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.
had a FET of two 5 day Blasts on 11/08. my first beta showed 83 on 11/16. my second beta showed 623.6 on 11/20. Last night 11/24 I tested on a First response test and my line was more faint than it was a week ago. Should I be worried and request another Beta before my ultrasound on 12/4. Or is it true that once HCG levels become so high, this can cause a pregnancy test to malfunction known as “hook affect? I have had 1 miscarriage and 1 chemical. I am worried I may miscarry again.
Frankly, I would just wait and do the US on Monaday the 4th.
Good luck and G-d bless!
Geoff Sher
I’m having a sET on Monday. Is there any harm with intercourse beforehand? What are your thoughts on intercourse afterwards?
In my opinion…no harm!
Geoff Sher
Hi Dr. Sher,
Thank you for answering all our questions. It is so helpful to people like us. Quick question: does your clinic do sex selection of embryos? I have several frozen embryos…and I live in Canada. I heard somewhere in the states they do gender selection and I’m wondering if your clinic is one of them. Would it be possible to ship all the embryos? Is it safe for the embryos to be shipped across the border?
Thank you for your help and advice.
Michelle
Yes we do gender selection. If the frozen embryos are day 2 or day 3, they can be thawed, taken to day 5-6, get biopsied and the blastocysts can be safely re-vitrified (frozen) while awaiting results for a subsequent transfer in a later cycle . However, while possible, in my opinion it is not a good idea (too traumatic) to thaw blastocysts for biopsy and and then immediately re-freeze them for later transfer.
Geoff Sher
Hi Dr Sher,
I am 26 years with severe endo, Fast recurring of endo cysts. My periods are regular and have severe pain on first day of period,normal 3 day flow, have fatigue through out month. I have done 2 laproscopic surgeries to remove chocolate cyst in 2012 & 2015. My AMH is 3.6. TTC for 4 years. Had 3 failed IVF(1 Fresh cycle and 2 FET). My husband has low motility and normal form but doctor told it is enough for IVF basis.
IVF 1: Lupron for 15 days and started stimulation, collected 13 eggs, 10 fertilized(8 cell and 7 cell on day 3) but poor quality, all embryos were fragmented. I had endometrioma of 4.1cm in left ovary and a small one of 2cm in right ovary before stimulation. Transfered 3 embryos. That Fresh cycle failed. After that i took 3 months of lupron and transfered remaining 3 embryos and that FET also failed.
IVF 2: 3 Months lupron, after that 5cm cyst aspirated and undergone 3 months of Ayurveda treatment. My cyst again grown back to 3.8cm by that time. But started stimulation without removing cyst and got 6 eggs this time but 2 fertilized , poor quality embryos, 1 transfered but failed.
Can you please suggest the best IVF Protocol for me?
How can i improve my egg quality? Is there any chance for me to get a baby with my own egg or should i consider donor egg?
How to test if there is any immunologic issue for me and if it is tested positive which treatments should i do ?
What is your opinion about Endometrial Receptor Gene Assay (ERGA) for implantation issues, is it helpful for my condition?
What is your opinion about taking naturopathy medicines 6 months prior to start IVF? I have consulted a naturopath he prescribed following medicines. will it interfere with IVF medicines?
1. L Glutamine 500 mg
2. Bee Propolis 1000, 500 mg
3. Omega-3 Wild Alaskan Salmon Oil 1000mg
4. New Chapter Perfect Prenatal Multivitamin
5. Femmenessence MacaHarmony 500 mg ( Natural Health International)
6. Nature’s Way Primadophilus Fortify Women’s Probiotic
7. NEPRINOL AFD 500 MG
8. Nature’s Way DIM-plus, Estrogen Metabolism
9. Pycnogenol 60 mg
10.NAC, 600 mg
Thank you
Endometriosis can impact IVF outcome profoundly. Advanced endometriosis can impact egg quality…especially if there are endometriomas, while and/or reduced ovarian reserve while endometriosis of any degree of severity is associated with an immunologic implantation dysfunction in about 1/3 of cases (see below).
