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by Dr. Geoffrey Sher on December 1, 2015

You are not alone. Dr. Sher is here to answer your questions and support you.

If you would like to schedule a one on one Skype, telephone, or in person consultation with Dr. Sher, please fill out the form on the right and our team will get you scheduled right away.

Dear Patients,

I created this forum to welcome any questions you have on the topic of infertility, IVF, conception, testing, evaluation, or any related topics. I do my best to answer all questions in less than 24 hours. I know your question is important and, in many cases, I will answer within just a few hours. Thank you for taking the time to trust me with your concern.

– Geoffrey Sher, MD

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  • Nicole McTaggart - February 4, 2016 reply

    HI Dr Sher, i have had 8 failed IVF’s 6 of which where fresh cycles on the last cycle which was a FET we transferred 2 hatching blasts all we had, i fell pregnant but lost the pregnancy at 7 weeks, incomplete miscarriage took 2 weeks to fully pass everything, I am 37 i have good AMH at 27.7 I am in Australia my FSH is always at 4 never changes from cycle to cycle. I produce good amounts of eggs, last time i got 29 20 mature 15 fertilized, had 11 top quality day 3 embryos but by day 5 only had one left. My partner is a smoker and drinks a bit his sperm seem ok, but we had no fertilization at all with normal ivf first cycle, so every other cycle have been ICSI. Are my eggs just plain crap, or do i have hope. Last cycle we added prednisone and aspirin and intralipids, and i did fall pregnant but i lost the baby. I have an Auto immune issue called AS (Ankylosing spondylitis). Last cycle i stimmed with menopur only started at 175 and ended up at 225 added ogralutran at day 4, we have also done long protocol with gonal f only and a nasel spray and also a short protocol with luveris and gonal f, none of these have given us any more than 3 blasts max, even though i get more than 20 eggs each pick up. Is there anything i can do or are we doomed to never having babies together. I have had 3 babies with my ex husband, i had a tubal ligation in 2004 after the birth of my son. So is it just that now I am to old even though my levels are still very good. Or is it something else that is causes such poor blasts and outcomes. Thanks for reading this.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 4, 2016 reply

    I do not think you are too old or that you intrinsically have bad eggs.When confronted with “unexplained” IVF failures where morphologically good embryos were transferred, the question arises as to whether the problem is due to inherent egg/embryo “incompetence” (which usually equates with an irregular chromosomal configuration [aneuploidy]) or whether it is due to an implantation dysfunction. The younger the woman and the higher the quality of available embryos (preferably blastocysts), the less likely it is that the fault lies with embryo “incompetence” and the greater is the likelihood that it is due to underlying implantation dysfunction.
    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)
    Implantation dysfunction (anatomical or immunologic) is a common cause of repeated “unexplained” IVF failure with good embryos. 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.

    Please visit my new Blog on this very site, find the “search bar” and 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)
    • 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.
    • The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
    • Frozen Embryo Transfer (FET): What does it Involve?
    • Recurrent Pregnancy Loss (RPL): Why do I keep losing my Pregnancies?
    • 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)
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF
    I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.

    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 4, 2016 reply

    When confronted with “unexplained” IVF failures where morphologically good embryos were transferred, the question arises as to whether the problem is due to inherent egg/embryo “incompetence” (which usually equates with an irregular chromosomal configuration [aneuploidy]) or whether it is due to an implantation dysfunction. The younger the woman and the higher the quality of available embryos (preferably blastocysts), the less likely it is that the fault lies with embryo “incompetence” and the greater is the likelihood that it is due to underlying implantation dysfunction.
    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)
    Implantation dysfunction (anatomical or immunologic) is a common cause of repeated “unexplained” IVF failure with good embryos. 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.

    Please visit my new Blog on this very site, find the “search bar” and 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
    • Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • 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)
    • The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • Hereditary Clotting Defects (Thrombophilia)
    • Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
    • Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
    • 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)
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF
    • The Role of Nutritional Supplements in Preparing for IVF
    I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.

    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

  • Kristin - February 3, 2016 reply

    Hi Dr. Sher, I recently had my first failed IVF cycle. I have a two year old daughter that I conceived naturally by taking 2.5 mg of Fermara with no trigger shot. Since that pregnancy, we have tried to have a second child with many failed attempts at IUI (7.5 mg of Fermara and Trigger) and now our first failure with IVF. During this process I learned that I have a low AMH .95. I am 34 years old and all other tests came back in the normal range. My husband also has normal sperm. During this IVF attempt, they had me on 2 weeks of birth control and then transitioned over to 450 of Follistim and 20 mg of mini-HCG. I had 7 “mature follicles” (the seven were all above 14 mm at the time of trigger and I believe about 4 of them were in the 16-18 range) at the time of the trigger shot and a total of 8 follicles showing up. At retrieval they were only able to retrieve 5 eggs, 3 of which were mature. All 3 fertilized properly and all three made it to the day 5 transfer. We transferred 2, one was an early blastocyst and the other was a 5AA blastocyst. The 3rd they monitored until day 6 and said it was not of good quality to freeze. We just received the news that this cycle did not result in pregnancy. My questions to you are the following: 1) Based on this information, if you were my provider would you use a different protocol for medications on my next cycle? 2) Is there anything that can be done to ensure that I will have more mature follicles on the next cycle at retrieval and also follicles that actually release an egg since 3 of mine were not able to have an egg retrieved? 3) Based on my AMH level do you feel that we can have success with another round of IVF or is it going to be an uphill battle that won’t be beneficial? 4) Is there anything that I can do before another cycle to be more successful? Ex. Taking CoQ10 or any other supplements, etc. Thank you so much for your time.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 3, 2016 reply

    1) Based on this information, if you were my provider would you use a different protocol for medications on my next cycle?

    A: I certainly would. I would use a robust modified long protocol (the agonist/antagonist conversion protocol-A/ACP) with human growth hormone augmentation…see below

    2) Is there anything that can be done to ensure that I will have more mature follicles on the next cycle at retrieval and also follicles that actually release an egg since 3 of mine were not able to have an egg retrieved?

    A: Please read the article below on “Empty Follicle Syndrome”

    3) Based on my AMH level do you feel that we can have success with another round of IVF or is it going to be an uphill battle that won’t be beneficial?

    A: Yes I do…but I think you should also consider “Embryo Banking” and PGS embryo selection.

    4) Is there anything that I can do before another cycle to be more successful?

    A: Mos supplements do not really help. However, please read the article below on “Nutritional Supplements in IVF”.

    Please visit my new Blog at http://goo.gl/4hvjoP, find the “search bar” and 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
    • Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
    • Ovarian Stimulation for IVF: Comparing “conventional” use of GnRH antagonists to the Agonist/Antagonist Conversion Protocol (A/ACP)
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • 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)
    • Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
    • The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • Hereditary Clotting Defects (Thrombophilia)
    • 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 Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
    • IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF
    • The Role of Nutritional Supplements in Preparing for IVF
    I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.

    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

  • M - February 3, 2016 reply

    Dear Dr Sher,
    I had a hysteroscopy last week and minor scar tissue/ adhesions were reported. I saw the video and they looked like white fluffy clouds. I have already had a chemical pregnancy after IVF and 1 failed FET & 2 years unexplained infertility. I have no history of prior pregnancy/ miscarriage/ surgery/ other trauma to the uterus prior to this hysteroscopy. The only risk factor I have was a prior chlamydia infection. The doctor said he cleared everything but that he does not think it was such a significant cause for my unexplained infertility”/ failed embryo transfers. He has always informed me that I have had a perfect triple lining during ultrasound and my period are largely regular and medium flow. I am currently taking antibiotics post hysteroscopy for 1 week but no other treatment. I have been advised that I can continue with embryo transfer after 2 cycles as I have more frozen embryos. I am feeling very confused.How can I know if the scar tissue will recur or even if it is completely removed? Even before the hysteroscopy nothing was visible on ultrasound/ HSG. What further treatments/ investigations are indicated in such a case? Do you think it is the likely cause of my infertility? Would you recommend a laparoscopy in my case to look for further pelvic adhesions? My doctor previously advised he does not think it is necessary as IVF is more efficient than laparoscopy.
    Thanking you so much for any guidance!

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 3, 2016 reply

    I would agree with your doctor regarding not doing a laparoscopy and as far as hystroscopic findings are concerned, it does not sound like a big issue either.

    When confronted with “unexplained” IVF failures where morphologically good embryos were transferred, the question arises as to whether the problem is due to inherent egg/embryo “incompetence” (which usually equates with an irregular chromosomal configuration [aneuploidy]) or whether it is due to an implantation dysfunction. The younger the woman and the higher the quality of available embryos (preferably blastocysts), the less likely it is that the fault lies with embryo “incompetence” and the greater is the likelihood that it is due to underlying implantation dysfunction.
    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)
    Implantation dysfunction (anatomical or immunologic) is a common cause of repeated “unexplained” IVF failure with good embryos. 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.

    Please visit my new Blog on this very site, find the “search bar” and 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)
    • 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.
    • The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • 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)
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF
    • The Role of Nutritional Supplements in Preparing for IVF
    • Endometriosis and Infertily
    I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.

    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

  • Liljana - February 3, 2016 reply

    Dear Dr. Sheer,
    Today on 8dp3dt I had my first beta hcg result. It is 66. Is this a good number?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 3, 2016 reply

    Yes Lijana…although a little early, this is hopeful!

    Repeat in 2 days.

    Good luck!

    Geoff Sher

  • Emily - February 3, 2016 reply

    So I am on day 3 of coasting have about 16 follicles between 18 and 22mm and another 15 over 15mm – waiting on e2 levels to decide weather we wait another day or trigger this evening. Which gives better results pregnal or ovitrel? My doctor says she won’t give me the 10000u but maybe 7500 if e2 levels are low enough… any advise at this stage. I personally think I should coast for another day and push for the full hcg?

  • Michelle - February 3, 2016 reply

    Hello Dr. Sher,

    I am a healthy 41 yr old and have gone through 4 failed ivf’s. I respond will to meds and produce about 10 eggs each time with over 80% mature and fertilising. Husband is good.

    Do you think there is an ideal protocol for someone with poor egg quality? to date, all cycles have consisted of 7 or 8 days of stim on 150 of Gonal and 150 Menopur with orgulatran, some with birth control and some without. Also did a short lupron protocol which was a total bust. Been taking ubiquinol for past 4-5 months and little improvement on last round.

    Any suggestions on supplements or changes in protocol?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 3, 2016 reply

    Hi Michelle,

    Hi Michelle,

    In my opinion, “microdose” (“flare”) Lupron and late antagonist protocols, are less than optimal in older women and hose with with DOR (see below). The former surges LH and the latter fails to suppress body’s own LH from the get-go of the stimulation process, often resulting in a rise in ovarian testosterone as the stimulation begins. Excessive ovarian testosterone can have a deleterious effect on egg quality/competency…especially in older women and also in women s who have DOR. In my opinion you need a modified, robust, long pituitary down-regulation protocol. I would use an agonist/antagonist conversion protocol with human growth hormone (HGH) augmentation and would recommend Staggered IVF with embryo banking of PGS (next generation gene sequencing)-normal blastocysts, to make hay while the sun still shines.

    I strongly recommend that you visit my NEW personal website at http://www.DrGeoffreySherIVF.com and when you reach the home page, go to my new Blog find the “search bar” and 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
    • Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the “Conventional” Antagonist Aproach
    • Ovarian Stimulation for IVF: Comparing “conventional” use of GnRH antagonists to the Agonist/Antagonist Conversion Protocol (A/ACP)
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • 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)
    • Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • Hereditary Clotting Defects (Thrombophilia)
    • Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
    • PGS-Biopsy for the Assessment of Embryo Numerical Chromosomal integrity (Ploidy): Should it be done on Day 3 or on Day 5-6 post fertilization?
    • Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
    • Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
    • IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
    • The Role of Nutritional Supplements in Preparing for IVF
    I invite you to call 702-699-7437 or 800-780-7437 and set up an one hour Skype consultation with me to discuss your case in detail.
    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

    Please visit my new Blog on this very site, find the “search bar” and 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
    • Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • 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)?
    • The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • Hereditary Clotting Defects (Thrombophilia)
    • 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 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?
    • IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF
    • The Role of Nutritional Supplements in Preparing for IVF
    I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.

    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

  • Evan - February 3, 2016 reply

    Dr Sher,

    Is there erally a difference between patient responses to Follistim versus Gonal-F? My insurance will pay for the follistim, but not Gonal-F. I just had an aweful cycle with Follistim. Can switching to Gonal-F really make a difference?

  • Melissa - February 3, 2016 reply

    Dear Dr. Sher,

    I am hoping you can provide insight on what went wrong and give your honest opinion how we could have had better results from IVF.

    Our history – I’m 34, husband is 41, trying to conceive our first child. We were told based on poor sperm morphology and sub par progression that our chance of conceiving without IVF was less than 5%. So after 2 years and three failed clomid/femara IUIs we moved on to IVF. I have never been pregnant and my husband has never impregnated anyone, but neither of us tried prior to us trying now. We have a known issue with the sperm , but after a very disappointing IVF cycle I am wondering whether my eggs have a quality issue and that is contributing to the problem, or the failure lies more with the IVF protocol we used.

    My lab stats for the pre IVF workup were all good numbers. RE says I don’t have PCOS because no hormone imbalance, but do have PCO due to high AMH and antral follicle count. My periods are very regular and I have “strong” ovulations.
    Day 3 labs:
    FSH: 5.1
    LH: 7.1
    Estradiol: 45
    AMH: 8.06
    Testosterone: 51 (slightly elevated?)
    Free testosterone: 2.6 pg/mL
    DHEAS: 249 mch/dL
    DHEA: 339 ng/DL
    TSH: 2.28

    IVF meds protocol: BCP for three weeks (Desogen)
    E2 check at baseline was 4 and over 30 AFC.
    Day 5 of cycle, start stims, 150 IU follistim.
    E2 level after 3 days of follistim: 687. Responding too quickly, instructed to lower dose to 100IU follistim.
    E2 day 5 stims: 1667. Level “good”, add in 75 IU Menopur and ganirelex to 100IU follistim.
    E2 day 7 stims: 3600.
    E2 day 8 stims: 5142. Instructed to trigger that night with 4mg Lupron and 600IU HCG.

    Was told HCG is superior for triggering, but I would end up very sick so going with a safer protocol. My fear was that the trigger would not finish the job and that I stimmed too quickly knowing slow and steady statistically has better outcomes.

    Retrieval day: RE is expecting 30 mature eggs based on E2 level morning of trigger and ultrasound. 32 eggs were retrieved, yet only 13 (initially) mature eggs. Was told by the embryologist that another 12 could maybe be mature and they would update us in a few hours. Final count of mature eggs was 18 for attempted fertilization with ICSI. 10 fertilize with ICSI but still waiting on embryo grading status. Of the 18 mature eggs, 3 were graded good (highest rating at our clinic) and 15 graded as fair. Are fair eggs good enough?

    Our question now, as it hadn’t even been discussed until the disappointing retrieval and fertilization, is are we dealing with an inherent quality issue with my eggs? Or rather was our IVF protocol not ideal and caused mainly immature eggs with a poor fertilization rate?

