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. Sher,
Hello Dr. Sher,
I am a 42 y.o. who has had a long history of unexplained infertility. In my early 30’s my husband and I tried for more than one year with no success; which is what prompted us to see a specialist. It was determined that one of my tubes was blocked. The doctor successfully opened that tube and also removed two fibroids. Initially the thought was because my husband already had a child that he was fine. It was later determined he had low sperm count. The doctor then performed several unsuccessful IUI’s.
From there we went to another specialist. It was again confirmed that he had low sperm count. I was told all my levels were good; lining was good, everything was fine but we would need to do IVF. We did a fresh round where 3 fertilized high quality eggs were transferred and no pregnancy resulted. We did a frozen transfer where 3 eggs were transferred and no pregnancy resulted.
My husband and I divorced 7 years ago. I was asked by a friend if I would consider co-parenting. He did not have children and had not been tested but said that he had gotten someone pregnant before and she decided not to continue with the pregnancy. He has never had a semen analysis. We tried for three months and nothing happened. We were both frustrated so we decided to not continue on that path.
Now fast forward two years ago. I began dating a man who has two children but had a vasectomy years ago. We decided we want to try to have a child. January of this year we went to my previous specialist. I had all the testing done again and again they said everything was good. The doctor did note that I had two large fibroids but stated that he did not believe they were preventing me from getting pregnant. My significant other met with a specialist and decided to have aspiration procedure.
Last month I started the IVF protocol …menapur -300 gonal f -300, and eventually cetrotide then ovidril. I was told I had 6-8 follices on one ovary and 5-7 on the other. Everything was going well until the retrieval. When I woke up after the retrieval everyone was looking at me strangely. Later I was told that the doctor could not find one of my ovaries during the procedure and that only 3 follicles were retrieved and only two of those were mature. They were able to get sperm and they ICIS both follicles but only one fertilized. I had a day 3 transferred but I did become pregnant.
The doctors have said they are baffled. They have no idea why it has not worked. Do you have any thoughts or suggestions?
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
. Uterine fibroids
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
Dear Dr Sher,
I just had my pretesting u/s and only had one single egg! :’-(((
Does it make any sense at all to go ahead and try IVF or is it pretty pointless and I’d better give up on my dream?
And if you think I should give it a try anyway, is there anything I can do to boost my numbers (and quality)?
THANK YOU for your help;
kind regards
Berry
The antral follicle count can be very unreliable. I would more interested in your ovarian reserve (i.e. day 3 FSH/LH/E2 and your AMH). Ultimately it would be this, your age and finally your response to the appropriately selected protocol for ovarian stimulation that will be relevant.
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
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 Doctor Sher. I read your articles on OHSS, they are very detailed. thank you. But I have a question on what to do the day before and days after egg collection to help for a speedy recovery?
I triggered last night with 10,000 of HCG. I had my last scan and last blood test yesterday morning. the results were:
E2: 1,900 pg/ml
LH: 0.49
total follicle count: 30
follicles: LHS, mm (22,20,19,17,17,17,16,16,16,15,15,14,14,13,13,12)
follicles: RHS, mm (19,18,14,14,14,14,14,11,11,11,10,8,8,7)
I feel extremely full today, and my belly is very tight. I will have my egg collection tomorrow morning.
Is there anything I can do to make sure of a speedy recovery and reduce any risks of OHSS? And are there any warning signs I should watch for in case things are going bad?
Thank you!
Unfortunately the dye was cast with the trigger shot. Now it will be a wait and see approach.
Good luck!
Geoff Sher
Dear Dr Sehr
Honor to whom honor is due! 🙂
Dr Sher, in the meantime, I’ve also got my day 2 blood test results (in addition to the devastating AMH of 1):
AMH 0,78 µg/l, FSH 13,0 U/l, LH 7, U/l, E2 30 µn/l, Prolaktin 17,1 µg/l, THS basal 1,11 mU/l, fT4 13,6 µg/l.
Obviously, I don’t even have to try PGD anymore because even if I was doing several banking cycles, the chances of getting enough eggs that a) fertilise, b) make it to day 5 and c) are normal (and d) implant) is next to nothing :’-(((
We are beyond shattered and are wondering if there is any treatment which might still make it possible for us to become parents (apart from using donor eggs)?
If we tried it naturally, would we stand a chance or rather not?
And is there anything we could do/take to increase chances?
Or will our dear baby never get a sibling? :’-(
With grateful but desperate regards
Berry
I have recently undergone fertility treatment, Gonal f daily from cd 2-20 starting at 50iu dose, ending in 100iu. Triggering with ovitrelle and had a progesterone test cd28 which would be equivalent to day 21 in normal 28 day cycle. It showed a level of 42.6 and showed i ovulated. So got pregnant and currently 8 weeks pregnant on Wednesday. I am on off spotting brown blood and had a scan seven weeks which showed a heartbeat. I had intercourse and bled lightly red/pink again. I thought sex was safe during pregnancy. Is this indicative of impending miscarriage. Thank you.
No it is not indicative of miscarriage, but I would advise against sexual penetration until all bleeding has ceased for about a week.
Good luck!
Geoff sher
Hello Dr. Sher,
I would sincerely appreciate any information or help you could provide. I am 39 and have had two antagonist IVF cycles with Gonal-F/Menopur/Cetrotide and 250 mcg Ovitrelle. For the first (no OCP given / daily injections of 150 IU Gonal/150 IU Menopur, only 6 days of injections, follicles grew big too fast), 4 eggs were collected of 10 mature, only 1 fertilised with ICSI, quality grade D. In the second cycle I had the OCP (0.15/0030 mg desogestrel/ethinyl estradiol) for the previous month and Menopur was lowered to 75 IU. This time follicle growth rate was normal, injections lasted 8 days, of 8 mature eggs 5 were collected and 3 fertilised with ICSI. Two were transfered on Day 2 and 1 implanted but HCG was only 48 on Day 16. Although it rose well, both 6 and 7 week transvaginal scans showed a gestational sac of just 7mm, so abortion was induced.
For both cycles the endometrium was above 14mm on trigger.
For the next cycle I believe the doctors are planning to use a variation of the same treatment, and I am worried this may not be the correct protocol. However, they are unwilling to discuss this (it is public healthcare funded and they say they do what they believe is best).
In one private consultation I had the doctor said my hormone profile was a bit irregular (Day 3 LH 2 times higher than FSH) and they would need to take that into account, but did not specify how.
My question is, given your expertise, do you believe I am on the right protocol or are there any changes you could possibly suggest?
My hormone results on Day 3 of my cycle were:
AMH 3.17 ng/ml
Anterior follicle count: 5 right ovary 3 left ovary
FSH 7.41 mUI/mL
LH 13.07 mUI/mL
17-Beta Estradiol 65.63 pg/mL
Prolactin 19.75 ng/mL (4.79 – 23.3) MBA
TSH 1.54 µUI/mL
Testosterone 0.3 ng/mL
After the first poor IVF cycle the doctor also asked me to do a glucose challenge test with insulin determination, the results of which I believe were normal:
Baseline glucose 79,0 mg/dL
Glucose dose 75g
Glucose 60 min 131,0 mg/dL
Glucose 90 min mg/dL
Glucose 120 min 63,0 mg/dL
Baseline insuline 4.33 µUI/mL
Insuline 60 min 73.77 µU/mL JBP
Insuline 120 min 19.01 µU/mL