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’ve been dealing with unexplained infertility for 5 years. I’m 30 years old, and have been an IVF patient for two years. My hormone tests, lining, fertilization reports, final blastocyst numbers, …etc. Basically everything leading up to pregnancy tests are great or above average, but I can seem to get and stay pregnant. I would like to ask, do you think low and/or slow doubling betas can indicate an immune implantation issue? I have gotten pregnant 3 out of 4 transfers, but my I’ve been through beta hell each time. Also, I would like to ask if immue issues can cause defects in the fetus? Three out four of my losses were very early at or just before 6 weeks. But I had a pregnancy last year that progressed a lot farther, then the baby was diagnosed with catastrophic midline defects (ectopia cordis and omphalocele) at 12.5 weeks. We decided to end that pregnancy soon after due to the fatal prognosis. I have read that the errors that occur with midline defects happen around 5.5 weeks so I’m wondering if it’s possible to be connected. I did a second egg collection and PGS this summer, then a FET this fall, which is the 4th loss I’m currently experiencing. All other losses could have potentially had a chromosomal factor. My PGS results were 6 euploid embryos out of 10 tested, and my husband and I are negative for translocations. We are struggling with all the losses and defeat we’ve had. Thanks for your time.
There is to my knowledge, no correlation between immunologic implantation dysfunction and developmental defects. There is however a strong correlation between recurrent early losses (especially when the embryos are chromosomally normal, the uterus is free of surface cavitary lesions and the lining measures >8mm). Additionally, since clinical and subclinical hypothyroidism is often associated with an autoimmune cause , this makes an undiagnosed/untreated immunologic implantation dysfunction even more likely.
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
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 .
*FYI
The 4th edition of my newest 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
Hello Doctor Sher
I had an IVF 5th day transfer. At week 6.4 the FHR was 120. on the US.
I went for an Ultra Sound at 8 w 6 days. The baby measured 9 w and FHR was 171. After three days i got a home Doppler and i could hear the heart beat of the baby. I was turned over to my OB and he felt it i too early to hear at home and it could have been mine. I am scheduled to see him after two weeks. Last night i could not hear the heart beat with home monitor and i am so worried and scared. Should i go for an US immediately or wait. Thank you for taking time to answer our questions.
I doubt there is a problem…but yes! I would go in for an US.
Good luck!
Geoff Sher
Hi Dr. Sher,
I am 7 weeks pregnant and my TSH is measured at 2.59. I understand that for pregnant woman, the TSH should be 2.5 or lower. I have been taking medication for the past week (eltroxin 25mcg). My Free T3 is 4.4. My free T4 is at 14. I do not know what these levels mean. Can you please let me know if my T3 and T4 levels are okay for pregnancy? I’m really worried that my baby is getting affected (they say baby will have low IQ) in the first trimester. Please let me know.
Thank you so much in advance!
Sherry
I respectfully do not agree that a TSH of 2.7MIU in pregnancy warrants treatment. However, I think your T#:T$ is fine.
Geoff Sher
Hi Dr. Sher-
I just went through my first IUI cycle, using 5 days of oral Femara followed by Ovidrel trigger injection (unsure if it was 250mcg or 500mcg). The first cycle was unsuccessful. I am about to begin my second attempt and I am concerned that with my RE group, I am being lumped into a traditional IUI protocol and my care is not being tailored to my specific reproductive issues/age and what may work best for my situation. Background: I am 44yo and I have a 19yr old daughter from a previous marriage, so I do not have a history of infertility. I truly believe this is age related infertility. I recently re-married and we have been TTC for over a year. My GYN had recommended we see an RE in March and coincidentally just after this referral recommendation, I began having AUB which I had never had before. US revealed a large cyst on my left ovary (possibly an endometrioma). The RE recommended surgical removal of the cyst as well as removal of a large uterine polyp and several uterine fibroids. The surgery was performed in Aug, (she also performed a D&C due to very thick uterine lining and she also cleaned out “a lot” of endometriosis lesions within my pelvic cavity). I recovered well from the surgery and had my first IUI Oct 20, which as I stated was unsuccessful. To my knowledge, all of my hormone levels including my Cycle Day 3 levels were all normal, my ONLY abnormal level is an extremely low AMH (0.2) which I understand means that I have a very low ovarian reserve, and a low number of antral follicles. My first cycle of Femara only gave me one good follicle (measured 23mm).
I want to do everything we can to increase our chances at having a healthy happy baby, as my RE has already told us we are not candidates for IVF. IUI is the only option outside of egg donor that has been offered to us. I am not opposed to egg donor, but for us this would be a last resort as my husband is not fond of using an egg donor. Any suggestions on medications/ovulation triggering for our upcoming IUI cycles (my RE will do up to 6 cycles, so I have 5 left) would be greatly appreciated. Also, what is your opinion on starting progesterone to prevent miscarriage since a woman of my age carries a high potential for miscarriage.
Thank you so much for any and all advice Dr. Sher!
Sincerely
Tamara
In my opinion, IUI is contraindicated for women in their mid-forties , for women with diminished ovarian reserve. It is also far less likely to succeed in women with endometriosis. While IVF with own eggs is also associated with low success rates in such cases, it is still far more likely to be successful than IUI . This having said, you only realistic recourse is IVF with egg donation…in my opinion.
Geoff Sher
Hello Dr. Sher,
I am again writing to you in panic. I will be 7 weeks tomorrow. I had bleeding last Mon/Tue (preceded by week of spotting) that turned again into small spotting for few days to go back to a heavier bleeding again this morning. You mentioned it could be not visible on ultrasound sub-chorionic bleed. Could this be caused by Lovenox (I have homogeneous MTHFR mutation) and Baby Aspirin? – should I stop those?
Is it better in your opinion to stay in bed or is it better to walk a little to let this blood out so it doesn’t collect in the uterus? I was just told to take it easy and to come for my next appointment on Tuesday – should I insist on being seen today? … but I guess it wouldnt change anything anyway…
I am sorry to bothet you again – I really hoped that my next message would be saying that the blood stopped and everything is good but here I am again bleeding and scared. I hope it will not endanger this pregnancy…
Tthank you,
Zuza
I would call your OB, go in for an ultrasound and then follow the advice he/she gives you based on findings!
Good luck!
Geoff Sher