    While still in recovery it was discussed a change of protocol (if next time is needed) and whether or not I should be treated more as a PCOS patient with egg quality issues and not as a woman without any known fertility issues seeking IVF to overcome MFI. Until now the diagnosis was MFI and that we would have excellent IVF success.

    Any insight or speculation as to where we went wrong is very much appreciated.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 3, 2016 reply

    I do not think you have inherently defective eggs, nor in my opinion, is this a sperm issue.

    Based upon your inverted FSH:LH ratio, your high AMH and the large number of follicles you produce, Ido think you have PCOS. This condition is typically associated with ovarian hyper-response and a higher % of poorer quality eggs. The problem is often that in an attempt to avoid severe ovarian hyperstimulation, the doctor often will trigger before follicles have reached optimal development and then use either a lower than ideal dosage of hCG or use Lupron for the trigger. In my opinion there is a better way to stimulate PCOS women…i.e. “prolonged coasting”.

    Down-regulation + “prolonged Coasting: My approach is consistently to use a long pituitary DR protocol with an agonist, coming off 1-2 months on the BCP. The latter is intended to lower LH and thereby reduce stromal activation (hyperthecosis) in the hope of controlling ovarian androgen release. I then stimulate with low dosage FSHr to which I add a smidgeon of LH/hCG (Luveris/Menopur) from the 3rd day and watch for the # of follicles and [E2] starting on the 7th day of COS. If there are > 25 follicles, I keep stimulating (regardless of the [E2] until 50% of all follicles reach 14mm. Then, provided the [E2] is >2500pg/ml, I stop the agonist and the gonadotropin stimulation and follow the E2 (only) daily, without doing further US examinations. The [E2] will almost invariably climb and I watch it go up (regardless of how high the concentration of E2reaches) and track it coming down again. As soon as the [E2] drops below 2500pg/ml (and not before then ever), I administer 10,000U hCGu or hCGf (Ovidrel/Ovitrel-500mcg) as the “trigger” and perform an egg retrieval 36h later. ICSI is a MUST because “coasted” eggs usually have no cumulus oophoris and eggs without a cumulus will not readily fertilize on their own. All fertilized eggs are cultured to blastocyst (up to 6 days). And up to two (2) are transferred transvaginally under US guidance.

    The success of this approach depends on precise timing of the initiation and conclusion of “prolonged coasting”. If you start too early, follicle growth will stop and the cycle will be lost. If you start too late, you will encounter too many post-mature/cystic follicles (>22mm) that usually harbor abnormally developed eggs.

    Use of the above approach avoids unnecessary cycle cancellation, severe OHSS, and optimizes egg/embryo quality. The worst you will encounter is mild to moderate OHSS and this too is uncommon.

    I do not use antagonists in high responders (e.g., PCOS) because it interferes with the assay of E2 (often causing the value to be understated), a valuable index in assessing risk for the development of severe/critical OHSS. I also do not believe in the agonist trigger to prevent OHSS. The reason is that the magnitude of the induced LH surge varies and if too little LH is released, meiosis can be compromised, thereby increasing the oocyte aneuploidy index.

    Please visit my new Blog on this very site, find the “search bar” and 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
    • nti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF)
    • Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF
    • The Role of Nutritional Supplements in Preparing for IVF
    • Understanding Polycystic Ovarian Syndrome (PCOS) and the Need to Customize Ovarian Stimulation Protocols.

    I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.

    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

  • Sue - February 3, 2016 reply

    Dr. Sher, I am cycling for 7th time after a miscarriage break. My stim is same under estrogen prime with ganirelix. However, my day 7 estrogen is only 200 instead of the usual 500 or 600. My protocol is 300 foll/75 menopur. Was wondering if I should speak to dr about increasing med at day 9, is it too late? Will it make a difference? If yes, is menopur is better or follistim? Your insight is much appreciated. I’m not sure if I should speak to doctor again on adjusting dose. My FSH is 8 and LH 2, amh 2 which I think is normal so no high LH concern, correct? Hope to hear from you soon. Many thanks. Sue

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 3, 2016 reply

    Hi Sue,

    I fear that it might be too late to really optimize response this cycle. I think the protocol used for ovarian stimulation needs to be reviewed and perhaps changed….see below.

    Please visit my new Blog on this very site, find the “search bar” and 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)
    • 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.
    • Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF
    • The Role of Nutritional Supplements in Preparing for IVF

    I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.

    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

  • Laura - February 2, 2016 reply

    Hello Dr Sher,
    I want to make sure the clinic here is doing this properly since they’re new at it. For autoimmune implantation dysfunction is the right protocol 100ml of 20% IL emulsion dissolved in 500ml saline, infused over 3-4h, administered once 7-14 days prior to ET and then once again upon confirmation of pregnancy? Thanks so much

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 2, 2016 reply

    Looks fine!. But preferably 10-14 days prior to transfer.

    Geoff Sher

    Laura - February 3, 2016 reply

    Thanks Dr Sher. Also, for autoimmune ID, is one supposed to start steroids on cycle day 3 for a FET?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 3, 2016 reply

    Yes!

    Geoff Sher

  • Jennifer Rams - February 2, 2016 reply

    Hi Dr. Sher,
    Would you recommend EPP for a 30 year old pt with normal AFC/AMH and low FSH/LH with a history of very poor response to stims? I only ever produced one mature follicle usually after 10+days of Menopur. Most of what I read states it’s used for poor responders with high FSH. Wonder what it would do for someone with a FSH of 4.5?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 2, 2016 reply

    No! I would not! I would recommend a robust, modified long pituitary down-regulation protocol (agonist/antagonist conversion protocol-A/ACP)-see below + human growth hormone augmentation. I would also suggest PGS embryo testing with embryo banking to ,make hay while the sun still shines.

    Please visit my new Blog on this very site, find the “search bar” and 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
    • Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
    • Ovarian Stimulation for IVF: Comparing “conventional” use of GnRH antagonists to the Agonist/Antagonist Conversion Protocol (A/ACP)
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • 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)
    • Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • Hereditary Clotting Defects (Thrombophilia)
    • Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
    • PGS-Biopsy for the Assessment of Embryo Numerical Chromosomal integrity (Ploidy): Should it be done on Day 3 or on Day 5-6 post fertilization?
    • Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
    • Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
    I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.

    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

  • Elizabeth - February 2, 2016 reply

    Hello Dr. Sher.
    I am 28 years old. FSH 16, AMH .56. Antral follicle count 8-10. I don’t know if it matters, but my low egg reserve is the result of 4 surgeries on my ovaries in my late teens/early 20s to remove ovarian cysts. I usually have 2-3 follicles one one ovary, 6-8 on the other.

    I am starting my first IVF next month and doing estrogren priming. My protocol seems to vary from yours and I wanted to know if you thought it was suitable or could use some modifications.

    Month 1
    CD10 start testing for LH surge
    Day of positive surge: Come in for bloodwork to confirm surge
    10 days post surge: Begin estrace 2 mg twice a day
    11 days post surge: Continue Estrace, add Ganirelix in the AM
    12 days post surge: continue estrace and Ganirelix in the AM
    13 days post surge: Continue estrace, take Ganirelix for last time.

    Continue Estrace until period starts.

    Month 2
    CD1: When period starts call clinic for baseline bloodwork. First day of period will be last day of Estrace twice a day.
    CD2: Baseline ultrasound, E2, P4, Beta. No medications.
    Cd3: Stim day 1. 225 iu menopur in AM and 225 iu in PM
    CD4: 225 iu menopur in AM and 225 iu in PM
    CD5: 225 iu menopur in AM and 225 iu in PM
    CD6: 225 iu menopur in AM. Return to clinic for bloodwork and ultrasound.
    Monitor every 1-2 days and adjustments to meds will be made as necessary and instructions on when to start ganirelix, administer trigger.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 2, 2016 reply

    There are no doubt different approaches to ovarian stimulation. This is not one that I use or prefer. I would use an agonist/antagonist conversion protocol with human growth hormone augmentation (see below). I would also seriously consider embryo banking of PGS normal blastocysts to enable you to try and make hay while thew sun still shines.

    Please visit my new Blog on this very site, find the “search bar” and 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
    • Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
    • Ovarian Stimulation for IVF: Comparing “conventional” use of GnRH antagonists to the Agonist/Antagonist Conversion Protocol (A/ACP)
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • 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)
    • Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • Hereditary Clotting Defects (Thrombophilia)
    • Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
    • PGS-Biopsy for the Assessment of Embryo Numerical Chromosomal integrity (Ploidy): Should it be done on Day 3 or on Day 5-6 post fertilization?
    • Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
    • Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
    I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.

    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

  • Carli - February 2, 2016 reply

    Hi Dr. Sher,
    I ran across your website in my search for information regarding premature ovarian failure/diminished ovarian reserve.
    A little bit about my reproductive background is as follows. I have had four dermoid ovarian cysts thoughtout my life which resulted in removal of my right ovary back in 2001. The first one was in 1993, at the age of 14 on the right ovary, and the second one also being on the right ovary in 2001. The following year, I had a dermoid cyst on my left ovary, which was removed laproscopically. Finally in 2009, I had another dermoid cyst on my remaining ovary, which was removed by a laporotomy. I seemed to have what was a normal cycle after my surgery, but about two months after surgery I started getting hot flashes, night sweats…basically all the symptoms of menopause. The RE did blood work, at which time, my FSH came back around 100. Immediately I was put on birth control. It helped with the symptoms, but basically that doctor wanted to just push me off to DE. In 2014 I consulted with a different RE who ran more labs. At this point my FSH was suppressed to the birth control pills, however my AMH came back at 0.03. This particular doctor put me on changing doses of Estrace, along with DHEA in order to try and recruit follicles. My AMH always remained the same. In May of 2015, I postponed treatment with this doctor, and decided to try out a NaPro doctor. They had me discontinue the Estrace and DHEA, and within a month my “menopausal” symptoms reappeared. My FSH had been back up to 85. Since then I have been doing cyclic HRT with Estrace and progesterone. I consulted with my third RE in November, who is willing to try a medicated cycle with TI for me and my husband due to our religious beliefs (we just got married in May). Currently he has me on estrogen primming to try and lower my FSH as much as possible, and increase my estrogen levels. From there it sounds like he will do either Femara, or a Femara/Follistim combo. In your opinion, what kinds of protocols have you had success with in patients like me? We are not ready to give up on my own eggs, as I have also included supplements, vitamins, and acupuncture. Is there any supplement regimine that you can suggest to help?

    Thanks,
    Carli

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 2, 2016 reply

    Hi Carli,

    It sounds as if your very severely diminished ovarian reserve is a prelude to an imminent menopause. I would encourage you not to “waste time” trying to conceive with own eggs and rather to come terms with the fact that to have a baby you will need egg donation.

    Please visit my new Blog on this very site, find the “search bar” and 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
    • The “Biological Clock” and how it Should Influence the Selection and Design of Ovarian Stimulation Protocols for IVF.:
    • IVF Egg Donation: A Comprehensive Overview
    I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.

    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

  • Niki - February 2, 2016 reply

    Dear dr sher , from where can I order the Intralipids please ? What is the name of the steroid and the milligrams you recommend to take with the intralipids ? Thank you

  • Emily - February 2, 2016 reply

    Dr.sher why would it be that a low percentage of my eggs will be mature when at least 50% of them were over 14mm when we started coasting?

  • Emily - February 2, 2016 reply

    Hi Dr. Sher I am on my second day of coasting and my e2 level is 5760. Tomorrow if it’s not below 2500 would you coast for another day or is there a risk of the follicles getting too big if I end up coasting for 4 days. Day 1 of coasting follies were 15/16 mm max. Thanks

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 2, 2016 reply

    The rate of follicle growth tapers off and by the 3rd day they usually do not grow any further. Unless the E2 is very close to 2500pg/ml, I personally would probably give it another day to get the E2 to under 2500pg/ml but that decision is not for me to make. It is up to your personal RE. Remember to alert your RE that many of the eggs are likely to be devoid of surrounding cumulus cells and will be hard to see as they might look like pin heads and be small. To you I say,do not expect a high maturation rate of eggs in this setting.

    Geoff Sher

    Good luck!

    Please keep me in the loop!

    Geoff Sher

    Emily - February 2, 2016 reply

    Thanks dr. Sher, why would it be that I would not have a high maturation rate when 50% of them were over 14mm when we started the coasting?

  • ramya - February 2, 2016 reply

    Hello doctor,

    I am 10 days post a frozen embryo transfer. I had a fertigyn injections on day 4, and day 7 after ET. I did an early beta HCG test and the value is 116. Am i pregnant?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 2, 2016 reply

    It could still be a residual hCG level in your blood that is coming up. I suggest you repeat the test in about 2 days to see if it doubles. If it does, then an US done in 10-14 days should be definitive.

    Good luck!

    Geoff Sher

  • Amanda - February 2, 2016 reply

    Hi Dr sher,
    Apologies I think I may have been posting my comment in the wrong box! I notice your egg donation sucess rate is 56%. And I have understood that the national average suces rate for egg donation is Aproximately 55%. Occasionally I read clinics advertising 70% sucess rate . How would a clinic be able to achieve this ? or should I be suspicious about such statements. Some research explains that the donor age is crucial ( younger the better, ) and some research says age is not crucial as long as they are under 35. Also some sucess rates are by embryo transfer and some by birth rate.. It’s a mine field to work out what is what sometimes. Whats your opinion on this?
    Many thanks

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 2, 2016 reply

    Indeed! I too am sKeptical Amanda!

    Geoff Sher

  • Evan - February 2, 2016 reply

    Dr. Sher,
    After tracking 10 follicles, my clinic was only able to retrieve 3 (2 mature). My doctor said the largest 2 follicles were cysts (3-4 mm bigger than the others) and most of the others did not have retrievable follicles. Does this seem reasonable? Started Lupron 2 days before stims (is that the short or long protocol) Saizen, Clomid, dexamethesone, menopur (2 vials), follistim 300. I’m 36- AMH 1.1, AFC 10-12, fsh 11-13. Would you recommend donor eggs? Or what is the next step?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 2, 2016 reply

    Very respectfully, I personally would use a different protocol. Obviously your age (not mentioned here would influence my decision, but your ability to produce 10 follicles omn a modest protocol of stimulation, suggests that you still might have a sufficient # of remaining eggs to negate the need to go directly to egg donation.

    In my opinion, you need a modified, robust, long pituitary down-regulation protocol. I would use an agonist/antagonist conversion protocol with human growth hormone (HGH) augmentation and would recommend Staggered IVF with embryo banking of PGS (next generation gene sequencing)-normal blastocysts, to make hay while the sun still shines.

    I strongly recommend that you visit my NEW personal website at http://www.DrGeoffreySherIVF.com and when you reach the home page, go to my new Blog find the “search bar” and 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
    • Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
    • Ovarian Stimulation for IVF: Comparing “conventional” use of GnRH antagonists to the Agonist/Antagonist Conversion Protocol (A/ACP)
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • 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)
    • Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • Hereditary Clotting Defects (Thrombophilia)
    • Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
    • PGS-Biopsy for the Assessment of Embryo Numerical Chromosomal integrity (Ploidy): Should it be done on Day 3 or on Day 5-6 post fertilization?
    • Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
    • Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
    • IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
    • The Role of Nutritional Supplements in Preparing for IVF
    I invite you to call 702-699-7437 or 800-780-7437 and set up an one hour Skype consultation with me to discuss your case in detail.
    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

    Evan - February 2, 2016 reply

    Thank you for your input. I’m 36. Would you modify your recommendation?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 2, 2016 reply

    No Evan, it would not!

