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.
My case seems similar to that of many of the women here. I’m 25, 4 years ttc and this year have done 2 fresh IVF cycles and 2 FET all same results. Beta is always positive yet low (18-23) on 12 days past 5 day transfer then falls. Last two FET were with PGS Normal embryos and most recent protocol O had endometrial scratch, transfered 1 PGS embryo and used intralipid 8 days before transfer, 20mg prednisone once daily, crinone 8% twice daily, folic acid and estrofem 2mg twice daily and baby aspirin. The initial beta was much higher this time at 74 but then dropped to 25 and 11.
It’s clear from my reading and the information in your book it’s implantation dysfunction.
Background
Had polypectomy in 2016, 4 removed and largest about 1cm, no endometriosis detected. Tubes clear, clockwork 29 days cycle. No issues with lining, always 10mm or above for transfers. Done all genetic and kyrotype tests with normal results.
Only result that wasn’t explained to me though high, was anti thyroglobulin at 8.9 (normal 0.0-4.1). I’ve never been on any thyroid medicines.
I’m not sure what to try next to prevent my body from rejecting embryos. What do you suggest?
Also my 4 remaining embryos are not PSG tested, do I continue with single embryo transfers or transfer two next to up my chances.
Thanks in advance for taking time to read my post.
Dr. Sher, I think I’m what you’d call a “poor responder” to IVF. Throughout my monitoring, all signs pointed to normal lining and follicle growth (from what I was told). I was stimmed for eight days with an antagonist protocol (412 units Gonal-F, 75 units Menopur throughout, plus Cetrotide for the later half of the cycle). However, upon egg retrieval, only three oocytes were found (and only one was mature). That egg fertilized normally and was transferred into me as a fresh blastocyst, but it failed to implant. I’m 33 years old, with moderate AMH (1.7) and an antral follicle count of 4-5 eggs per ovary. I have reviewed my monitoring records and I see that my E2 on the day I triggered (roughly 12 hours before 10,000 hCG trigger shot) had dropped from the day before (a drop from 1980 to 1620). On that last day of monitoring, my lining was “11B”, my P4 was 0.9, and I had 12 follicles of the following sizes: 22, 20, 20, 20, 20, 20, 17, 16, 16, 15, 15, 13. (Again, only 3 were found at retrieval, and just 1 mature). What would you recommend for another cycle? Very grateful for any insight you may have.
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”.
Women 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.
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 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
Hey Dr. Sher, hope you had a nice Thanksgiving. Wanted to ask you– what’s the consensus on lifting moderate things after a FET? We transfer on January 11th and it was easy to not lift anything the first time we did this, but now that I have a 13 month old son, not lifting him/holding him is virtually impossible. He’s about 23-24 pounds. Will I be really putting my embryo at risk by holding my son on transfer day/thereafter? Everything I read online says yes, but I’m so baffled by how that’s possible. I mean most women who get pregnant naturally wouldn’t think twice about lifting heavy objects. What’s the real risk there? I wonder if it might be more related to fresh cycles where you are at risk for ovarian torsion due to the hormonal stimulation.
Would appreciate hearing your thoughts/recommendations. Thanks in advance!
HimKate,
I aware of the fact that the standard advice given patients after ET is to avoid lifting anything heavy. However, in my opinion, this is both an unreasonable and often (as in your case)an impractical demand. Frankly, within 6-16 hours of the embryo reaching the uterus (naturally of following ET), it is wedged firmly in uterine glandular tissue and will not “fall out”. So, again in my opinion, intermittently lifting your child should not, in and of itself, be harmful.
Discuss with your RE.
Geoff Sher
Dear Dr Jeoffry,
I’m 3o years old and have been doing ICSI with my husband since we had 2 years of failed targeted attemps. I have multifollicular ovary but AMH 1.4.
I’m italian so sorry if my English is not so good.
With my stimulation protocol (based on gonal F: first day 225; then 125 and orgalutran from day 3 and suprefact for ovulation induction) last 9 days I produced 19 oocytes of which 13 mature and 6 fertilized.
After 7 days only 1 embryo reached the blastocysts stage (in day 7). This leave me very sad and afraid and so I started do deep dive on pubmed to understand which could be the reasons of this bad outcome.
I found that it could depend on
1) sperm DNA frangmentation ( my husband has 42 million sperm; only 4% normal; 50% total motility) but we didn’t tested this parameter
2) eggs quality: it is pretty rare at my age but not impossible (this makes me desperate and lost)–> in addiction eggs quality can not be assessed right? it’s just an hypothesis..
Now we are waiting for the result of the pre implantation diagnosis on our day-7 blastocystis but I’m not optimistic about this results.
In your opinion is there some hope that I will have a success by changing protocol or doing something else?
I will really appreciate your consult/advice, unfortunately my doctor didn’t use lot of empathy with me and I feel very lost.
Thank you in advance, looking forward to hearing from you soon,
have a good day,
Sara
In my opinion, the protocol used for ovarian stimulation and “triggering” with Lupron could be the problem.
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
Hi Dr. I do not understand if you answer to me…
Dr Sher, do you recommend natural FET with progesterone support? If not, why not? How do you normally do your FETs?
I rarely (if ever) do FET’s in natural cycles. Firstly, it is not always possible to have assurance that the hormonal balance will favor optimal implantation in such cases, and more importantly, determination of the “window for optimal implantation” is much more difficult to pinpoint without hormonal preparation and in my opinion this is a pivotal determining factor.
Geoff Sher