrium.
A normal uterine cavity and endometrial lining are essential in order to conceive and maintain a pregnancy. Scar tissue in the uterine cavity (Asherman’s syndrome) can interfere with conception, or increase the risk of miscarriage. The condition is often so severe that it destroys most of the basal (germinal) layer of the endometrium from which the uterine lining (endometrium) develops each month. When most of the basal endometrium is incapacitated, no regeneration of the endometrium can take place and amenorrhea (cessation of menstruation) or infertility can follow. The condition often results in fusion/adhesion of the opposing endometrial surfaces, but can also simply destroy the basal layer of endometrium without resulting in adhesions (non-adhesive Asherman’s).
Asherman’s syndrome most commonly results from post-partum or post-abortal inflammation involving the uterine lining (endometritis), but it can also occur (although infrequently) following uterine surgery such as removal of fibroid tumors (myomectomy) that encroach upon (or penetrate into) the uterine cavity.
The treatment of adhesive Asherman’s syndrome is resection of scar tissue by hysteroscopy. A hysteroscope is a telescope-like instrument that is introduced via the vagina and cervix into the uterine cavity allowing visualization of and access to the entire uterine cavity, enabling surgical resection of scar tissue. The objective is to remove as much scar tissue as possible and to free adhesions that fuse the walls of the uterine cavity together, so as to enable viable basal endometrium to resume growth and progressively cover as much of the surface of the uterine cavity as possible. Post-operatively, a small balloon is often placed in the uterine cavity for a day or two, to keep the opposing surfaces separated in the hope of preventing recurrence of adhesion formation. The woman usually receives supplemental estrogen to encourage endometrial growth.
Endometritis of a severity sufficient to produce Asherman’s Syndrome often scars and blocks the uterine entrances into the Fallopian tubes. However it is not always the case. The lining can be damaged while the tubes remain open. In such cases, if the uterine lining cannot support proper embryo implantation, a pregnancy could still implant in a Fallopian tube leading to an ectopic (tubal) pregnancy. Unless it is diagnosed early (by blood testing in combination with ultrasound examination) and treated medically or surgically, the ectopic pregnancy will rupture with serious and potentially life endangering consequences.
About 8 years ago, we reported on the use of Viagra vaginal suppositories to improve blood flow and hence enhanced delivery of estrogen to the endometrium. In this manner, we have been able to improve endometrial development in about 75% of women who otherwise were unable to develop an “adequate” uterine lining. Most of these women had undergone several failed IVF attempts. Many of the women who were successfully treated with Viagra subsequently conceived following IVF and went on to deliver healthy babies. One such case immediately comes to mind. It involved a woman who was from Singapore and who following 15 failed IVF attempts due to poor endometrial development conceived on her first IVF-Viagra attempt with us following Viagra therapy.
But Viagra is often ineffective in thickening the uterine lining in women with Asherman’s syndrome. The reason is that with Asherman’s there is often such widespread destruction of the basal endometrium (from which fresh endometrial cells must be generated), that regardless of the improvement in uterine blood flow and improved estrogen delivery, the endometrium just can’t respond. In such cases, the woman should consider using a gestational surrogate or pursuing adoption.
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.
Good luck!
Geoff Sher
Hi Dr. Sher, I am losing hope, and really hoping you can help me out.
I am 35 (will be 36 in September), was diagnosed with DOR of February of this year. AMH 0.52, FSH ranged from 14-18 and once 22. AFC around 6.
I have zero medical history, and always had regular menses (every 28-30 days). I have also never been pregnant, and did TTC with my husband when I was 30. Tried with Clomid for 4 months, but was unsuccessful. We then divorced, so I guess that worked out, but not really.
My first IVF cycle (300 Gonal F, 300 Menopur, Clomid and Cetrotide) was canceled after 6 days of stims for ‘poor response’. I only developed 2 follicles on my Right. The following month, I tried again, this time with Estrogen priming, but I think my RE dropped the ball, because he had me put the patch on CD 22 at 8pm, and I wound up getting my menses on CD 25. So I only had the patch on for 2-3 days. When we started stims, he kept me on same protocol as before (300 menopur, 300 gonal f, clomid and cetrotide). At one point I had SEVEN follicles (the most EVER), but then around day 9, my left ovary just stopped, and the only 3 kept growing on my right. I made it to ER, with only 3 follies. Two fertilized, and one made it to blast. I sent out for PGS, and found out today that the embryo was abnormal. I am crushed!!! I dont know where to go from here, but I know I cant give up and am not ready to do donor egg. Please help me!! Do you think I needed more days of estrogen priming??? Do you think he has me on too high dose?? Should I be taking supplements ?? ( I already take co q 10 and regular vitamins).. oh, also I am doing this alone, with donor sperm, so I know there isnt a male factor involved. Please help… im losing all hope 🙁 and feel like I am lost. Why doesnt my RE change my protocol???? Thank you so much in advance!!!!