    Geoff Sher

  • Jasmine - February 2, 2016 reply

    Hi Dr. Sher,

    I came across your website, trying to search answers for multiple miscarriages that I have faced with ART. I have found a lot of great information on your website and your blog is very helpful.

    I wanted to share my journey so far with you and get your opinion. For us it started out as male factor (husband 31 y/o), the reason we had to go with IVF/ICSI. For me (now 32 y/o) all investigations blood work including autoimmune profile was negative, HSG was normal. Through altogether 7 ivf cycles though I got pregnant 3 times. 2 blighted ovum and 1 chemical pregnancy. We have had PGD testing on 4 embryos once, that showed 2 normal, 1 inconclusive and 1 abnormal. I ended up transferring 1 normal and 1 inconclusive together and ended up with flu as well at the same time, and another 1 normal with non PGD tested embryos; recently I learned that should be advised against. I also underwent endometrial biopsies to increase chances of implantation and once pathology study to estimate best timing for transfer; it was done on non medicated cycle. It turned out that my endometrium was late by 2 days but also that cycle my period was off by 2 days, otherwise my periods are very regular like clock work q 28 days. We considered there maybe immunity factor, never tested for it, but with that assumption since second IVF cycle, I have had IV intralipid prior to transfer and 4-6 weeks after transfer. our progesterone levels werent monitored initially but I made sure we did and i have taken PIO alternating with crinone. In last cycle which resulted in blighted ovum I also took heparin SQ bid though MTHFR and thrombocytic panel were negative. My AMH recently was 0.77 ng/ml, I have taken DHEA and coq10 supplements, I have always had good number of follicles with okay quality of eggs as per my RE.

    We were contemplating to do further testing for NK cell assay, for my husband DFI percentage. Having gone through quite a bit, I wanted your expert opinion as to any particular testing or any particular treatment we should look for?

    Sorry for long message. I would appreciate your feedback.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 2, 2016 reply

    Thank you for this post!

    I strongly suspect that you have an implantation problem which could be anatomical (lining receptivity) or immunologic. Simply taking IL is not sufficient because if the problem is alloimmune the IL infusion needs to be modified and a single blastocyst needs to be transferred at a time. Also, unless the IL therapy is augmented with steroids, it is not likely to be fully effective…please see below.

    When it comes to reproduction, humans are the poorest performers of all mammals. In fact we are so inefficient that up to 75% of fertilized eggs do not produce live births, and up to 30% of pregnancies end up being lost within 10 weeks of conception (in the first trimester). RPL is defined as two (2) or more failed pregnancies. Less than 5% of women will experience two (2) consecutive miscarriages, and only 1% experience three or more.
    Pregnancy loss can be classified by the stage of pregnancy when the loss occurs:
    • Early pregnancy loss (first trimester)
    • Late pregnancy loss (after the first trimester)
    • Occult “hidden” and not clinically recognized, (chemical) pregnancy loss (occurs prior to ultrasound confirmation of pregnancy)
    • Early pregnancy losses usually occur sporadically (are not repetitive).
    In more than 70% of cases the loss is due to embryo aneuploidy (where there are more or less than the normal quota of 46 chromosomes). Conversely, repeated losses (RPL), with isolated exceptions where the cause is structural (e.g., unbalanced translocations), are seldom attributable to numerical chromosomal abnormalities (aneuploidy). In fact, the vast majority of cases of RPL are attributable to non-chromosomal causes such as anatomical uterine abnormalities or Immunologic Implantation Dysfunction (IID).
    Since most sporadic early pregnancy losses are induced by chromosomal factors and thus are non-repetitive, having had a single miscarriage the likelihood of a second one occurring is no greater than average. However, once having had two losses the chance of a third one occurring is double (35-40%) and after having had three losses the chance of a fourth miscarriage increases to about 60%. The reason for this is that the more miscarriages a woman has, the greater is the likelihood of this being due to a non-chromosomal (repetitive) cause such as IID. It follows that if numerical chromosomal analysis (karyotyping) of embryonic/fetal products derived from a miscarriage tests karyotypically normal, then by a process of elimination, there would be a strong likelihood of a miscarriage repeating in subsequent pregnancies and one would not have to wait for the disaster to recur before taking action. This is precisely why we strongly advocate that all miscarriage specimens be karyotyped.
    There is however one caveat to be taken into consideration. That is that the laboratory performing the karyotyping might unwittingly be testing the mother’s cells rather than that of the conceptus. That is why it is not possible to confidently exclude aneuploidy in cases where karyotyping of products suggests a “chromosomally normal” (euploid) female.
    Late pregnancy losses (occurring after completion of the 1st trimester/12th week) occur far less frequently (1%) than early pregnancy losses. They are most commonly due to anatomical abnormalities of the uterus and/or cervix. Weakness of the neck of the cervix rendering it able to act as an effective valve that retains the pregnancy (i.e., cervical incompetence) is in fact one of the commonest causes of late pregnancy loss. So also are developmental (congenital) abnormalities of the uterus (e.g., a uterine septum) and uterine fibroid tumors. In some cases intrauterine growth retardation, premature separation of the placenta (placental abruption), premature rupture of the membranes and premature labor can also causes of late pregnancy loss.
    Much progress has been made in understanding the mechanisms involved in RPL. There are two broad categories:
    1. Problems involving the uterine environment in which a normal embryo is prohibited from properly implanting and developing. Possible causes include:
    • Inadequate thickening of the uterine lining
    • Irregularity in the contour of the uterine cavity (polyps, fibroid tumors in the uterine wall, intra-uterine scarring and adenomyosis)
    • Hormonal imbalances (progesterone deficiency or luteal phase defects). This most commonly results in occult RPL.
    • Deficient blood flow to the uterine lining (thin uterine lining).
    • Immunologic implantation dysfunction (IID). A major cause of RPL. Plays a role in 75% of cases where chromosomally normal preimplantation embryos fail to implant.
    • Interference of blood supply to the developing conceptus can occur due to a hereditary clotting disorder known as Thrombophilia.
    2. Genetic and/or structural chromosomal abnormality of the embryo.Genetic abnormalities are rare causes of RPL. Structural chromosomal abnormalities are slightly more common but are also occur infrequently (1%). These are referred to as unbalanced translocation and they result from part of one chromosome detaching and then fusing with another chromosome. Additionally, a number of studies suggest the existence of paternal (sperm derived) effect on human embryo quality and pregnancy outcome that are not reflected as a chromosomal abnormality. Damaged sperm DNA can have a negative impact on fetal development and present clinically as occult or early clinical miscarriage. The Sperm Chromatin Structure Assay (SCSA) which measures the same endpoints are newer and possibly improved methods for evaluating.

    IMMUNOLOGIC IMPLANTATION DYSFUNCTION
    Autoimmune IID: Here an immunologic reaction is produced by the individual to his/her body’s own cellular components. The most common antibodies that form in such situations are APA and antithyroid antibodies (ATA).
    But it is only when specialized immune cells in the uterine lining, known as cytotoxic lymphocytes (CTL) and natural killer (NK) cells, become activated and start to release an excessive/disproportionate amount of TH-1 cytokines that attack the root system of the embryo, that implantation potential is jeopardized. Diagnosis of such activation requires highly specialized blood test for cytokine activity that can only be performed by a handful of reproductive immunology reference laboratories in the United States.
    Alloimmune IID, i.e., where antibodies are formed against antigens derived from another member of the same species, is believed to be a relatively common immunologic cause of recurrent pregnancy loss.
    Autoimmune IID is often genetically transmitted. Thus it should not be surprising to learn that it is more likely to exist in women who have a family (or personal) history of primary autoimmune diseases such as lupus erythematosus (LE), scleroderma or autoimmune hypothyroidism (Hashimoto’s disease), autoimmune hyperthyroidism (Grave’s disease), rheumatoid arthritis, etc. Reactionary (secondary) autoimmunity can occur in conjunction with any medical condition associated with widespread tissue damage. One such gynecologic condition is endometriosis. Since autoimmune IID is usually associated with activated NK and T-cells from the outset, it usually results in such very early destruction of the embryo’s root system that the patient does not even recognize that she is pregnant. Accordingly the condition usually presents as “unexplained infertility” or “unexplained IVF failure” rather than as a miscarriage.

    Alloimmune IID, on the other hand, usually starts off presenting as unexplained miscarriages (often manifesting as RPL). Over time as NK/T cell activation builds and eventually becomes permanently established the patient often goes from RPL to “infertility” due to failed implantation. RPL is more commonly the consequence of alloimmune rather than autoimmune implantation dysfunction.
    However, regardless, of whether miscarriage is due to autoimmune or alloimmune implantation dysfunction the final blow to the pregnancy is the result of activated NK cells and CTL in the uterine lining that damage the developing embryo’s “root system” (trophoblast) so that it can no longer sustain the growing conceptus. This having been said, it is important to note that autoimmune IID is readily amenable to reversal through timely, appropriately administered, selective immunotherapy, and alloimmune IID is not. It is much more difficult to treat successfully, even with the use of immunotherapy. In fact, in some cases the only solution will be to revert to selective immunotherapy plus using donor sperm (provided there is no “match” between the donor’s DQa profile and that of the female recipient) or alternatively to resort to gestational surrogacy.
    DIAGNOSING THE CAUSE OF RPL
    In the past, women who miscarried were not evaluated thoroughly until they had lost several pregnancies in a row. This was because sporadic miscarriages are most commonly the result of embryo numerical chromosomal irregularities (aneuploidy) and thus not treatable. However, a consecutive series of miscarriages points to a repetitive cause that is non-chromosomal and is potentially remediable. Since RPL is most commonly due to a uterine pathology or immunologic causes that are potentially treatable, it follows that early chromosomal evaluation of products of conception could point to a potentially treatable situation. Thus I strongly recommend that such testing be done in most cases of miscarriage. Doing so will avoid a great deal of unnecessary heartache for many patients.
    Establishing the correct diagnosis is the first step toward determining effective treatment for couples with RPL. It results from a problem within the pregnancy itself or within the uterine environment where the pregnancy implants and grows. Diagnostic tests useful in identifying individuals at greater risk for a problem within the pregnancy itself include:

    • Karyotyping (chromosome analysis) both prospective parents
    • Assessment of the karyotype of products of conception derived from previous miscarriage specimens
    • Ultrasound examination of the uterine cavity after sterile water is injected or sonohysterogram, fluid ultrasound, etc.)
    • Hysterosalpingogram (dye X-ray test)
    • Hysteroscopic evaluation of the uterine cavity
    • Full hormonal evaluation (estrogen, progesterone, adrenal steroid hormones, thyroid hormones, FSH/LH, etc.)
    • Immunologic testing to include:
    a) Antiphospholipid antibody (APA) panel
    b) Antinuclear antibody (ANA) panel
    c) Antithyroid antibody panel (i.e., antithyroglobulin and antimicrosomal antibodies)
    d) Reproductive immunophenotype
    e) Natural killer cell activity (NKa) assay (i.e., K562 target cell test)
    f) Alloimmune testing of both the male and female partners
    TREATMENT OF RPL
    Treatment for Anatomic Abnormalities of the Uterus: This involves restoration through removal of local lesions such as fibroids, scar tissue, and endometrial polyps or timely insertion of a cervical cerclage (a stitch placed around the neck of the weakened cervix) or the excision of a uterine septum when indicated.
    Treatment of Thin Uterine Lining: A thin uterine lining has been shown to correlate with compromised pregnancy outcome. Often this will be associated with reduced blood flow to the endometrium. Such decreased blood flow to the uterus can be improved through treatment with sildenafil and possibly aspirin.
    Sildenafil (Viagra) Therapy. Viagra has been used successfully to increase uterine blood flow. However, to be effective it must be administered starting as soon as the period stops up until the day of ovulation and it must be administered vaginally (not orally). Viagra in the form of vaginal suppositories given in the dosage of 25 mg four times a day has been shown to increase uterine blood flow as well as thickness of the uterine lining. To date, we have seen significant improvement of the thickness of the uterine lining in about 70% of women treated. Successful pregnancy resulted in 42% of women who responded to the Viagra. It should be remembered that most of these women had previously experienced repeated IVF failures.

    Use of Aspirin: This is an anti-prostaglandin that improves blood flow to the endometrium. It is administered at a dosage of 81 mg orally, daily from the beginning of the cycle until ovulation.
    Treating Immunologic Implantation Dysfunction with Selective Immunotherapy: Modalities such as IL/IVIg, heparinoids (Lovenox/Clexane), and corticosteroids (dexamethasone, prednisone, prednisolone) can be used in select cases depending on autoimmune or alloimmune dysfunction.
    The Use of IVF in the Treatment of RPL
    In the following circumstances, IVF is the preferred option:
    1. When in addition to a history of RPL, another standard indication for IVF (e.g., tubal factor, endometriosis, and male factor infertility) is superimposed.
    2. In cases where selective immunotherapy is needed to treat an immunologic implantation dysfunction.
    The reason for IVF being a preferred approach in such cases is that in order to be effective, the immunotherapy needs to be initiated well before spontaneous or induced ovulation. Given the fact that the anticipated birthrate per cycle of COS with or without IUI is at best about 15%, it follows that short of IVF, to have even a reasonable chance of a live birth, most women with immunologic causes of RPL would need to undergo immunotherapy repeatedly, over consecutive cycles. Conversely, with IVF, the chance of a successful outcome in a single cycle of treatment is several times greater and, because of the attenuated and concentrated time period required for treatment, IVF is far safer and thus represents a more practicable alternative
    Since embryo aneuploidy is a common cause of miscarriage, the use of preimplantation genetic diagnosis (PGD), with tests such as CGH, can provide a valuable diagnostic and therapeutic advantage in cases of RPL. PGD requires IVF to provide access to embryos for testing.
    There are a few cases of intractable alloimmune dysfunction due to absolute DQ alpha matching where Gestational Surrogacy or use of donor sperm could represent the only viable recourse, other than abandoning treatment altogether and/or resorting to adoption. Other non-immunologic factors such as an intractably thin uterine lining or severe uterine pathology might also warrant that last resort consideration be given to gestational surrogacy.
    The good news is that if a couple with RPL is open to all of the diagnostic and treatment options referred to above, a live birthrate of 70%–80% is ultimately achievable.

    Please visit my new Blog on this very site, find the “search bar” and 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
    • Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
    • Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • Hereditary Clotting Defects (Thrombophilia)
    • Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
    • Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
    • IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • 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)
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF

    I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.

    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

  • Niki - February 1, 2016 reply

    After first transfer of IVF with egg donor 21 years old , and PGS testing , of 2 Blast A embryos it’s failed .
    My doctor told me he is in shock , and offer me before my second transfer , to do scratching and to have in the day of transfer right after Intralipids iv treatment , he said he think it will help me succeed .
    I want to ask you if you recommend to do blood check first for natural killers cells ? And if one test or two test !
    Because he said its expensive to do this blood check and that only one time it’s not indicate and better to do again because sometimes the first results showing normal results and second showing not normal results !
    Please tell me your opinion !
    And also I know that this cells supposed to fight against tumors and cancers , so I afraid that the Intralipids iv treatments can damage the health !
    Please tell me your suggestion!
    Thank you very much !
    My second transfer is on 02/15/2016
    If I will do the test I will receive results on time do you think ?
    And how much it’s supposed to cost ?
    Thank you sooooooo much Dr

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 2, 2016 reply

    ABSOLUTELY, the fact that PGS-normal embryos failed to propagate a viable pregnancy suggests that there is likely to be an underlying implantation dysfunction …possibly immunologic in origin. It would in my opinion be a travesty not to evaluate this thoroughly before going to ET.

