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 there first of all thank you for taking questions! I briefly looked through your web page and see you are the doctor of all ivf doctors and have helped so many people get their babies! My situation isn’t an infertility issue( I don’t belive I have one) my fiance and I have a random matching gene mutation which caused our one and only beautiful baby girl to be diagnosed with a terminal mitochondrial disease and unfortunately we only had her in our physical lives for 85 days. The heartbreak of loosing our little Luciella has been extremely difficult. We are now faced with the knowledge that we have 1 in 4 chance of another pregnancy being affected by the mutation. We are scared and heartbroken. My main questions for you are ( I know everyone’s different) but tipically when pgd is used for genetic testing and no other fertility issues are known, what are the chances of ivf working the first time? Also I have never taken birth control or hardly any medications at all in my life and I’ve been discovering there are many many meds needed for this process do any of them have major long term effects like breast cancer because of all the hormone confusion? Would I need to take all of the meds even though fertility isn’t the problem? What would be the protocol for me in your office? Thank you for your time it is much appreciated.
My heart goes out to you for your loss. I think we should talk and discuss at length. Please call 800-780-7437 and ask Julie to arrange for a Skype consultation with me.
Geoff Sher
Hi,
I did a FET and have been taking 2mg estradiol 2x day and 1cc progesterone injection once a day since 6 days before transfer. After getting a positive beta I added in cronine vaginally once a day. Today at 6 weeks my dr. Told me to continue the estradiol 2x per day but to just pick 1 progesterone. He said to either take the PIO 1cc injection or the cronine once a day but that i don’t need both. I haven’t gotten any bloodwork to determine my levels so I am afraid if I stop one of the progesterones I might jeopardize my pregnancy. Is taking only 1 cronine a day enough progesterone for a frozen cycle in which I am not making any on my own? Please let me know if you think this is okay or if I should consider getting a second opinion before I stop one of the progesterones. Thanks!
In my opinion, you should adhere to the recommendations of your treating RE. In my practice I usually recommend PIO/estradiol but if Crinone 8% is used instead, I recommend using it twice daily.
Geoff Sher
Hi Dr. Sher,
With my last two miscarriages via IUI, the 6 week gestational sacs were measuring a week (then more) behind, Currently I am 6 weeks pregnant again, but with a PGS-normal embryo via FET, and found that it is also measuring a week behind. In all these cases, the fetal poles were just a couple days behind, but the yolk sacs and heartbeats looked perfect.
What is the cause of gestational sacs measuring small? Is it a genetically abnormal embryo or uterine/implantation issue? I am not sure why this keeps happening and appreciate your insight.
This is not that uncommon and often picks up in growth. You need to wait a week or more and reassess. Hopefully all will be fine!
Good luck!
Geoff Sher
Dr Sher
I just completed my 2nd ISCI which was another failed cycle. First cycle i was 36 in 2015 with .74 AMH and higher killer cells. I had 7 follicles but few days before retrieval my left ovary was hiding. Dr said due to constipation. We ended up with only 1 follicle from right ovary with no egg. Fertility Speciliast was aware of High killer cells and i was given intralipids and Humira Injection prior to retrieval.
2ND CYCLE- i went to a different clinic out of country, my AMH when tested was 1.4 which i am shocked, is it possible For AMH levels to increase?
This cycle i had 6 follicles, 2 stopped growing, 4 eggs retrieved , 2 eggs were immature and only 1 fertilized , it was 8 cell grade 1 embryo and we did 3 day transfer. However i got negative result after 2 weeks. This Fertility Dr says high killer cells is not a concern so i was not treated for it.
I am devastated because on this cycle i found out my husband is Hep C + and he did not freeze his sperms and already started treatment for HEP c.
I have beem following your blog since my first cycle and now im thinking maybe i should have just stayed in the USA. My concern is i am in NY and i see you are located in Las Vegas. If i visit your clinic here in NY would you also be involved in the process or do i have to travel to Las Vegas?
Please advise.
I would not be involved in treatment of patients outside of Las Vegas. I will however say that most of my patients travel here from out of state and out of country for treatment.
