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.
Hi Dr. Sher!
I just discovered your blog and I’m so grateful that you offer such sound medical advice to so many struggling with infertility. I’d love your opinion about my situation, if you have time. . .
As a teenager I never started my period. I thought it was because I was a ballerina and almost no body fat. I was put on birth control in my late teens, which produced a regular period, and I continued that way for a long time. At the age of 30, I went off BC and my husband and I began trying to conceive, with no luck (and no period). After several months, I met with a fertility doctor (who I still see) who discovered through various blood work tests that I have no eggs as a result of Translocation of the X and 1 chromosomes. Luckily, nothing else was affected by my translocation. I had genetic counseling and they confirmed I could be a good fit for an egg donor. I had my first fresh ET with an egg donor (healthy 28 yr old) and got pregnant and delivered a perfect baby boy. We are now 2.5 years later. In January, we started another cycle for a FET for our #2. I had some fluid and a difficult time building a thick lining (same as I did with the cycle that produced my son years ago), but my doc got rid of the fluid, uped my estrogen to achieve a thicker lining (7.5mm) and we did the FET. The embryo (untested, but great quality) implanted but quickly failed after and I miscarried early. I had a hysteroscopy, which show some very minor scaring that was removed. My doc said my uterus just barely dipped down in shape, but wasn’t significant. A month later we started another cycle. My lining grew at a faster pace, no fluid formed and we got excited, but then it started to shrink. We continued to monitor and it came back up to an adequate amount. We did another FET with a tested embryo (PGS tested normal) of great quality. This time the embryo didn’t implant at all. We recently started a third attempt. This time, we got an adequate lining quickly (around 9mm), I did an intralipid drip, and my doc put me on daily medrol. We did an FET of 2 embryos, one another tested from the PGS and a non tested, lower quality one (to boost our chances). I haven’t gone in for my pregnancy test yet (I need to wait a few more days), but I don’t feel pregnant at all. I know it’s too early to tell, but when I got pregnant with my first, I felt strong symptoms days before the pregnancy test. I’m concerned that our third trial may have not worked. Is it possible to have Repeated Implantation Failure after having a successful pregnancy and delivery? I fear the embryos from the donor (young and healthy) aren’t the issue and that it’s my uterus/body somehow – what could change?
Thanks so much for any insight and I know I should wait until the pregnancy test to find out our situation, but I can’t help but wonder if this doesn’t work, are there any more options for me?
I’m so grateful!
Indeed, it is possible to be successful and then fail thereafter. It can sometimes be due to an alloimmune implantation dysfunction and if this is the case, a very individualized approach to addressing the problem may be required.
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
•Use of GnRH Antagonists (Ganirelix/Cetrotide/Orgalutron) in IVF-Ovarian Stimulation Protocols.
•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
After > 30 years in the field of Assisted Reproduction (AR), the time has finally come for me to contemplate retiring from full-time clinical medicine. 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
hello sir or mam,
plz tell me the mild stimulation protocols & it’s advantages and disadvantages
Mini-IVF is in my opinion a bad idea. You get far fewer eggs while the monitoring/egg retrieval and transfer remains the same. Success rates are far too low it is thus especially not cost-effective. Moreover, f clomiphene is used, you can compromise egg quality.
Geoff Sher
Dr Sher
My husband (41yo) has completed his pretesting for our first attempt at IVF for GS. We have 2 boys already. His report says the following.. what does it mean re anomalies and should he be worried? Is there anything he can be doing to help? Thanks
SEMINAL PLASMA ANOMALIES
LOW COUNT/ml (concentration 13.5 : 15 or more) and (total count 69 : 39 or more) I don’t know what these numbers mean, are they vs the average
ALL OTHER PARAMETERS WITHIN RANGE
MOTILE SPE DISPLAU RAPID PROGRESSION
Honestly, I do not know either. It is unfamiliar to me….You need to discuss this with your RE.
Geoff Sher
Hi Dr Sher, I just watched your video on Embryo Mosaicism. In the video you mentioned that complex abnormalities are generally caused by the egg. Is it possible that complex abnormalities can be caused by the sperm? The reason I ask is that my partner has sub-optimal sperm measures. Many thanks!
Yes it is but it is far, far less likely. What is certain is that meiotic embryo aneuploidy can be both egg or sperm related, it is infrequently due to the latter. I should perhaps have clarified this. Thanks for pointing it out.
Geoff Sher
Hi Dr. Sher,
I am diagnosed with low ovarian reserve. I fail 9 fresh cycles and 5 FETs. Some of my cycles using embryo banking methods. In The last 3 cycles, the embryos were cultivated to blastocyst. Each cycle I manage to have 2-3 blastocysts (5AA x 2, 5BB x 1, 5CA x 1, 5CB x 1, 5AC x 1). All these good quality embryos failed to implant despite my uterine lining thickness was good too. Now I am left with one 5CA and one 5CB embryos.
I visit 3 difference doctors for all these cycles. All of them said I have a perfect uterus. Triple layer and Lining looks good. I even done endo scratch before my FET cycle.
I just don’t understand why all my cycles failed. Dr Sher, Can you give me some advice please?