    When confronted with “unexplained” IVF failures where morphologically good embryos were transferred, the question arises as to whether the problem is due to inherent egg/embryo “incompetence” (which usually equates with an irregular chromosomal configuration [aneuploidy]) or whether it is due to an implantation dysfunction. The younger the woman and the higher the quality of available embryos (preferably blastocysts), the less likely it is that the fault lies with embryo “incompetence” and the greater is the likelihood that it is due to underlying implantation dysfunction.
    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)
    Implantation dysfunction (anatomical or immunologic) is a common cause of repeated “unexplained” IVF failure with good embryos. 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.

    Please visit my new Blog on this very site, find the “search bar” and 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
    • Ovarian Stimulation for IVF using GnRH Antagonists:
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • Unexplained IVF FailureImmunologic 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)
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF
    • The Role of Nutritional Supplements in Preparing for IVF
    • IVF Egg Donation: A Comprehensive Overview

    I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.

    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

    Niki - February 2, 2016 reply

    Thank you sooo much for your reply , I checked already all of it and everything is healthy and normal not A “thin uterine lining
    Not A uterus with surface lesions in the cavity (polyps, fibroids, scar tissue)
    The only thing I didn’t check was the blood check of natural killers that you send to Boston ! Please tell me if it is dengerous to the health the Intralipids? And if you recommend me to do it before my next transfer ? Thank you dr

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 2, 2016 reply

    Hi Niki,

    ABSOLUTELY! I think it would be a serious omission not to test for an immunologic implantation dysfunction here. Obviously this should be considered when PGS-normal embryos fail to propagate a viable pregnancy.

    When confronted with “unexplained” IVF failures where morphologically good embryos were transferred, the question arises as to whether the problem is due to inherent egg/embryo “incompetence” (which usually equates with an irregular chromosomal configuration [aneuploidy]) or whether it is due to an implantation dysfunction. The younger the woman and the higher the quality of available embryos (preferably blastocysts), the less likely it is that the fault lies with embryo “incompetence” and the greater is the likelihood that it is due to underlying implantation dysfunction.
    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)
    Implantation dysfunction (anatomical or immunologic) is a common cause of repeated “unexplained” IVF failure with good embryos. 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.

    Please visit my new Blog on this very site, find the “search bar” and 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)
    • Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
    • Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • Recurrent Pregnancy Loss (RPL): Why do I keep losing my Pregnancies?
    • 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)
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF
    • The Role of Nutritional Supplements in Preparing for IVF
    • IVF Egg Donation: A Comprehensive Overview
    I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.

    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

  • aziz - February 1, 2016 reply

    Please can you tell me about my test! If i can conceive naturally
    Thank you

    Physical characters:
    Appearance Normal
    Volume 2 ml
    pH 8
    Viscosity Normal
    Liquefaction 30 min
    Sperm quantitification:
    Sperm Count / ml 47000000 Sperm
    Total Sperm Count / ejaculate 94000000
    Motility assessement : (After liquefaction)
    Motility 70 %
    Progressive (PR) 20 %
    None Progressive (NP) 50 %
    Immotile 30 %
    Microscopic Examination:
    Leucocytes 500000 cell /ml
    RBCs: 0 – 1 H.P.F
    Spermatogenic Cells 2 – 4 H.P.F
    Agglutination Absent
    Sperm Morphology :
    Normal forms 60 %
    Abnormal heads 20 %

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 1, 2016 reply

    Yes Aziz,

    this count is compatible with normal fertility. However, if you are having problems, see an andro-urologist to have other parameters evaluated as well. Or call 800-780-7437 and set up a consultation with me via Skype.

    Geoff Sher

    aziz - February 1, 2016 reply

    Dr. Geoffrey
    Thank you for your time , i appreciate your help.
    Thank you again

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 2, 2016 reply

    You are very welcome Aziz!

    Geoff Sher

  • Maya - February 1, 2016 reply

    Dear Dr Sher,

    Congrats on the new website.

    I have a question regarding stimulation protocol.

    My husband and I are young and have been trying to conciece naturally for a few years, we found out my husband has male factor infertility (low count, motility and morphology). We did 2 cycles of ICSI which the first failed and the second was a chemical pregnancy. Our embryos growth slows down after day 3.

    After reading your blog I started wondering if the protocol was wrong.
    Both cycles I was on Gonal F alone for stimulation, do you think I should have been on another stimulating drug as well? Does Gonal F alone lead to poor egg quality/and or chromosome issues within the egg.

    Your valueble input would be very much appreciated, as we are financially struggling and I want to ensure the 3rd cycle is done correctly.

    Thank you!

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 1, 2016 reply

    Hello Maya,

    thanks for posting here!

    It is possible that the protocol for stimulation could be a problem. Also, your husband needs to be evaluated carefully to see whether he has a reversible cause for male infertility.

    Please visit my new Blog on this very site, find the “search bar” and 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)
    • 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)
    • Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • Unexplained IVF Failure
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF
    • The Role of Nutritional Supplements in Preparing for IVF
    • Measuring and Interpreting Blood hCG to Assess Pregnancy Viability Following ART Treatments.
    • Male Factor Infertility
    • The Sperm Chromatin Structure Assay (SCSA): A Measure of the Potential of Sperm to Help Propagate a Viable Pregnancy
    • Intrauterine Insemination (IUI): Who Needs it & who Does Not: Pro’s & Con’s!

    I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.

    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

  • G and C - February 1, 2016 reply

    Good day Dr.
    I always go to your blog as support for the IVF journey and today I feel compelled to write. This is our 2nd IVF attempt, first ended with a MC slow risinh Beta and failed FET. We transfered two grade AA expanding blasts with no PGD and got our first Beta today which is 8dp5dt and it was 33. We were supposed to do the test tomorrow but had some red blood spotting last night and Dr. told us to come in a day sooner for blood. They have upped the endometrium dosage to 2 am and 2 pm from 1 am and 2 pm. With all this do you feel 33 at 8dp5dt is a good number or should we be worried?
    Thanks again for all you do!

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 1, 2016 reply

    Thank you for your kind words and for visiting this site!

    When confronted with “unexplained” IVF failures where morphologically good embryos were transferred, the question arises as to whether the problem is due to inherent egg/embryo “incompetence” (which usually equates with an irregular chromosomal configuration [aneuploidy]) or whether it is due to an implantation dysfunction. The younger the woman and the higher the quality of available embryos (preferably blastocysts), the less likely it is that the fault lies with embryo “incompetence” and the greater is the likelihood that it is due to underlying implantation dysfunction.
    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)
    Implantation dysfunction (anatomical or immunologic) is a common cause of repeated “unexplained” IVF failure with good embryos. 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.

    Please visit my new Blog on this very site, find the “search bar” and 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)
    • 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)
    • Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • Hereditary Clotting Defects (Thrombophilia)
    • Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
    • PGS-Biopsy for the Assessment of Embryo Numerical Chromosomal integrity (Ploidy): Should it be done on Day 3 or on Day 5-6 post fertilization?
    • Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
    • 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?
    • IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF
    • The Role of Nutritional Supplements in Preparing for IVF
    I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail.

    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

  • Laura - February 1, 2016 reply

    Thanks for taking the time to read these Dr. Sher! My husband was diagnosed with a form of muscular dystrophy this month. Needless to say my world has been turned upside down, and we now must turn to IVF with PGD. I just made an appointment with one of your doctors for a consult. I am having so much anxiety over the appointment though, because even though my age is okay and I believe I ovulate normally (get my period regularly, and tracking my cervical fluid/temp) I have a very high BMI. I’ve been reading some IVF clinics won’t even see patients with higher BMIs and I’m distraught thinking I’m going to be treated badly/differently than other patients (mainly because I’ve experienced this from other doctors in the past). Does your practice turn away patients due to BMI, or will they make me try to lose weight first (currently trying of course). Thanks for addressing my concerns, I really appreciate it.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 1, 2016 reply

    There should be no concern that you would in any way be treated differently or be the target of ANY discrimination because of having a high BMI. Notwithstanding. it is important for you to keep the following in mind:

    Recent evidence indicates that excessive weight in women of reproductive age is associated with decreased birth rates, increased miscarriage rates, higher rates of premature delivery and a marked increase in pregnancy complications.While being overweight clearly has an adverse affect on overall reproductive performance, the situation is less clear when it comes to its influence on women undergoing In Vitro Fertilization (IVF). Several studies have been conducted and while the results vary and in some cases conflict, the general trend is in the direction of women who are moderately overweight (BMI>25-30) and those who are obese (BMI>30) having poorer IVF outcomes than do controls with a BMI of less than 25. It would appear that in general, moderately overweight women, and more particularly those who are obese, exhibit a poorer ovarian response to fertility drugs (impaired follicle and embryo development with fewer blastocysts becoming available for transfer). They also might have a reduced ability to implant transferred embryos into their uterine linings (perhaps due to reduced endometrial receptivity).

    It is of interest that many women with Polycystic Ovarian Syndrome (PCOS) are also overweight. In such women, the hormonal environment in the ovaries is known to adversely affect follicle and egg development. Given that there is often no clear-cut distinction between PCOS and overweight women, it is possible that many of the factors that are believed to affect egg/embryo quality in PCOS might similarly affect egg development and endometrial receptivity in overweight women. Such factors could include increased production of luteinizing hormone (LH), hyperinsulinemia and increased production of ovarian male hormones (androgens such as testosterone). The link between increased LH and resulting increased production of ovarian androgens (mainly testosterone) and poor follicle and egg development is well established. It is also well known that such hormonal changes can be transmitted to the adjacent uterus, thereby adversely affecting endometrial development.

    Clearly the question arises as to whether the negative effect of an elevated BMI (>25) on general fertility potential and IVF outcome compromises egg development, endometrial receptivity to the implanting embryo, or both. In my opinion, while a direct ovarian influence probably predominates, there is also likely to be an adverse influence on endometrial development. This endometrial affect is commonly seen in PCOS women who, when they develop severe ovarian hyperstimulation on fertility drugs, often have a very thin (< 8mm) endometrium. Finally, it is important to emphasize that overweight women are at far greater risk during pregnancy than are women of normal body weight. As previously mentioned, the miscarriage rate is much higher. So is the incidence of diabetes, high blood pressure, preeclampsia, premature labor, surgically assisted deliveries, stillbirth and neonatal death. Maternal complications that occur after birth of the baby (i.e., infection, uterine post partum hemorrhage, etc.) are also much more common. Babies born to such mothers are also at great risk of developing respiratory distress syndrome (RDS). This condition, which ordinarily only occurs in preterm babies, can also occur in the absence of prematurity in such cases. RDS is the most common reason for the newborn having to be admitted to a neonatal intensive care unit, and also the most common cause of death in the first week of life. Please visit my new Blog on this very site, find the “search bar” and 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 • Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach • Ovarian Stimulation for IVF: Comparing “conventional” use of GnRH antagonists to the Agonist/Antagonist Conversion Protocol (A/ACP) • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS) • 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) • Launching Ovarian Stimulation with a BCP: How Does it Affect Response?• The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response? I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up a one hour Skype consultation with me to discuss your case in detail. I also suggest that you access the 4th edition of my book ,"In Vitro Fertilization, the ART of Making Babies". It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

    Laura - February 1, 2016 reply

    I’m sorry I must be confused. This is the site that the link directs me to.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 1, 2016 reply

    Indeed Laura,

    And this is where you shoud be posting your questions.

    Thanks!

    Geoff Sher

  • lucie - February 1, 2016 reply

    i did my 2nd icsi now days embryo transfere was 1/19 /2015
    2 grade A4 embryos and today i did qualitative beta hcg which gave me negative result and i did home pregnancy test (urine ) today also which was negstive is it sure or i have to do the quantitative to confirm ??? thanks in advance

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 1, 2016 reply

    Hi Lucie!

    Thanks for posting here!

    Alas this does not look good. However you should do the second hCG test because the urine test is much less sensitive than the blood test also sometimes the implantation can be delayed slightly.

    G-d bless!

    If it turns out to be negative again, consider booking online for a Skype consultation with me or call 800-780-7437 and set up a skype consultation so we can discuss your case in detail.

    Geoff Sher

    Geoff Sher

  • Rachel - February 1, 2016 reply

    Hello Dr. Sher, I am 33 with low ovarian reserve and poor egg quality. My husband and I have completed 2 IVF retrievals and had no fertilization success; the first time multiple sperm fertilized the eggs and the second time we used Injection of sperm into the egg with no fertilization. Additionally upon retrieval some of the eggs were cracked. The RE told me that my egg quality was poor and that I would be throwing money away if I continued to do IVF with my own eggs. She recommended that I use donor eggs. I would really like to use my own eggs though so I was wondering, is there is anything that can be done to improve my egg quality? or tests to understand why I have this problem? I was told I have unexplained infertility.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 1, 2016 reply

    Hi Rachel!

    Thank you for posting here.

    Rachel, very respectfully, I do not agree with this opinion. Yes, it is possible that you have inherently poor quality eggs…this acan happens BUT it is extremely rare that a woman as young as you are would have this problem. In most cases it has to do with the protocol used for ovarian stimulation and would be potentially reversible through using a more individualized and strategic protocol for ovarian stimulation. Given your DOR, you in my opinion probably need a modified, robust, long pituitary down-regulation protocol. I would use an agonist/antagonist conversion protocol with human growth hormone (HGH) augmentation and would recommend Staggered IVF with embryo banking of PGS (next generation gene sequencing)-normal blastocysts, to make hay while the sun still shines.

    Please go to my Blog on this web site, find the search bar and 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 further questions or comments with the full expectation that I will (as always) respond promptly.
    • Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
    • Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
    • Ovarian Stimulation for IVF: Comparing “conventional” use of GnRH antagonists to the Agonist/Antagonist Conversion Protocol (A/ACP)
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • 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)
    • Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • Hereditary Clotting Defects (Thrombophilia)
    • Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
    • PGS-Biopsy for the Assessment of Embryo Numerical Chromosomal integrity (Ploidy): Should it be done on Day 3 or on Day 5-6 post fertilization?
    • Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
    • Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
    • IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
    • The Role of Nutritional Supplements in Preparing for IVF
    I invite you to call 702-699-7437 or 800-780-7437 and set up an one hour Skype consultation with me to discuss your case in detail.
    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

  • Alice - February 1, 2016 reply

    Dear Dr. Sher,
    Congratulations on your new blog. It looks great! My question is that I am having nausea after my egg retrieval. I had 3 eggs from 3 follicles that did not fertilise and I am a low responder. I have very low AMH and I have never had nausea before from any retrievals. What could cause this? What can I do to recover from it?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 1, 2016 reply

    The nausea is probably related to the anesthesia. As for your DOR and the resulting poor response to ovarian stimulation, in my opinion, this likely has a great deal to do with the protocol used for ovarian stimulation and can be addressed through using a more individualized and strategic protocol for ovarian stimulation. I think you probably need a modified, robust, long pituitary down-regulation protocol. I would use an agonist/antagonist conversion protocol with human growth hormone (HGH) augmentation and would recommend Staggered IVF with embryo banking of PGS (next generation gene sequencing)-normal blastocysts, to make hay while the sun still shines.