For more than three decades, about 70% of the patients that I have performed IVF on, have journeyed to see me from out state or out of country. Over the years, I have been repeatedly asked how, given the distance separates us from our patients, we are able to provide optimal, efficient, and congenial services. This blog represents an attempt to describe how we accomplish this. It will outline the processes involved, and explain how the system we have put in place allows us to fully prepare and triage our patients at a distance, receive them in Las Vegas, monitor and treat them here, discharge them back to their home environments and then follow up with them through the diagnosis of pregnancy and post-IVF treatment (often with the welcomed and invited participation of their local primary physicians). It will also spell out how we are able to provide full and ready access to me and my team constantly, and finally, it will emphasize that the core of our success is routed in a commitment to being as accessible and affable as possible, at all times. In truth treating patients from afar is really not more complicated than is treating local patients. I am quite confident that if you were to ask those that have gone through the process, most, if not all, would tell you that we are well organized, seasoned in what we do and that the entire process is comfortable, easy and seamless.
Arranging for a Skype Consultation with me: Patients largely hear of Sher-IVF through word of mouth coming from the many thousands of women I have assisted in having babies over the years. Others reach Sher-IVF through Physician referrals, access to books and articles I have written on IVF and related topics, media and internet exposure or through personal online research by way of search engines. They then contact my wonderful “patient concierge”, Julie Dahan to set up a Skype consultation, either directly by calling 702-533-2691 or by email at julied@sherivf.com. Others access us by going to the Sher-IVF website at http://www.sherivf.com and making an online appointment for a Skype consultation with me that way. Regardless of how we are contacted, be assured that Julie (or her designee) will respond promptly to any such requests.
The Initial Consultation and the Report: During the initial consultation we discuss the medical and reproductive history in detail and I recommend additional testing necessary to identify the exact cause of the infertility and define an optimal approach to solving the problem. I thereupon promptly dispatch a comprehensive report by email along with a list of recommended reading of relevant articles to be found on my blog (to be found on http://www.sherivf.com).
Follow-up Administrative consultation: One or two working days later, patients receive a call from us to set up a date for a 1 hour phone consultation with our Practice Administrator, Sharon Jochman on the relevant logistical and financial considerations relating to IVF treatment with me. Thereupon, she will forward email information on such issues to patients for their review. At this point, no financial commitment to undergo treatment with me is requested or required. However, Sharon will place the patient (s) name on a tentative list for treatment in an upcoming IVF cycle batch (see below) and as that cycle draws near, she will contact the patient/couple to determine whether they wish to proceed with treatment, defer or cancel. This process protects the patient/couple from losing a chosen spot in the upcoming IVF cycle.This is because, unless in spite of best effort to contact them they are unreachable, or they expressly indicate a change of heart and wish to defer to a later cycle batch or opt out of the program, they will not lose their spot in their selected cycle of treatment. Then, subject to an expressed interest to proceed, the patient/couple would, for the 1st time, be required to make a financial commitment.
Consultation with a Nurse Coordinator: The nurse coordinator prepares patients for a cycle of treatment with me. She will discuss all the recommended testing and medical visits necessary.
Follow-up Consultation with me: Once the initial Clinical Coordinator consultation is completed and the requested tests and preparatory investigations have been done, the patient/couple has a wrap-up Skype or telephone consultation with me patients to discuss results advise and to finalize the protocol necessary for ovarian stimulation and fine tune the complete strategy for treatment.
The Nurse Coordinator Develops a Color-coded Calendar for the Upcoming IVF Cycle: At this point, the Nurse Coordinator generates an individualized and detailed color-coded electronic calendar that lays out the precise protocol that will be implemented. It starts with the use of a birth control pill, to be overlapped (for a few days) with a GnRH agonist (Lupron/Buserelin/Superfact), followed by all necessary medications involved in the process of preparation. She will go over the entire process and answer questions. A standard consent form will be forwarded to the patient/couple for their review and they will be invited to ask any questions on issues that are unclear. Thereupon consent form must be signed before we can proceed to treatment.
Access to us Throughout the Process: I provide all my patients with my cell phone number and encourage them to contact me with any medical issues at any time. They are informed that if they call and I am not immediately available, to leave their name and phone number on my voice mail and I will respond. Patients are also provided with Julie’s cell phone number and are invited to call her on any non-medical issue. Julie does an outstanding job of assisting patients with scheduling appointments with our staff and for testing, both locally and afar. She will also gladly assist and advise on travel/accommodation/and transportation to and from our office. I am told that rapidly Julie creeps into the hearts of my patients who rapidly bond with her and feel comfortable reaching out to her for advice and comforting.
