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.
Hello Doctor! I had 3, 5 day very good embryos transferred on the 16th of November. I’ve been on vaginal susten, inj clexane, oral progyanova, duphastone and ecosprin daily and inj susten once every 4 days. My hcg on the 27th of November is 13.9. My doctor has advised another beta in two days but says that chances are slim. This is our first attempt (I’m 42 yo). What would your advice be?
Hi Kate,
The level is on the low side, but if it were to double (or better in the next 2 days, that would be encouraging.
Good luck!
Geoff Sher
Hi Dr sher.I have undergone 2 ivf cycles through icsi.as my husband cannot ejaculate due to absence of vas defernes and also he has morphology.and all my reports are clear.in my first cycle I had 3 embryos transfered on day 2.in second cycle 2 embryos were transfered on day 3.both the cycles failed.and now I have got 2 blastocysts from my 2 cycle.my doctor says this is because of poor sperm quality.medication given after ET are volfol FS and utrogestan 200mg 3 times vaginal use.how my cycle could be better this time please guide me.my doc says as this time it is blastocyst the success rate would be more.
It is important to also be try and determine if there is an implantation dysfunction.
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 Sher !
Hope you are well. I had a question on intrallipds/ivig. I know in the past you were an advocate for ivig but prefer to use intrallipds now . With ivig I know it was usually administered one week befor FET is intrallipds the same or a different animal all together? Is intrallipds something that can be done weekly ? Thanks so much !
No! Both are administered 10-14 days before ET and again with a positive beta hCG test!
Geoff Sher
Hi Dr Sher. You say BCP should be taken for a minimum of 10 days. Does this ten days include the lupron overlap such that it’s 10 days on BCP with last 5 days being Lupron (so 10 days of BCP all up) or did you mean 15 days of BCP with last 5 days of lupron (so 15 days of BCP all up)?
Yes, it does include the Lupron overlap!
Geoff Sher
gEOFF sHER
Hello,
I have recently gone through my first Retrieval. I am 32 and my husband is 37. We have unexplained infertility. We have had 5 failed IUIS over the last year. My husbands analysis is normal, though a little on the slow side. For this stim cycle I was taking 150IU Menopur and 225IU Gonal-F. On day 4 my doctor added in the cetrotide. on the 11th day of stems, i had 29 measurable follicles. 5 of them were 18mm and above. 10 more of them were between 15 and 18 mm. My estrogen was just north of 4000. I triggered that night at 930pm with .8ml Lupron and my retrieval was scheduled for 36 hours later. On the morning of the retrieval, the clinic was running late and I was taken back an hour and a half late. After the retrieval, I was told that because of the delay, a lot of my follicles had already released. Only 6 eggs were retrieved. I later found out that of those 6, only 2 were mature. Those two were fertilized with ICSI. Now we are currently waiting to see if they make it to be frozen. I am not very optimistic. We were stunned and devastated. My clinic has acknowledged the error and is working to make it right as best they can. In the mean time, if we are going to have to do another cycle, I want to make sure that we are doing the right thing. My doctor seemed a little surprised that even a 90 minute delay had such an impact and is thinking that maybe I ovulated a little early. We are considering an earlier retrieval next time (maybe 35 hours instead of 36 hrs after trigger).
What can we do to try to ensure that we don’t have this issue again? This is assuming of course that the do not have the same snafu in thing at the clinic. Is there any way to prevent this possible early ovulation. Would my clinic have been able to tell that follicles had already released?