    Please go to my Blog on this web site, find the search bar and 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 further questions or comments with the full expectation that I will (as always) respond promptly.

    • Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
    • Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
    • Ovarian Stimulation for IVF: Comparing “conventional” use of GnRH antagonists to the Agonist/Antagonist Conversion Protocol (A/ACP)
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • 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)
    • Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • Hereditary Clotting Defects (Thrombophilia)
    • Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
    • PGS-Biopsy for the Assessment of Embryo Numerical Chromosomal integrity (Ploidy): Should it be done on Day 3 or on Day 5-6 post fertilization?
    • Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
    • Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
    • IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
    • The Role of Nutritional Supplements in Preparing for IVF
    I invite you to call 702-699-7437 or 800-780-7437 and set up an one hour Skype consultation with me to discuss your case in detail. You can also set this up online on this blog. I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

  • Tania - February 1, 2016 reply

    Hi Dr Sher,
    Thanks for the detailed information on aneuploidy on your web site.
    My reproductive history in brief is: one 3 year old daughter conceived naturally and easily at 37 years old.
    Since trying for a second child I have had 2 early miscarriages due to trisomy.
    Due to my advancing age we decided to use IVF with pre-implantation genetic screening(PGS).
    My ovarian reserve was found to be good for my age and all other lab work and ultrasounds were NAD.
    I am in Australia so some of the drug names are slightly different so I will try and use active ingredients as well.
    A brief summery of my IVF results and the drug regimes on each cycle are as follows:
    I have had 2 stimulation cycles the first was with Gonal F (follitropin alfa) 300 iu from day 3 then Orgalutran (ganirelix 250 ug) plus Gonal F once lead follicle reached 1.4cm till trigger injection, this cycle resulted in 6 oocytes, of which 2 were mature, one fertilised and genetic testing determined that embryo to have normal chromosome numbers.
    The second cycle used a different drug regime – 3 weeks on the pill(OCP) then 3 days after stopping OCP, I was started on lucrin (Leuprorelin) 4iu for 3 days with Gonal F 450 iu and Luveris (lutropin alfa) 75 iu daily started on the final(3rd) day of lucrin until lead follicle reached 1.4cm then Gonal F, Luveris and Orgalutran 250 ug till trigger injections. This cycle resulted in 14 follicles 11 of which were retrieved, 10 fertilised and 4 survived till blastocyst stage and were tested by PGS – all were found to be aneuploid.
    I am soon to start a third round of IVF and I would sincerely appreciate your opinion on the Drug regime, I am particularly interested in your opinion of the use of Luveris as it is my understanding that LH early in the stimulation phase can be detrimental to oocyte quality.
    Yours sincerely
    Tania

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 1, 2016 reply

    Tania,

    Thank you for posting here!

    Firstly let me say that age is by far the most common cause of egg/embryo aneuploidy and of course this cannot be reversed. However, aside from age, the protocol used for ovarian stimulation is the next in line as far as relevance is concerned and here is where I belive that with a few changes made, it might be possible to improve matters. Given your age and DOR, you in my opinion probably need a modified, robust, long pituitary down-regulation protocol. I would use an agonist/antagonist conversion protocol with human growth hormone (HGH) augmentation and would recommend Staggered IVF with embryo banking of PGS (next generation gene sequencing)-normal blastocysts, to make hay while the sun still shines.

    Please find my blog on this site . Go to the search bar and 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 further questions or comments with the full expectation that I will (as always) respond promptly.

    • Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
    • Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
    • Ovarian Stimulation for IVF: Comparing “conventional” use of GnRH antagonists to the Agonist/Antagonist Conversion Protocol (A/ACP)
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • 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)
    • Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • Hereditary Clotting Defects (Thrombophilia)
    • Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
    • PGS-Biopsy for the Assessment of Embryo Numerical Chromosomal integrity (Ploidy): Should it be done on Day 3 or on Day 5-6 post fertilization?
    • Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
    • Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
    • IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
    • The Role of Nutritional Supplements in Preparing for IVF

    I invite you to call 702-699-7437 or 800-780-7437 or go online on this site and set up an one hour Skype consultation with me to discuss your case in detail.

    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher,

  • Amit Mehta - February 1, 2016 reply

    – [ ] Dear Dr Sher,
    – [ ] We are in a real quandry as to what to do no next, feeling our resources of time and money are now running low. I have included a comprehensive history of our fertility treatment to date below – this shows our specific problems of low ovarian reserve and poor response to IVF. But in a nutshell, we have had 2 failed cycles of IVF, and our most recent cycle which we changed from the long protocol to the short has had to be cancelled as we only got two lead follicles at 16mms. Rachael did get pregnant naturally in between our first and second cycles with a foetal heartbeat detected at 6 weeks, but sadly she suffered a missed miscarriage at 12 weeks with the embryo failing to grow after 7 weeks.
    – [ ] In addition to the information below, we also had tests for NK cells and these were found to be elevated. It was found that their effect would be halved by using IVIg infusions. We had decided to do this until our third cycle was cancelled.
    – [ ] We are not sure whether we should just continue on the same path, or try something different. Our plan was to do a third cycle using the long protocal again and also to do the immunotherapy treatment using IVIg infusions. But we have also read about the Augment treatment from Ovoascience and we are debating whether we should try this? We also were wondering if we should try ICSI this time, even though there have been no problems with fertilising any eggs produced.
    – [ ] Any thoughts would be hugely appreciated as to what should be our next step
    – [ ] Many thanks,
    – [ ] Amit and Rachael Mehta
    – [ ] We have been having our fertility treatment at the Lister Clinic in London.

    – [ ] Couple’s History 
Wife’s Date of Birth: _05/28/1977
    – [ ] Husband’s Date of Birth: _03/31/1981
Female BMI: __19.43, Male BMI: _24.49
    – [ ] How long have you been actively trying to get pregnant? ___3 years_________________
How long have you been trying to conceive with the help of a doctor? ______1 ½ years______________
Number of years not using contraception? 3
Do either of you have children from a previous marriage? No
    – [ ] Any known reasons for infertility?
Poor Quality Eggs ?? Low # of Eggs
One tube possibly Blocked/Damaged

    – [ ] Wife’s Medical History
    – [ ] Obstetrical History
Number of pregnancies: __1___________________
Number of full-term pregnancies: _______0_______
Number of miscarried pregnancies: _____1_______
Number of ectopic pregnancies: ___0____________
Number of twin pregnancies: _____0__________
Number of triplet pregnancies: ______0_________

    – [ ] Were any babies stillborn or did any babies die after birth? No
    – [ ] Menstrual & Sexual History
Date of your last menstrual period _14/1/16____________________
At what age did you have your first menstrual period? ____13_________________
Are your periods regular? Yes No
(every 25-32 days) Every ___28-34______ days
How many days do you bleed? __4__________________
Describe the amount of menstrual flow: Light ____________________
Do you experience excessive menstrual pain during cycles? No
Do you bleed/spot between cycles? No
Do you bleed after intercourse? No
How many times on average do you have sexual intercourse per month? _______8_____________
Frequency of intercourse around ovulation: _____4________________
Do you have problems with intercourse? No

    – [ ] Gynecological History
Date of your last Pap Smear _____september 2015_______________
Was it normal? Yes
History of abnormal Pap smears? No
Are you using contraception now? No
Previous contraception? Yes
Type and date of last use: _____Cilest, last used in 2013
    – [x] Previous Tests
AMH Level 15/9/14 3.23 pmol/L TSH Jannary 2016 – normal________________
FSH level 15/9/14 13 iu/L T4 January 2016 – Normal
LH 15/9/14 6.7 iu/L 
Progesterone 04/06/14 93.8nmol
    – [ ] 
Dilatation and Curettage (D & C) Yes If yes, when? June 2015________________

    – [ ] Social History
Do you currently smoke?
No
Do you drink alcohol?
No
Do you drink caffeinated beverages? If so, how many servings per day? No
_________________
    – [ ] 
Pregnancy? Yes
Baby? No Have you had In-Vitro Fertilization (IVF) or IVF-ICSI? Yes If so, please provide details below:

- 28/01/16 – Short protocol with Menopur 375, Cetretide, 2 follicles at 16mm – cancelled cycle.
    – [ ] – 28/08/15 Long Protocol 13 days Fostimon 300iu and Merionol 150iu, Pregnyl 10,000 8 follicles, 4 eggs, 3 fertilised, 1 transferred at day 6 blastocyst – Not pregnant
- 10/11/14 Long Protocol 17 days Fostimon 300iu and Merionol 75iu, Pregnyl 10,000 8 follicles, 2 eggs, 1 transferred, 1 transferred on day 2 – Not pregnant
    – [ ] Husband’s details:
    – [ ] Previous Tests
Semen Analysis Sperm Count ______108 10*6/mL_____________
Date: ____6/10/14__________________ Sperm Motility ____85______________%
Sperm Morphology ____________7______%

    – [ ] Family History
Have you fathered children with your wife? No
Does he have a history of Infertility? No
Any hormonal disorders in the family? No
    – [ ] History of Fertility Therapy
Treated for Infertility Before? No
Drugs Taken for Infertility? No

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 1, 2016 reply

    Clearly, you have 2 issues. The first is your immunologic implantation dysfunction (IID) and the second is that with your DOR you do not have a great deal of time. Treatment of the IID first requires that it be determined whether this is due to an autoimmune (the commonest) cause or whether it is alloimmune in origin. While the NKa points squarely at an IID, it does not make this distinction. To do so you and your partner will need to be teated for DQ alpha and HLA genetic matching (see below). Treatment of the IID will differ depending on the cause. The second issue is your DOR and its impact on your response to stimulation. Here, in my opinion the protocol used for ovarian stimulation needs to be carefully reviewed and probably changed. In my opinion you might be best served through a modified, robust, long pituitary down-regulation protocol. I would use an agonist/antagonist conversion protocol with human growth hormone (HGH) augmentation and would recommend Staggered IVF with embryo banking of PGS (next generation gene sequencing)-normal blastocysts, to make hay while the sun still shines.

    Please go to my Blog on this site, find the “search bar” and 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
    • Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
    • Ovarian Stimulation for IVF: Comparing “conventional” use of GnRH antagonists to the Agonist/Antagonist Conversion Protocol (A/ACP)
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • 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)
    • Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • Hereditary Clotting Defects (Thrombophilia)
    • Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
    • PGS-Biopsy for the Assessment of Embryo Numerical Chromosomal integrity (Ploidy): Should it be done on Day 3 or on Day 5-6 post fertilization?
    • Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
    • Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
    • IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • Unexplained IVF Failure
    • 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)
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF
    • The Role of Nutritional Supplements in Preparing for IVF
    I invite you to call 702-699-7437 or 800-780-7437 or to go online here, and set up an one hour Skype consultation with me to discuss your case in detail.
    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

  • Laura - February 1, 2016 reply

    Hello Dr Sher, you asked me to write you on this blog instead.

    I’m 32, live in Canada, was pregnant (by accident w/boyfriend at the time) at age 25, terminated at 7 weeks, no complications.

    At age 29 got pregnant with husband after trying for 9 months- MMC @12w, embryo age was 9w. Was immediately pregnant again after MC, but MMC again @15w, embryo age was 14w. Both MC the heartbeat just stopped. A year after the 2nd MC we were still not pregnant again despite actively trying so we followed all your advice and got tested for everything through your clinic and clinic here: normal karyotype, no alloimune issues, no blood clotting factors other than mild protein C deficiency , no structural issues, excellent FSH ans AMH, no ATA but TSH at 4 so on Synthroid ever since, no apparent autoimmune factors BUT activated NK cells 14% (you thought on Skype appointment it may be due to mild endometriosis- the only symptom I possibly have is mildly painful ovulation).

    We just did IVF with 0.75mg dex and IL, had 2 excellent quality embryos transferred but it failed. We have 1 embryo left over which we will transfer next month. We’re just not sure why it didn’t work, the “soil” was taken care of with the dex and IL and the “seeds” were good too. We were told heparin wasn’t necessary. Was this just bad luck that it did not work?

    I’m baffled and afraid that upcoming FET will fail too. My questions are:

    1) if no alloimune issues why was it relatively easy getting pregnant naturally at first, twice, but now I can’t?

    2) is it possible that my very first pregnancy (terminated) at age 25 may have caused issues in that partner at the time may have had a DQHLA match with me and as a result fired up my NK cells? Would this cause issues with subsequent pregnancies even with current partner with whom I don’t have a match?

    3) why did IVF fail if I followed all the indicated treatments?

    I guess I’m just trying to figure out what could possibly have gone wrong and why it didn’t work out if theoretically it should have. We are saving to come see you in Vegas this May for IVF #2. Until then we’d love to understand what’s going on and what needs to be done differently. Thank you.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 1, 2016 reply

    Hi Laura,

    Thanks for posting here, as requested.

    Clearly you have an autoimmune implantation dysfunction. Since you really have only had one go at IVF with immunotherapy, I strongly believe that you were unlucky this time. What you need in my opinion is the same type of immunotherapy (see below) but next time I would suggest that you do Staggered IVF (see below) with PGS (next generation gene sequencing-NGS) to insure that the embryos transferred are chromosomally competent next time round (see below).

    I strongly recommend that you visit my new Blog on this site, find the “search bar” and 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
    • Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
    • Ovarian Stimulation for IVF: Comparing “conventional” use of GnRH antagonists to the Agonist/Antagonist Conversion Protocol (A/ACP)
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • 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)
    • Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
    • The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • Hereditary Clotting Defects (Thrombophilia)
    • Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
    • PGS-Biopsy for the Assessment of Embryo Numerical Chromosomal integrity (Ploidy): Should it be done on Day 3 or on Day 5-6 post fertilization?
    • Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
    • 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?
    • IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • Unexplained IVF Failure
    • Recurrent Pregnancy Loss (RPL): Why do I keep losing my Pregnancies?
    • 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)
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF
    • The Role of Nutritional Supplements in Preparing for IVF
    I invite you to call 702-699-7437 or 800-780-7437 and set up an one hour Skype consultation with me to discuss your case in detail.
    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

  • Lindsay - February 1, 2016 reply

    Thank you for the information. To be sure I understand, it is recommended that I use lupron or other agonist for the last 5-7 days of bcp use. Followed by a baseline sonogram and initiation of stims a few days later (they plan on using menopur and follistim). Then ganirelix up until the hcg trigger. This protocol would be ok for DOR?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 1, 2016 reply

    Sounds like it is OK !

    Good luck!

    Geoff Sher

  • Krista Whitley - January 31, 2016 reply

    Testing to confirm that this comment goes directly 🙂

  • Sonya - January 28, 2016 reply

    Dr Sher,
    I know normally you prescribe folgard to patients but what about the studies saying folate is the better option? I’ve read that people with mthfr issues can’t break down folic acid so folate is better for everyone.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - January 28, 2016 reply

    In my opinion, you can go either way and it will likely not make a difference.

    Geoff Sher

  • Kate - January 25, 2016 reply

    Hey Dr. Sher,

    I posted in your other forums in prep for my first FET cycle. Have a follow up question in regards to MTHFR.