For information regarding Nutritional Supplements in Preparing for IVF, also see below!
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.
•Endometriosis and Infertily
•Endometriosis and Immunologic Implantation Dysfunction (IID) and IVF
•Endometriosis and Infertility: Why IVF Rather than IUI or Surgery Should be the Treatment of Choice.
•Endometriosis and Infertility: The Influence of Age and Severity on Treatment Options
•Early -Endometriosis-related Infertility: Ovulation Induction (with or without Intrauterine Insemination) and Reproductive Surgery Versus IVF
•Treating Ovarian Endometriomas with Sclerotherapy.
•Effect of Advanced Endometriosis with Endometriotic cysts (Endometriomas) on IVF Outcome & Treatment Options.
. 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 Dr Sher,
My name is Colleen. I have been struggling with infertility for quite some time. I have a toddler whom was conceived via IUI and born via c-section. I have been attempting to have a second child for over a year and a half now. I do a history of endometriosis; however, both tubes are clear, and my husband does have a slightly higher than average abnormal morphology count. My husband and I are both 33 years of age. In addition to the endo, I also have a lower normal range AMH (1.22 tested in March of this year). I also did experience ovarian torsion at the beginning of my pregnancy with my child, but my ovary did not have to be removed. I have had two sonos completed over the past 1.5 years and both were clear of fibroids, etc. I attempted three IUIs prior to my first IVF egg retrieval. Each IUI I took 75 iu of follistim and would get 2-3 follicles.
I began my first IVF egg retrieval July 2016. I took 200 iu of follistim, lovenox, baby aspirin, and ganirelex, triggered with lupron. I ended up with 5 blastocysts, high gradings, but NOT PGS tested. I transferred one per cycle, two resulted in chemical pregnancies, and the remaining were negative. Two of the cycles I did have an endo scratch completed.
Moved onto a second egg retrieval earlier this year with PGS testing. I was a low responder to the follistim at 300 iu so eventually my dose was increased to 450 iu, along with ganirelex, lovenox and baby aspirin, triggered with ovidrel. No healthy embryos resulted.
Third egg retrieval I took 450 iu of follistim with HCG, ganirelex, lovenox, baby aspirin, and triggered with ovidrel, 1 healthy embryo resulted.
Fourth egg retrieval I took 450 iu of follistim with 150 iu of menopur and 100 mg of clomid, ganirelex, lovenox, baby aspirin, triggered with ovidrel, 1 healthy embryo resulted.
Completed an FET the month after with one of the PGS tested embryos, negative.
Moved onto a fifth egg retrieval with 450 iu of follistim, 150 iu of menopur, 100 mg of clomid, ganirelex, lovenox, baby aspirin. Only difference was I triggered with lupron instead of ovidrel. 3 embryos made it to be biopsy, still awaiting results.
6 days after my last egg retrieval, we tried something different and did essentially a fresh transfer but with a frozen embryo. The embryo was PGS tested and fully hatched (zona free). I just found out that it did not implant.
I am at a loss here. I don’t understand how two PGS embryos have failed when I have technically been pregnant three times. I was able to get pregnant on just 75 iu of follistim via IUI with my daughter, but have completed 5 egg retrievals and 6 transfers with IVF and I’m still not pregnant.
One other thing to note, not sure of its importance, each FET cycle I have completed, I also get fluid accumulation in the uterine cavity. Once medrol and progesterone are started, fluid reabsorbs into the body.
Do you have any suggestions of something I should try differently? I am scheduled to meet with my Dr next week to discuss potential options. Any insight is greatly appreciated!
Please be cognizant of the fact that endometriosis is associated with implantation dysfunction due to immunologic implantation dysfunction in 1/3 of cases (see below).
Also, 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.
• Endometriosis and Infertility: Why IVF Rather than IUI or Surgery Should be the Treatment of Choice.
•Endometriosis and Infertility: The Influence of Age and Severity on Treatment Options
•Early -Endometriosis-related Infertility: Ovulation Induction (with or without Intrauterine Insemination) and Reproductive Surgery Versus IVF
. 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