Hi Dr Sher, in your opinion do I have PCOS? My only symptoms are irregular periods and in some scans I have more than 12 AFCs in each ovary (in a couple of recent scans there have been less than 12 AFCs in each ovary though). The blood tests (FSH/LH) were not showing PCOS. But my AMH is high at 17 for my age of 43. Thanks in advance.
It is very possible Sheena. And you need IVF with PGS embryo selection and possible banking of embryos.
Let me start by saying that there is no doubt that PCOS exacts a toll on egg quality. This having been said, the egg quality can in large part protected through the judicious implementation of an individualized protocol for ovarian stimulation.
Women with PCOS are hypersensitive to gonadotropin stimulation and are often at risk of developing serious complications associated with severe ovarian hyperstimulation syndrome (OHSS). Concern for this occurring often leads the treating physician to take precautionary measures aimed at slowing down or stopping hyperstimulation. Such measures include:
1. Cutting the stimulation short to prevent the E2 from rising too high. Unfortunately this often results in the eggs being underdeveloped at the time of the “trigger” and thus, far more likely to end up being “immature”., “dysmature” and “incompetent”.
2. Administering a lower “trigger dosage” of hCG , supplanting it (partially or completely) with an Agonist trigger (e.g. Lupron/Buserelin/aminopeptidyl/Superfact). While such measures can certainly reduce the risk/severity of OHSS, it often comes at the expense of egg competency (see below).
In my opinion, another error of commission during ovarian stimulation of women with PCOS is the indiscriminate use of drugs that either elicit an exaggerated ovarian LH-induced testosterone response (e.g. clomiphene or Letrozole), or provide too much LH (e.g. Menopur/Menogon). Too much ovarian testosterone is harmful to egg development and thus prejudicial to embryo quality/competency.
In my opinion the best way to approach ovarian stimulation for IVF in women with PCOS, is through the use of a low dosage, FSH-dominant Long ovarian down-regulation protocol, done in readiness for “prolonged coasting” (see below) and “triggering” egg maturation with a full 10,00U dosage of hCG or (no less than) 500mcg of recombinant hCG (Ovidrel)….see below is If this is implemented appropriately, with proper timing, egg/embryo quality can be optimized.
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.
•Egg Maturation in IVF: How Egg “Immaturity”, “Post-maturity” and “Dysmaturity” Influence IVF Outcome:
•Commonly Asked Question in IVF: “Why Did so Few of my Eggs Fertilize and, so Many Fail to Reach Blastocyst?”
•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?
•Taking A Fresh Look at Ovarian Hyperstimulation Syndrome (OHSS), its Presentation, Prevention and Management
•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?
•My Retirement in the Year Ahead: A letter of Thanks From me to You!
ANNOUNCEMENTS:
1.About my Retirement
After > 30 years in the field of Assisted Reproduction (AR), the time has finally come for me to contemplate retiring from full-time clinical practice. 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
Thanks so much for all the advice you’ve given me previously. I just have a new question with some more recent updates of my situation. I have had an underactive thyroid for a number of years and have been on 100ml thyroxine. My thyroid antibodies are high (352 IU/ml). I’m having second IVF this time with intralipids and steroids and have had prostap injection. I have just started my period but have received results today of my thyroid (TSH level) being 3.39. My stims are starting soon but based on my recent thyroid results would it be ok to continue on this cycle or best to wait? What would you advise?
If the T3/T4 is normal, you should in my opinion, continue!
Geoff Sher
Dear Dr.Sher,
I’m Ob-Gyn and infertilty specialist from Turkey. I would like to discuss with your great experience. I wonder do you have any oppinion regarding to ozone gas or ozonated water administration into the cyst after endometrioma cyst aspiration instead of tetracycline?
Regards,
Dr. Adnan Ozkutucu Ob&Gyn
Mobile: +905326158265 whatsapp
While I have no knowledge or experience on this, it does not seem likely to have merrit on the face of it!
Geoff Sher