    I just did my 23andme/genetic genie analysis and found out I’m heterozygous for both MTHFR C677T and MTHFR A1298C.

    Is this something I should be concerned about and prep for prior to my March 1 transfer? I’ve read conflicting info as to whether heterozygous is a problem– or if it’s just homozygous that can lead to problems with fertility/miscarriages.

    Since this will be my first FET and transfer, I can’t speak from experience, but I’d much rather be proactive about it, if there’s a chance this could cause problems.

    What’s your understanding of MTHFR? If one of your patients was heterozygous for both alleles, what precautions (if any) would you recommend?

    Thank-you so much for your time.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - January 25, 2016 reply

    I strongly recommend that you visit my NEW Blog on this site, find the “search bar” and type in ” Hereditary Clotting Defects (Thrombophilia)”. “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.

    I invite you to call 702-699-7437 or 800-780-7437 and set up an one hour Skype consultation with me to discuss your case in detail.
    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

    Kate - January 25, 2016 reply

    Thank-you Dr Sher. I read the articles and have a couple follow up questions.

    1) Given that I am heterozygous (not homozygous), do you feel there’s warrant for concern? The article stated that treatment was necessary for those homozygous for the genes but didn’t mention heterozygous. What’s been your experience with the latter?

    2) A quote from the article,”For other (milder) thrombophilias and no history of prior pregnancy complications: Low-dose aspirin with the B vitamins folic acid, B6 and B12.”

    Does that mean in these situations you would deem low dose aspirin appropriate/beneficial? (I know you mentioned in some other posts that you were against low dose aspirin)

    Thank-you kindly!

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - January 25, 2016 reply

    1) Given that I am heterozygous (not homozygous), do you feel there’s warrant for concern? The article stated that treatment was necessary for those homozygous for the genes but didn’t mention heterozygous. What’s been your experience with the latter?

    A: Heterozygous mutations simply require folic acid therapy (4mg of Folgard)

    2) A quote from the article,”For other (milder) thrombophilias and no history of prior pregnancy complications: Low-dose aspirin with the B vitamins folic acid, B6 and B12.”

    A: I do not prescribe aspirin . It , in my opinion, does not work. B6 and B12 can be used but are of doubtful value.

    Does that mean in these situations you would deem low dose aspirin appropriate/beneficial? (I know you mentioned in some other posts that you were against low dose aspirin)

    A: Since you will already be pregnant by the time you start Aspirin, it would not really be harmful but I doubt it has any benefit.

    Good luck!

    Geoff Sher

    Kate - January 25, 2016

    Thank-you!!

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - January 26, 2016

    You are very welcome, Kate!

    Geoff Sher

  • ange koko - January 22, 2016 reply

    Hi there dr sher!
    I have tried a to post a few times but I’m not sure they have been working? sorry if I’ve doubed up somewhere.
    Heres our story,
    We are 38 with 2 children ages 7 and 9, we have had periods of infertility and miscarriages and would love another child!
    We tried for our first child for 5yrs then went on to miscarry. We then conceived our daughter 9months later and conceived our son when daughter was 15months old. We have had 2 miscarriages after our son, the last one being 2.5years ago.
    With each miscarriage we get to 8.5wks plus, see heartbeat and baby is growing well at each scan then for some reason heart stops and i go on to miscarry?
    We have both had lots of tests done and they have never found anything wrong with either my husband or myself, he has a good sperm count and my amh is 18.
    We are trying to decide where to from here? We have been given two different lots of advise and I would love your advise to help make our decision.
    Specialists suspect I have endometriosis because of painful,heavy periods and infertility.
    So do I have a laparoscopy to remove endo and have a d&c done and then try to conceive naturally if not successful go on to have ivf? or go straight to ivf?
    I can get the laparoscopy etc public but will have to pay ourselves for ivf. Before ivf they are recommending a hysteroscopy while Im awake to check uterus, but if i have laparoscopy they will do hysteroscopy and d&c at same time.
    I tried chlomiphine for 9 months, have been told there is another drug similar to that starting with an L? that I could possibly try after laparoscopy. I will be eligible to receive funded ivf and go on the waiting list when i am 40.
    Basically I would like to know if you think laparoscopy before ivf would be beneficial? and a good idea?
    I really appreciate your help,
    Thanks soo much!
    Blessings Ange

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - January 22, 2016 reply

    No! I respectfully suggest that unless you have an ovarian endometriotic cyst that needs removal, there is no benefit (as far as your fertility is concerned) in doing a laparoscopy. I suspect that you might have developed an implantation dysfunction, possibly related to uterine NK cell activation. ..please read below as well as the articles referenced here.

    I strongly recommend that you visit my NEW personal website at http://www.DrGeoffreySherIVF.com and when you reach the home page, go to my new Blog find the “search bar” and 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
    • Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
    • Ovarian Stimulation for IVF: Comparing “conventional” use of GnRH antagonists to the Agonist/Antagonist Conversion Protocol (A/ACP)
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • 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)
    • Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
    • The BCP: Does Launching a Cycle of Controlled Ovarian
    • Stimulation (COS). Coming off the BCP Compromise Response?
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • Hereditary Clotting Defects (Thrombophilia)
    • Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve
    • IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • Unexplained IVF Failure
    • Recurrent Pregnancy Loss (RPL): Why do I keep losing my Pregnancies?
    • 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)
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
    • The Role of Nutritional Supplements in Preparing for IVF
    • IVF for Women Who Have Previously Conceived (Secondary Infertility).
    • Endometriosis and Infertily
    • Treating Ovarian Endometriomas with Sclerotherapy.
    • Implications of “Empty Follicle Syndrome and “Premature Luteinization”

    • IVF for Same Sex Couples
    • Confronting the Financial and Emotional Costs Associated with Doing IVF

    I invite you to call 702-699-7437 or 800-780-7437 and set up a one hour Skype consultation with me to discuss your case in detail.

    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

    ange koko - January 23, 2016 reply

    Thank you for your reply, I will check out those articles and would love to organise a skype consultation.
    Ange

  • Katy - January 21, 2016 reply

    Dear Dr Sher

    I just thought I would follow up on some very kind advice you gave me a few months back:

    http://haveababy.com/fertility-information/ivf-authority/ask-dr-sher-open-forum/comment-page-1975#comments

    In Oct 2010, at the age of 28, I was diagnosed with lean PCOS (3/3 of the Rotterdam criteria), with AMH 28 pmol/l, FSH 3.1, and an AFC of 42

    In July 2015, at the age of 33, it was found that I fulfiled 0/3 of the Rotterdam criteria and have DOR: my July bloods showed AMH 1.5 pmol/l, FSH 17.6 and an AFC of just 5

    You advised me (quite understandably, given these horrendous results) that I was likely heading towards an early menopause, and my chances of success were remote

    Well, I thought you might appreciate an update, as apparently bloods may not tell the entire story

    In Oct 2015 I underwent my first round of IVF, on a high stims antagonist protocol – retrieving 7 eggs (6 mature) – however due to issues with obtaining a fresh sample on the day (my husband was v unwell on the day – brilliant timing!!!), the 6 mature eggs went straight into the freezer unfertilised

    In Jan 2016, I underwent my second round of IVF, again on a high stims antagonist protocol, aiming to get more eggs to batch with those retrieved the first time around.

    At my baseline scan, my AFC had doubled to 10.
    Before trigger, I had 15 good sized follicles.
    At retrieval on Mon 18th Jan, we retrieved 17 eggs, all mature

    Meaning we had a total of 23 mature eggs from two cycles. Not bad for a woman with severe DOR supposedly in peri menopause!

    16 fertilised, and currently at day 3 we are on track to go to blastocyst – with 11 top quality embryos, 2 good quality, and 3 laggards on a go-slow.

    We are expecting a significant drop off between day 3 and 5 -but considering we expected to get a very small number of eggs to begin with, I am over the moon with 13 decent quality embryos at day 3

    Obviously none of this guarantees we will have any good quality blastocysts to transfer in 2 days time, nor indeed that any of these embryos will become a baby

    But for someone that the NHS had written off as a lost cause, and many clinics would have given the donor eggs speech, I feel that it really is a case of ‘you don’t know until you try’!!

    I very much hope this cycle results in a successful outcome. However even if it doesn’t, I am feeling encouraged that despite my apparent severe DOR, 23 eggs from 2 round of IVF doesn’t feel too shabby!

    V best regards

    Katy

    Katy - January 21, 2016 reply

    Two different embryologists asked me if the AMH could have been a lab error – I told them it had been repeated three times, and each time it came back at 1.5 pmol/l (which I believe is < 0.16 ng/ml or thereabouts? anyway – rubbish!!)

    Needless to say, I am very pleased that someone with undetectable AMH has managed to produce 17 mature eggs in one go, of which 12 fertilised beautifully, and 10 are excellent quality embryos at day 3. Any idea how this might be?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - January 21, 2016 reply

    Clearly a different lab should do the AMH.

    G-d bless!

    Geoff Sher

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - January 21, 2016 reply

    I am delighted for you . I wish you well and I thank you for this input. Clearly, the AMH measurement done most recently was incorrect. I believe if you were to repeat it now, it would likely be much higher and you probably do NOT have severe DOR.

    Good luck!

    Geoff Sher

    Katy - January 21, 2016 reply

    Thank you for your reply – I shall certainly look into getting my AMH retested!

    However, even if one assumes that all three AMH and two FSH levels were ALL lab errors, my antral follicle count still declined from 42 to 5 in the space of 5 years (between the ages of 28 and 32). 5 years ago my cycles were exceptionally irregular – I could go 6 months without a period. After my PCOS diagnosis I went on the pill for 5 years , and came off it about 7 months ago – and ovulated my first month off the pill. It was then that we discovered my ovaries had seemingly un-polycystic-ed themselves (as well as my apparent sky rocketing FSH and plummeting AMH). I have ovulated like clockwork since then, and my AFC has still been at the low end.

    So even if one takes the bloods as lab errors, wouldn’t such a huge decline in my antral follicle count suggest a significant drop in ovarian reserves?

    The outcome of my treatment and my response to COS is the most important thing, but just wondered what you thought – as it’s most baffling to me!!

    Kindest regards

    Katy

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - January 21, 2016 reply

    All I can say Katie, is that this just goes to show how inaccurate and inexact AFC really is.

    Good luck!

    Geoff Sher

    Katy - January 22, 2016

    Indeed!!! I do worry if my blood were ALL lab errors as the lab is the one used by pretty much every physician, medical practice and fertility clinic in the London area, all of Harley St’s finest. I’m actually struggling to find a different lab as every single place in London that offers blood tests ALL use TDL. Hmm!!!

    I do wonder if my epilepsy diagnosis played any part in my seemingly vanishing PCOS. I was only diagnosed a year ago and given my medication (Lamotrigine) not only interacts with the metabolism of the BCP (despite not being in the enzyme inducing class, apparently it’s a special case according to my neurologist, and so I had to double pack my pills) but according to the Epilepsy Foundation, it can be known to reduce the symptoms of PCOS. Who knows?!

    Apparently my case is a bit of a mystery, the outcome is what matters, but the 6 months I have spent thinking I was suffering from very very severe DOR and my dreams of becoming a Mum were in tatters, have been emotionally horrendous. I guess I just would like some answers even if it is ‘every single test is unreliable and here is why your PCOS symptoms all disappeared and you began ovulating when you never had before’ so that no one else has to go through the heartache I have been through!!

    Kindest regards

    Katy

    Katy - January 24, 2016 reply

    7 of our embryos made it to blastocyst – one perfect 4AA is on board, four great quality blasts are on ice, and the remaining two weren’t sufficiently good quality to freeze.

    Hopefully I do NOT indeed have DOR despite what all the many many tests indicated! Tests are indeed an imperfect science, it seems!!

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - January 24, 2016 reply

    That sounds quite good actually. Stay in touch and let me know how you do!

    Good luck!

    Geoff Sher

    Katy - February 2, 2016

    Got a BFP @ 8dp5dt on a HPT, 10dp5dt beta hCG 299. Going back for my next beta in 2 days. So, for now, I am pregnant!

    BTW I checked and my identical, undetectable AMH levels came from 2 different labs. So either they’re both lab errors, or I really did have appalling AMH….

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - February 2, 2016

    Copy!

    Good luck Katy!

    Geoff Sher

  • Melanie - January 19, 2016 reply

    Hi Dr. Sher,
    My husband and I are trying to get pregnant, and are seeing one specialist who is prescribing various courses of treatment, but without elaborating much on her reasoning.

    I had a very regular cycle for about 13 years, then (due I think to weight loss) I stopped menstruating. It’s been 20 months now. I tried a cycle of 50mg x 5 days clomiphene, but developed 7 large follicles. I didn’t naturally ovulate from that cycle, so had to take progesterone in order to induce a bleed. The next cycle was unmedicated, but I only managed to develop a few follicles to about 10mm, with a reasonable endometrium thickness. Once again I didn’t ovulate, and had to take progesterone to induce the bleed.

    Now I am on FSH, I have taken 25IU for 8 days, and only have a couple of 8-10mm follicles with a thin (5mm) endometrium. My doctor has recommended increasing the dose to 50 for a few days and checking again.

    I have gained back the weight I lost and am at a weight where I would normally get regular periods.

    Do you have any thoughts, comments or guidance? What are the chances of successful timed intercourse if FSH stimulation goes on for more than 10 days? Is my cycle likely to start up on its own again? Why did I over respond to the clomid, but underrespond to the FSH? Would you also recommend FSH stimulation in my case?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - January 19, 2016 reply

    Hi Melanie,

    The good news is that given your response to a very low dosage of FSH stimulation means that you are not in ovarian failure. It now becomes important to determine the cause of your anovulation…before proceeding any further. I would recommend that your blood be tested forAMH/basal FSH, LH, E2/Testosterone/DHEAS/androstenedione and 17-OH progesterone. Also, can you tell me whether you started the stimulation after a hormone withdrawal bleed was effected, what the peak estradiol level was/is and what the thickness of your uterine lining reached.

    I strongly recommend that you visit my new Blog on this website find the “search bar” and 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): Selecting the ideal protocol
    • Preventing Severe Ovarian Hyperstimulation Syndrome (OHSS) with “Prolonged Coasting”
    • Understanding Polycystic Ovarian Syndrome (PCOS) and the Need to Customize Ovarian Stimulation Protocols.
    • Intrauterine Insemination (IUI): Who Needs it & who Does Not: Pro’s & Con’s!
    • Micro-IVF: Often Preferable to Ovarian Stimulation with or Without IUI

    I invite you to call 702-699-7437 or 800-780-7437 and set up a one hour Skype consultation with me to discuss your case in detail.

    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

    Melanie - January 20, 2016 reply

    Hi, thanks! I don’t know if I did respond, because I also produced a few follicles to 8-10cm on a natural cycle after the clomiphene cycle.. so I’m not convinced that the FSH has done anything. But I will see what happens now that the dose has been increased.

    Other than AMH, the other levels you mentioned were investigated and most were normal. The only out of range values were free androgen index (low), testosterone (borderline low) and LH (low).

    I do wonder if using LH as well as FSH would have more success in stimulating me.

    My E2 isn’t being measured during these cycles – just ultrasound. On the clomiphene and natural cycle my endometrium was I think around 8 or 9, but on this cycle so far only 5.