How long will Patients Need to Spend in Las Vegas for Treatment? For fresh IVF cycles with embryo transfer the female partner needs to plan on being in las Vegas for up to 2 weeks here. While male partners are encouraged to spend as much time with their partners in Las Vegas as possible, they are really only required to be here on the day of egg retrieval (and we can provide them with a 3-4-day advance notification of that day). Actually, if the man is perfectly fertile, he does not even need to come to Las Vegas at all. Instead we could arrange for a specimen of his frozen sperm to be delivered to the clinic. This will not prejudice IVF results in any way. In cases where we do frozen embryo transfers (FET), it is not imperative that the male be present at all. However, we do encourage the male partner to be here with his partner to provide emotional support wherever possible. In cases of embryo recipient cycles (egg donation/embryo adoption/gestational surrogacy and FET the woman is needed to be present in Las Vegas for about 7-9 days. Those times can be calendared a few months in advance. In cases involving FET, the male partner is really not needed onsite at all, although his presence is encouraged for the purpose of providing his partner with the support she needs. In cases of Staggered IVF which involves preimplantation genetic sampling (PGS) of embryos for chromosomal selection, the embryo transfer is deferred to a later cycle to allow for genetic testing to be completed. This means that the woman is only required to be present onsite with us for about 7 days. The day following the ET, both she and her partner can return home. We stay in touch with them regarding embryo development and planning for the future.
Follow-up at home: The day after embryo transfer (or following egg retrieval in cases where all eggs or embryos are frozen and no ET is contemplated in the same cycle), the woman and her partner (as applicable) can return home to be followed at a distance by us and/or locally by their own primary care physician who (under our oversite) will conduct pregnancy testing and subsequent gynecologic services and when applicable, prenatal care.
IVF Cycle Batches and how use of the Birth Control Pill Facilitates this: At Sher-IVF, we perform IVF cycles in 9-10 two, week “batches per year. This means that a number of patients arrive together at a predetermined date for treatment. These batches are prescheduled to start on set dates that are calendared for an entire year in advance. This enables patients to make travel and accommodation arrangements well in advance. In order to effect this, patients who are to be treated in a particular batch need to start their cycles (onset of menstruation) on or around the same date. To synchronize their cycles, we place each woman on a birth control pill (BCP) to lead into the cycle of stimulation. By shortening or lengthening the time on the BCP, we can ensure that menstrual bleeding starts at the required time to coincide with the start of a given cycle batch. Contrary to the erroneous belief that the BCP suppresses response to gonadotropin therapy, provided that in the last few days of using the BCP, it is overlapped with a GnRH agonist (e.g. Lupron, Superfact, Buserelin), this approach actually improves response to ovarian stimulation.
Following the launching an ovarian stimulation cycle on a BCP and the subsequent addition of a GnRH-agonist the woman will have a bleed. At this point she will be required to have a baseline ultrasound assessment and have blood drawn for measurement of estradiol (E2). If she is from out of town, this will have to be done by her primary OB/GYN. Provide that the ultrasound does not detect an ovarian cyst and her estradiol level is <70pg/ml), she will be eligible to start taking gonadotropins for ovarian stimulation under our oversight. . We will by this time have schooled her and partner in administering the shots…so this should not present a problem. Thereupon she will need to arrange to arrive in Las Vegas for me to begin monitoring her response, 7-8 days after commencing ovarian stimulation. It is unusual (and even inadvisable) for a woman undergoing controlled ovarian stimulation (COS) for IVF to be ready for triggering with hCG prior to the 8th day of stimulation so her arrival should be timely and not be too late..
The process of treating patients who journey to Sher-IVF in Las Vegas from afar, might at first glance seem somewhat complex, but it really is not. I have, over the last 3 decades, developed a system that is very easy, convenient, safe, seamless, uncomplicated and highly effective. The vast majority of the seventy percent (70%) of my IVF patients who journey from out of state and from abroad for treatment with us in Las Vegas would attest to this. In fact, many of my patients who underwent IVF in their own environments before coming to Las Vegas have commented on our availability and accessibility, in spite of the distance separating us.
ADDRESSING DOR:
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”.
Older women as well as those 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
Dr. Sher have you ever seen a 1PN embryo at Fert check on day 1 that then progressed to 2 cells on day 2 make it to morula or blast and become a viable pregnancy?
Yes I have.
Geoff Sher