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’m not sure if this is the best way to reach out as I am new to the forum and wasn’t sure where to put my question. If you think I should put this somewhere else, please let me know and I will do so. And sorry for the long message! I just wanted you to have all the details.
My husband and I are both 33, own a gym and are personal trainers. We eat well most of the time, exercise, and I drink a cup of caffeine a day. We’ve been married for six years and I’ve had been intimate for that long and have never gotten pregnant. Ouch!
We have both been tested for genetic Karyotyping and it came back normal, his numbers are great and his DNA fragmentation test came back normal. However, I do have a history of unexplained infertility in my family. It took my mother seven years to get pregnant and then with her first ended up using Clomid to get pregnant. my sister has two children naturally but got pregnant with one of my nephews without a normal cycle and ended up getting pregnant with the second one after a failed IVF cycle. She had one normal period That year and got pregnant. Both my sister and my mom did not have regular periods.
I have normal periods that range from 28 days up to 40 but have seen them become a lot more regular since I gained the prescribed body fat that my RE suggested I did.
Two years ago my FSH was normal as well as the other hormones they tested, this past October, I somehow completely deleted those numbers. With gaining body fat, Those numbers are getting better.
Treatments:
2 iuis ( first one we got to do the iui , second one was canceled due to me overstimulating from Follistim.)
2 IVF cycles this summer
– (1) 3 weeks BC, 10 days Lupron, and stimmed with a combination of follistim and menopur. Triggered with 5000 units of hCG because was at risk for OHSS. Retrieved 19 eggs, 15 mature, 12 fertilized with icsi. Pushed me to a day five transfer and it was canceled because none of the embryos made it past six cells.
– (2) RE decided to see if my body would do better without the antagonist protocol and better with my natural cycle. We bathed my ovaries with estrogen before we started stimming. We use the same combination of meds to stim, 10,000 units of hCG to trigger, 17 eggs retrieved, 15 mature, 14 fertilized, pushed me to a day five again and the exact same thing happened, 0 made it past 6cells.
My RE who is based in Chicago has never seen two cycles in a row that this has happened. I am getting a second opinion with CCRM to see if a better lab would help my embryos grow past D3 but wanted to get your opinion on if we should try again, or consider an egg donor now? Different med protocol? Have you seen this before?
My RE is reaching out to colleagues to see if there is a supplement protocol they can put me on and also is going to use their other lab this time with my embryos to see if they do better there. He basically called this next cycle the Hail Mary to see if it will work. I also want to push for a day three transfer but he’ll only put them in if they are at 6cells and we aren’t even sure they are dividing to 6 by day 3 or later. Do you think no matter what a day 3 would be best?
Have you ever seen this before? Should we consider a new lab or get any additional testing done?
Thank you so much even at the very least for reading this. It just feels good to get it off my chest. If you do have any suggestions, advice, etc. it would be greatly appreciated. If not, that’s okay too! I’m sure you get bombarded with questions like these from all of us women who are just trying to make sense of the situation we are in.
Angela
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).
Here is the protocol I advise for women, <40Y who have adequate ovarian reserve.
My advice is to use a long pituitary down regulation protocol starting on a BCP, and overlapping it with Lupron 10U daily for three (3) days and then stopping the BCP but continuing on Lupron 10u daily (in my opinion 20U daily is too much) and await a period (which should ensue within 5-7 days of stopping the BCP). At that point an US examination is done along with a baseline measurement of blood estradiol to exclude a functional ovarian cyst and simultaneously, the Lupron dosage is reduced to 5U daily to be continued until the hCG (10,000u) trigger. An FSH-dominant gonadotropin such as Follistim, Puregon or Gonal-f daily is started with the period for 2 days and then the gonadotropin dosage is reduced and a small amount of menotropin (Menopur---no more than 75U daily) is added. This is continued until US and blood estradiol levels indicate that the hCG trigger be given, whereupon an ER is done 36h later. I personally would advise against using Lupron in “flare protocol” arrangement (where the Lupron commences with the onset of gonadotropin administration.
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
If you are interested in seeking my advice or services, 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 .
*The 4th edition of my book,”In Vitro Fertilization, the ART of Making Babies” is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.
Geoffrey Sher MD
Hi Dr Sher, what is your opinion on ERA tests? Do you think this improves the chance of IVF success? Many thanks in advance.
I do not personally believe in any value to the ERA and only use it when nmy patients so demand.
Geoff Sher
Hi Dr. Sher,
I am a breast cancer survivor. I had eggs frozen prior to receiving treatment in 2009. However, I recently found out all 6 of my eggs are immature. Is it possible to mature them, then fertilize them. Based on what I’ve read I think so. I would love your input on this matter. Also, I was told I’m not a candidate for fresh IVF due to my numbers. I just turned 43. Thank you!
Sincerely,
Hilda Rodriguez
It is in my opinion sadly , unlikely that immature eggs will survive the thaw in a state that they would mature up and be fertilizable.
Sorry!
Geoff Sher
Hey Dr. Sher,
First, thank-you for all your time! Your advice helped me get pregnant via IVF/FET with my now 9 month old son!
We have 6 frozen embryos, 1 of which is the same quality as our successful embryo and 3 of which are average/above average quality. We’re trying to decide whether to do a regular FET transfer, trying one embryo at a time until we’re successful (or doing another cycle if none of them take) OR doing PGS/PGD testing on our frozen embryos. That would require us to thaw them, test them, then refreeze and then thaw again at time of transfer (testing results take 1-2 weeks, I’m told).
My concern with that is that the embryos could potentially be damaged/destroyed during the thawing/refreezing/thawing process. I’ve read really mixed things about this “risk” and would be interested to hear your take. Would an embryo that gets destroyed in the thawing/refreezing/thawing process not be viable anyway? Or could doing the procedure potentially destroy good, viable embryos/babies?
I look forward to hearing your thoughts, god bless!
No doubt,pregnancies are reported from secondarily thawed-biopsied-refrozen and then re-thawed (for transfer)embryos BUT in my opinion, the process is too traumatic for the embryos. I would rather transfer them without this undue added stress. Remember, PGS can never improve embryo quality. It only helps select those that are more likely to be competent.
Good luck!
Geoff Sher
Dear Dr Sher,
My husband and I need to use a sperm donor and we are in the process of selecting. I am CMV negative though. Do we need to pick a sperm donor who is CMV negative as well? We are going to bank embryos and transfer them on a later date. I can see how CMV may be transmitted to the mother through IUI-but does the same thing apply when creating embryos, freezing them and transferring on a later date? Thank you very much.
It is only significant if the SD vis IgM + ve fort CMV at the time of producing the sperm. IgM + is not relevant as it points to past infection.
Geoff Sher