    I will have a look through the articles you suggested.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - January 20, 2016 reply

    Please do so and then if you wish to consult with me via Skype, call 800-780-7437 and talk with Tina.

    Good luck!

    Geoff shder

  • Monika - January 14, 2016 reply

    Hello, Dr. Sher,
    Not long ago I was diagnosed with endometrioma in my left ovary which is about 4 cm in size. I am 38 and planning to start trying to conceive in about a year. Is it possible to perform a sclerotherapy procedure in your clinic to get rid of the cyst. I really don’t want to undergo a laparoscopic surgery as it is done under general anaesthesia and i would loose a part of my healthy ovary tissue. I am so concerned about that as I already had this kind of surgery on my right ovary 13 years ago and now the ovary is smaller than it used to be. I don’t want to reduce my chances of getting pregnant even more. Thank you.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - January 15, 2016 reply

    In the era of assisted reproductive technology (ART), there are two reasons for the treatment of endometriosis. The first is to alleviate symptoms of pain. The second is in preparation for In Vitro Fertilization (IVF). Conventional surgical treatment of ovarian endometriosis involves either an abdominal incision or laparoscopic drainage of the cyst contents with subsequent removal of the cyst wall. Unfortunately, in many cases, normal ovarian tissue is inadvertently removed along with the cyst wall, which may decrease the number of available oocytes for subsequent fertility treatment. A large percentage of such women have advanced stage disease and have had multiple previous surgeries. In the presence of pelvic adhesions, visualization of anatomic structures may be inadequate, leading to inadequate surgical removal with frequent cyst recurrence, which could further diminish the potential response to ovarian stimulation with gonadotropins. In addition, most women with advanced endometriosis (ie; those who are also more likely to have endometriomas) are likely to have developed pelvic adhesions and accordingly are at increased risk of surgical complications. Many patients with recurrent ovarian endometriomas are uncomfortable with the prospect of repeat surgery and its avoidance is often a factor in the decision to proceed with IVF. There have been several reports on the use of sclerotherapy in the treatment of recurrent ovarian endometriomas. We have experience with the use of sclerotherapy in many women with endometriomas, who were preparing for treatment with IVF.

    Sclerotherapy for ovarian endometriomas involves; needle aspiration of the liquid content of the endometriotic cyst, followed by the injection of 4-5% tetracycline into the cyst cavity. Treatment results in disappearance of the lesion within 6-8 weeks, in more than 75% of cases so treated. Ovarian sclerotherapy can be performed under local anesthesia or under general anesthesia. It has the advantage of being an ambulatory office- based procedure, at low cost, with a low incidence of significant post-procedural pain or complications and the avoidance of the need for laparoscopy or laparotomy.

    Sclerotherapy is a safe and effective alternative to surgery for definitive treatment of recurrent ovarian endometriomas in a select group of patients planning to undergo IVF. Since the procedure is associated with a small, but yet realistic possibility of adhesion formation; it should only be used in cases where IVF is the only treatment available to the patient. Women who intend to try and conceive through fertilization in their fallopian tubes (e.g; following natural conception or intrauterine insemination) will be better off undergoing laparotomy or laparoscopy for the treatment of endometriomas.

    I strongly recommend that you visit my NEW personal website at http://www.DrGeoffreySherIVF.com and when you reach the home page, go to my new Blog find the “search bar” and 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
    • Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
    • Ovarian Stimulation for IVF: Comparing “conventional” use of GnRH antagonists to the Agonist/Antagonist Conversion Protocol (A/ACP)
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
    • Measuring and Interpreting Blood hCG to Assess Pregnancy Viability Following ART Treatments.
    • Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
    • IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • Unexplained IVF Failure
    • 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)
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
    • The Role of Nutritional Supplements in Preparing for IVF
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • Hereditary Clotting Defects (Thrombophilia)
    • Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
    • PGS-Biopsy for the Assessment of Embryo Numerical Chromosomal integrity (Ploidy): Should it be done on Day 3 or on Day 5-6 post fertilization?.
    • Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
    • Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.

    • The Sperm Chromatin Structure Assay (SCSA): A Measure of the Potential of Sperm to Help Propagate a Viable Pregnancy
    • IVF for Women Who Have Previously Conceived (Secondary Infertility).
    • Endometriosis and Infertily

    I invite you to call 702-699-7437 or 800-780-7437 and set up a one hour Skype consultation with me to discuss your case in detail.

    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

  • Daisy - January 14, 2016 reply

    Hi Dr. Sher,

    I asked a question at your other website, and you redirected me here and offered to review my immune testing results. I tested negative for Anti-thyroglobulin antibodies, anti-microsomal antibodies, anti-phospholipid antibodies. I had an NK Assay done and everything came back zero. In addition TH1/TH2 intracellular cytokines tested normal. We are totally stumped and very scared about our second FET!

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - January 14, 2016 reply

    Hi daisy,

    I was hoping you would post the exact results pertaining to the K-562 target cell test done for assessing NK cell activation. Remember, the concentration of NK cells is totally irrelevant. It is the % killing of target cells that matters (i.e. NK cell activity). Also i would like to know your and your partner’s Dq alpha and HLA genotypes . Also please post the exact TNF alpha and Interferon (cytokine values too.

    Finally, please note that there are VERY FEW Reproductive Immunology reference laboratories in the world that can evaluate these parameters with sufficient sensitivity and specificity.

    The reason I am dwelling on all this is that your situation sounds so much like an immunologic implantation dysfunction that I find it hard to believe that proper testing will not confirm this. Also, it is important to differentiate between alloimmune and autoimmune implantation dysfunction because IL alone cannot be used as a shotgun approach. If the treatment is not individualized you will be wasting your time.

    I strongly recommend that you go to my Blog on this site and 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.

    •IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
    •Unexplained IVF Failure
    •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

    I invite you to call 702-699-7437 and set up a one hour Skype consultation with me to discuss your case in detail.

    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

  • Melanie Bell - January 7, 2016 reply

    I wasn’t sure which blog was still active, so sorry if I double posted

    Dr Sher,

    I’m currently in cd6 and my first scan this morning showed I have a total of six follicles, three of which are already at 16mm. My RE plans on triggering me this Saturday on CD8. I’m concerned over egg quality/maturation. The trigger that he prescribed to me is ovidrel 250. Should I talk to him about adding on 10,000 hcg like noravel and trigger with both?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - January 7, 2016 reply

    This is definitely the preferred site for me Melanie.

    Obviously I cant tell your RE what to do, but I either use 500mcg of Ovidrel or 10,000U hCGu.

    Good luck!

    Geoff Sher

  • Donna - January 5, 2016 reply

    Dear Dr. Sher,

    My husband and I are both 32. He was diagnosed with azoospermia as a result of undescended testicle and I was diagnosed with endometriosis. I had a laparoscopy to remove a right endometrioma and widespread nodules in 2013.

    Our first cycle wasn’t successful and our second ended up being ectopic, it ruptured and I had my right tube removed.

    We tried the agonist protocol on our first cycle using 300 IU Gonal F. On our second cycle we tried the antagonist protocol using a combination of Gonal F 100 IU and Menopur 150. Cycle one I had 6 retrieved, 4 was mature and 2 fertilised, we transferred a 6 and 8 cell embryo with some fragmentation on day 3. Cycle two I had 12 follicles, 6 eggs retrieved, 4 was mature and 2 fertilised, we transferred 2 compact morals with no fragmentation.

    On both cycles both eggs and sperm where not of great quality.

    I have a AMH < 4.0 pmol/L and FSH is 7.4 U/L.

    Would you recommend trying the agonist/antagonist protocol? Or would you recommend switching to donor?

    Also, would you recommend that I get immune testing done?

    Thanks,
    Donna

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - January 6, 2016 reply

    Thanks for posting, Donna,

    First, you need to be aware that in 30% of cases, endometriosis is associated with an immunologic implantation dysfunction and this needs to be addressed in the ET cycle.

    You have severely diminished ovarian reserve and no doubt, your biological clock is running out of time. You need toi be very proactive. i would use a modified long pituitary down-regulatuion protocol with estrogen priming (agonist/antagonist conversion protocol with estrogen priming) + human growth hormone supplementation. i would also seriously consider Staggered IVF with “Embryo banking” of PGS-selected embryos to try and make hay while the sun still shines and I would not waste a minute in starting.

    Your husband’s issue probably mandates that you consider using donor sperm.

    I urge you to access my new blog. When you get to the “home page” of the Blog on this website. Go to the home page of the blog and find the “search bar”. Typeype in any of the articles below by title, “click” and you will immediately be taken to these. While on this blog, please take the opportunity 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
    • Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
    • Ovarian Stimulation for IVF: Comparing “conventional” use of GnRH antagonists to the Agonist/Antagonist Conversion Protocol (A/ACP)
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?.
    • Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
    • IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
    • The Role of Nutritional Supplements in Preparing for IVF
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • Hereditary Clotting Defects (Thrombophilia)
    • Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
    • PGS-Biopsy for the Assessment of Embryo Numerical Chromosomal integrity (Ploidy): Should it be done on Day 3 or on Day 5-6 post fertilization?
    • Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
    • Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
    • Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
    • Male Factor Infertility
    • The Sperm Chromatin Structure Assay (SCSA): A Measure of the Potential of Sperm to Help Propagate a Viable Pregnancy
    • Endometriosis and Infertily
    • Treating Ovarian Endometriomas with Sclerotherapy
    • IVF Egg Donation: A Comprehensive Overview

    Might I suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Call 702-699-7437 if you wish to discuss your case with me in detail via Skype.

    Geoff Sher

  • Lou - January 3, 2016 reply

    @GeoffreySherMD what would you recommend after 3failed icsi. D2,D5,then D3 transfer.unexplained infertility both 30yrs old.had D&C ’07 With a previous partner

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - January 4, 2016 reply

    Lou, when confronted with “unexplained” IVF failures where morphologically good embryos were transferred, the question arises as to whether the problem is due to inherent egg/embryo “incompetence” (which usually equates with an irregular chromosomal configuration [aneuploidy]) or whether it is due to an implantation dysfunction.The younger the woman and the higher the quality of available embryos (preferably blastocysts), the less likely it is that the fault lies with embryo “incompetence” and the greater is the likelihood that it is due to underlying implantation dysfunction.
    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)
    Implantation dysfunction (anatomical or immunologic) is a common cause of repeated “unexplained” IVF failure with good embryos. 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.

    I urge you to access my new blog on this website. When you get to the “home page” of the Blog, find the “search bar” and type in any of the articles below by title, “click” and you will immediately be taken to these.
    • Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
    • IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • 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)
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
    • The Role of Nutritional Supplements in Preparing for IVF
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • Hereditary Clotting Defects (Thrombophilia)
    • Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
    • PGS-Biopsy for the Assessment of Embryo Numerical Chromosomal integrity (Ploidy): Should it be done on Day 3 or on Day 5-6 post fertilization?
    • Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
    • Male Factor Infertility
    • The Sperm Chromatin Structure Assay (SCSA): A Measure of the Potential of Sperm to Help Propagate a Viable Pregnancy
    • Endometriosis and Infertily
    I invite you to call 702-699-7437 or 800-780-7437 and set up a one hour Skype consultation with me to discuss your case in detail.

    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

    Lou - January 4, 2016 reply

    With my last cycle they used time lapse imaging which showed that whilst the embryos got to 8 cell on day 3 not all did it in the correct pattern. Would this suggest embryo quality issue? Could previous D&C affect implantation? I had an endometrial scratch last cycle too. I suffer with psoriasis could that have any impact?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - January 4, 2016 reply

    My suggestion is to do Staggered IVF with PGS testing of your embryos (see below). We use next generation gene sequencing (NGS). A previous D&C should not have impacted implantation potential, but endometrial thickness and immunologic implantation dysfunction certainly can.

    Embryo scratch is in my opinion of little (if any) value.

    I urge you to access my blog on this very website. When you get to the “home page” of the Blog, find the “search bar” and type in any of the articles below by title, “click” and you will immediately be taken to these. While on this blog, please take the opportunity to post any questions or comments with as always, the full expectation that I will (as always) respond promptly.
    • IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • Unexplained IVF Failure
    • 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)
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
    • The Role of Nutritional Supplements in Preparing for IVF
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • Hereditary Clotting Defects (Thrombophilia)
    • Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
    • PGS-Biopsy for the Assessment of Embryo Numerical Chromosomal integrity (Ploidy): Should it be done on Day 3 or on Day 5-6 post fertilization?
    • Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
    • Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
    • Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.

    I invite you to call 702-699-7437 or 800-780-7437 and set up a one hour Skype consultation with me to discuss your case in detail.

    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

  • Tammy - December 13, 2015 reply

    Good Morning DR. Sher;

    I am really hoping you can give me some insight as to what direction I should take. I have been trying to conceive for the last 15 years. The first 10 years of IVF’s we suffered repeated miscarriages. The last 5 I ended up with what they said was DOR. My Fsh varies from 5 -12. I was told to move onto donor eggs. My first donor egg cycle in June resulted in twin blighted ovum. We did a fresh cycle with a new donor in November that was negative. After being fed up, I took it upon myself to do immune testing with RMI in California. These tests showed a normal Nk assay result, Treg at 0.3. and my TNF-a-IL-10 was horrible at 45.9. I do have Hashimoto’s and am on Synthroid. I also did intralipids, 5mg of prednisone starting on the day of the donors retrieval as well as lovenox 40mg 1x a day. After my pregnancy in June for some reason another IL was not done. My RE’s office is suggesting that I move on to surrogacy. Since my embryo’s are in Europe, this is not possible. Is this something that is treatable so that I can use my last 4 blasts, or should I just call it quits?
    Thank you so much for your time, and all that you do to help those of us that are in desperate need.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - December 13, 2015 reply

    The TNFa result suggests that you do have NK cell activation, since activated NK cells are the main source of TH-1 cytokines. I thus suspect an error in interpretation. Remember also that NK cell concentration is irrelevant. Itis NK cell activity as measured by the K-562 Target cell test that matters. Also, taking IL on the day of ER is far too late for it to be effective. Finally, it is essential before going any further to determine whether you have autoimmune or allimmune implantation dysfunction and that requires that you and your partner be tested for DQ alpha/hHla matching.

    I urge you to consider allowing me to review your case. For that to happen we need to consult. Please call 1-702-699-7437 or 1-800-780-7437 ASAP and ask Tina to arrange for us to interact via Skype.

    Also, please read all the articles referenced below and which can be found on my blog on this very website,www.DrGeoffreySherIVF.com which also hosts the blog. From the home page of this website you can access the blog and the “search bar” where you can type in a topics (below) , click and you will be taken to the article of your choice.

    • Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
    • Ovarian Stimulation For Women with Diminished Ovarian Reserve (DOR) and in Older Women undergoing IVF
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
    • Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
    • Unexplained IVF Failure
    • 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)
    • Recurrent Pregnancy Loss (RPL): Why do I keep losing my Pregnancies?
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
    • The Role of Nutritional Supplements in Preparing for IVF
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • Hereditary Clotting Defects (Thrombophilia)
    • Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
    • PGS-Biopsy for the Assessment of Embryo Numerical Chromosomal integrity (Ploidy): Should it be done on Day 3 or on Day 5-6 post fertilization?
    • Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
    • Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
    • Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.

    Finally, perhaps you would be interested in accessing the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores.

    Geoff Sher

    Tammy - December 13, 2015 reply

    Thank you so much for your response. I will look into the blogs you recommended and call on Monday to arrange a consult.
    I also made a mistake in my text. My prednisone was started on ER and the intralipid usually 7-14 days before. My Nk results were as followed
    50:1 =7.1 25:1=5.2 12.5:1 = 3.5 Target ranges were IGG 12.5 , 50.1 =3.1
    %CD3=77.9 %CD19 = 11.7 %CD56CD16 =7.5 %CD19CD5=7.8
    %CD3+CD56+(NKT)=0.5
    It was recommended IVIG would be our only option for success… I do find the 77.9 value high. I was told these were o.k levels. I thought that if you used donor eggs having the DQ alpha matching wasn’t necessary. Am I wrong? Hopefully you and I can figure this out.
    Thanks again

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - December 14, 2015 reply

    Unless you have NKa+, DQ alpha ,matching wont matter and would not require treatment.with IVIG or intralipid. But as I stated, something does not fit here. We really need to talk.

    Geoff Sher

    Venesa - January 1, 2016 reply

    Hi Dr.Sher
    I’m 28/f with unexplained infertility.I have pcos but regular with periods other than that my reports and my husbands are normal .I’m married for 5 years but took conterceptive pill for 2 years after that I was diagnosed with chronic vaginal infection .I took medicine several times for infection and now I think it’s fine.I took ovulation medicine 15 times but failed, iui but failed , ivf with icsi(agonist protocol) 4blastocyst were transfered but failed, fet 3 embryos 3 day embryo were transferred but failed.now I don’t know what to do I gave up hope .I’ll be grateful if u could help.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - January 1, 2016 reply

    Hi Venesa,

    Something has probably been missed here. The fact that you are young and have had blastocysts transferred with no success points to something other than a PCOS-related egg issue. It is likely due to implantation failure.

    When confronted with “unexplained” IVF failures where morphologically good embryos were transferred, the question arises as to whether the problem is due to inherent egg/embryo “incompetence” (which usually equates with an irregular chromosomal configuration [aneuploidy]) or whether it is due to an implantation dysfunction. The younger the woman and the higher the quality of available embryos (preferably blastocysts), the less likely it is that the fault lies with embryo “incompetence” and the greater is the likelihood that it is due to underlying implantation dysfunction.
    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)
    Implantation dysfunction (anatomical or immunologic) is a common cause of repeated “unexplained” IVF failure with good embryos. 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.

    I urge you to access my new personal website at http://www.DrGeoffreySherIVF.com and from there, my new blog. When you get to the “home page” of the Blog, find the “search bar” and type in any of the articles below by title, “click” and you will immediately be taken to these. While on this blog, please take the opportunity 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
    • Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
    • Ovarian Stimulation for IVF: Comparing “conventional” use of GnRH antagonists to the Agonist/Antagonist Conversion Protocol (A/ACP)
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
    • Measuring and Interpreting Blood hCG to Assess Pregnancy Viability Following ART Treatments.
    • IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • Unexplained IVF Failure
    • 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)
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
    • The Role of Nutritional Supplements in Preparing for IVF
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • Male Factor Infertility.
    • Endometriosis and Infertily
    • Preventing Severe Ovarian Hyperstimulation Syndrome (OHSS) with “Prolonged Coasting”
    • Understanding Polycystic Ovarian Syndrome (PCOS) and the Need to Customize Ovarian Stimulation Protocols.
    • Intrauterine Insemination (IUI): Who Needs it & who Does Not: Pro’s & Con’s!

    I invite you to call 702-699-7437 or 800-780-7437 and set up a one hour Skype consultation with me to discuss your case in detail.

    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

  • LENA - December 10, 2015 reply

    Hello Dr Sher,
    I have pcos and I my situation is worsen by immune issues
    I tested for various immune issues and my results are as follows:

    [u][b]DQ Alpha Genotype[/b][/u]

    Me HLA Genotype: 1.3, 2.0
    Spouse HLA Genotype:1.4, 2.0

    [u][b]NK Cells[/b][/u]: normal

    [u][b]Anti-Paternal Leukocyte Antibody:(Negative)[/b][/u]

    T-Cells : 0.3

    B-Cells: 8.1

    No Auto Nuclear Anitbody and Anit Phospolid antibody.

    I would like to understand what these results mean. Please help.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - December 10, 2015 reply

    In the absence of activated NK cels (NKa), the partial genotypic matching will not compromise implantation in my opinion. Both NKa+ and DQ alpa/HLA matching need to co-exist to create the problem. The absenece of paternal leukocyte antibodies is irrelevant.

    PCOS is a separate issue that requires that the protocol used for ovarian stimulation be carefully selected. Please go to the article on PCOS, to be found on the blog in this website.

    I am proud to announce the establishment of my new website, http://www.DrGeoffreySherIVF.com which also hosts my new blog which I will be servicing with articles on an ongoing basis and where I will be addressing your questions and comments.

    From the home page of this website you can access the blog and the “search bar” where you can type in a topics (below) , click and you will be taken to the article of your choice. I will also continue to answer all questions you post on the “IVFauthority” blog but will no longer be contributing new articles on that site.
    • Understanding Polycystic Ovarian Syndrome (PCOS) and the Need to Customize Ovarian Stimulation Protocols.Controlled Ovarian

    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
    • 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)
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
    • The Role of Nutritional Supplements in Preparing for IVF
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • Hereditary Clotting Defects (Thrombophilia)
    • Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
    • PGS-Biopsy for the Assessment of Embryo Numerical Chromosomal integrity (Ploidy): Should it be done on Day 3 or on Day 5-6 post fertilization?
    • Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
    If you are interested in having a Skype consultation with me and discussing your case in detail, please call 1-702-699-7437 or 1-800-780-7437.

    Finally, perhaps you would be interested in accessing the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores.

    Geoff Sher

    Lena - December 20, 2015 reply

    Thanks dr sher. I tested these at Ria lab and they mentioned that Although your nk cell number and activity are normal, with the dq alpha sharing you are at high risk for developing elevated nk cell activity in early pregnancy. That is why initially I am recommending 2 days of IVIg not just one. I don’t know what it means I had a miscarriage and ivf failure and trying to understand the reason for those failure

    Lena - December 20, 2015 reply

    Also I have partial do alpha sharing does it mean I have alloimmune issues

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - December 20, 2015

    Yes…but only if/when you develop NKa.

    Geoff Sher

    Lena - December 21, 2015

    What are the chances of me developing nk cells? Should I test for it after some months again ?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - December 21, 2015

    With a DQa partial match it could happen later. I would test in a year or so, again.

    Geoff Sher

    Lena - January 4, 2016

    I have 10 frozen embryos and I am planning to do fet next month. Given my past history of miscarriage and failed ivf would you recommend taking ivig

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - January 4, 2016

    Hi Lena,

    I would not suggest treating this as if it were an immunologic issue, unless there is evidence to suggest such. If you have had repeated miscarriages in the past, have a personal or family history of autoimmune disease (e.g. Lupus Erythematosis, Hypothyroidism, Rheumatoid Arthritits etc) or a history of unexplained repeated IVF failures or endometriosis, then indeed you should be tested (see below). However, a single miscarriage could be due to a sporadic embryo defect. About 15% of pregnancies do miscarry and it does not mean it will recur.

    I urge you to access my new blog on this very website. When you get to the “home page” of the Blog, find the “search bar” and type in any of the articles below by title, “click” and you will immediately be taken to these. While on this blog, please take the opportunity to post any questions or comments with the full expectation that I will (as always) respond promptly.

    • IVF Failure and Implantation Dysfunction: The Role of Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • Unexplained IVF Failure
    • 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)
    • Recurrent Pregnancy Loss (RPL): Why do I keep losing my Pregnancies?

    I invite you to call 702-699-7437 or 800-780-7437 and set up a one hour Skype consultation with me to discuss your case in detail.

    I also suggest that you access the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoff Sher

    Lena - January 4, 2016

    Continued ..are there any other recommendations., my uterine lining is thick.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - January 4, 2016

    See below in my prior response, Lena.

    Good luck!

    Geoff Sher

  • Amy - December 8, 2015 reply

    Dr Sher,
    I am currently almost 9 weeks pregnant. I am taking .5 mg of Dexamethasone for high DHEA-S levels. Before I got pregnant I stopped getting my period due to this hormonal imbalance. As soon as I started taking the steriod I ovulated and conceived. My doctor would like me to wean off the Dex around 10 weeks. I am scared to do this because I do not want the pregnancy to result in a miscarriage because my testosterone levels increased after stopping the steroid. What is the oulook for a healthy pregnancy after stopped the steroid?
    Thank you.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - December 9, 2015 reply

    Hi Amy,

    I must be candid, I concur with the advice given by your RE to start tailing off the dexamethasone.

    Geoff Sher

    Amy - December 9, 2015 reply

    Thank you for your input. I will start weaning off at ten weeks

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - December 9, 2015 reply

    Good luck!

    Geoff Sher

  • karishma vishal lamchhane - December 3, 2015 reply

    3yrs are over for my marriage stil i dnt hve baby earlier i had my misscariage im suffering frm tyroid nd pcod sometimes periods are delay im so tense plz hlp me doc

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - December 4, 2015 reply

    Hi karishma.
    There is a link between hypothyroidism and reproductive dysfunction, as well as between PCOS and the same problem:
    Thyroid dysfunction:

    Thyroid Disease:

    Between 2% and 5% of women of the childbearing age have reduced thyroid hormone activity (hypothyroidism). Women with hypothyroidism often manifest with reproductive failure i.e. infertility, unexplained (often repeated) IVF failure, or recurrent pregnancy loss (RPL). The condition is 5-10 times more common in women than in men. In most cases hypothyroidism is caused by damage to the thyroid gland resulting from of thyroid autoimmunity (Hashimoto’s disease) caused by damage done to the thyroid gland by antithyroglobulin and antimicrosomal auto-antibodies.
    The increased prevalence of hypothyroidism and thyroid autoimmunity (TAI) in women is likely the result of a combination of genetic factors, estrogen-related effects and chromosome X abnormalities. This having been said, there is significantly increased incidence of thyroid antibodies in non-pregnant women with a history of infertility and recurrent pregnancy loss and thyroid antibodies can be present asymptomatically in women without them manifesting with overt clinical or endocrinologic evidence of thyroid disease. In addition, these antibodies may persist in women who have suffered from hyper- or hypothyroidism even after normalization of their thyroid function by appropriate pharmacological treatment. The manifestations of reproductive dysfunction thus seem to be linked more to the presence of thyroid autoimmunity (TAI) than to clinical existence of hypothyroidism and treatment of the latter does not routinely result in a subsequent improvement in reproductive performance.
    It follows, that if antithyroid autoantibodies are associated with reproductive dysfunction they may serve as useful markers for predicting poor outcome in patients undergoing assisted reproductive technologies.
    Some years back, I reported on the fact that 47% of women who harbor thyroid autoantibodies, regardless of the absence or presence of clinical hypothyroidism, have activated uterine natural killer cells (NKa) cells and cytotoxic lymphocytes (CTL) and that such women often present with reproductive dysfunction. We demonstrated that appropriate immunotherapy with IVIG or intralipid (IL) and steroids, subsequently often results in a significant improvement in reproductive performance in such cases.
    The fact that almost 50% of women who harbor antithyroid antibodies do not have activated CTL/NK cells suggests that it is NOT the antithyroid antibodies themselves that cause reproductive dysfunction. The activation of CTL and NK cells that occurs in half of the cases with TAI is probably an epiphenomenon with the associated reproductive dysfunction being due to CTL/NK cell activation that damages the early “root system” (trophoblast) of the implanting embryo. We have shown that treatment of those women who have thyroid antibodies + NKa/CTL using IL/steroids, improves subsequent reproductive performance while women with thyroid antibodies who do not harbor NKa/CTL do not require or benefit from such treatment.

    2. PCOS:

    Polycystic ovary syndrome (PCOS) is a common hormonal system disorder among women affecting between 5% and 10% of women of reproductive age worldwide. Women with PCOS may have enlarged ovaries that contain small collections of fluid — called follicles — located in each ovary as seen during an ultrasound. The condition is characterized by abnormal ovarian function (irregular or absent periods, abnormal or absent ovulation and infertility), androgenicity (increased body hair or hirsutism, acne) and increased body weight –body mass index or BMI. The ovaries of women with PCOS characteristically contain multiple micro-cysts often arranged like a “string of pearls” immediately below the ovarian surface (capsule).interspersed by an overgrowth of ovarian connective tissue (stroma).

    PCOS is one of the most common causes of menstrual irregularities, infertility, and hirsutism, Despite an enormous effort to define its cause, the etiology of PCOS remains unclear, and there is no definite cure at this time. PCOS is clearly a heterogeneous disorder which often has a familial (genetic) basis. Infertility associated with PCOS has been attributed to numerous factors, including dysfunctional gonadotropin pituitary secretion, peripheral insulin resistance, elevated adrenal and/or ovarian androgen (male hormone) levels, and dysfunction of several growth factors. Women with this condition are often obese and insulin resistant. The compensatory hyperinsulinemia further stimulates ovarian androgen production which may be detrimental to egg maturation and there is a clear link between the degree of insulin resistance and anovulation. PCOS is also a significant long-term health risk for women, thus necessitating vigilance through regular annual examinations (non-insulin dependent diabetes mellitus, hypertension, hypercholesterolemia, cardiovascular disease and endometrial cancer). Whereas PCOS-related infertility is usually manageable through the use of fertility drugs, lifestyle changes (diet and exercise) remain a mainstay of long-term therapy. More recently, ovulation rates, circulating androgens, pregnancy rates and perhaps even first-trimester miscarriage rates have been shown to improve when insulin sensitizers like metformin are used to correct the underlying insulin resistance.

    Most patients with PCOS are young and have excellent pregnancy rates with oral clomiphene. Those that require more aggressive treatments with injectable medications probably represent a subgroup of PCOS patients with severe ovarian dysfunction. These women often have explosive response to gonadotropins which can result in serious complications like Severe Ovarian Hyperstimulation Syndrome (OHSS…see below) and high order multiple births. In those women, the ability to perform “prolonged coasting” (see below) and selectively transfer fewer embryos during IVF offers a clear advantage over standard gonadotropin injections.

    Egg quality in PCOS

    The potential for a woman’s eggs to undergo orderly maturation, successful fertilization and subsequent progression to “good quality embryos” is in large part genetically determined. However, the expression of such potential is profoundly susceptible to numerous influences, especially intra-ovarian hormonal changes during the pre-ovulatory phase of the cycle. Proper follicular stimulation as well as precise timing of egg maturation with LH (Luteinizing Hormone) or hCG (human chorionic gonadotropin) is crucial to optimal egg maturation, fertilization and ultimately embryo quality. Both pituitary gonadotropins, LH and FSH (follicle stimulating hormone) play a pivotal but different role in follicular development. The action of FSH is mainly directed toward granulosa cell (cells lining the inside of the follicle) proliferation and estrogen production (E2). LH, on the other hand, acts primarily on the ovarian stroma (the connective tissue that surrounds the follicle) to produce androgens. While small amounts of ovarian androgens, such as testosterone, enhance egg and follicle development, over-exposure to them can have a deleterious effect. Furthermore, excessive ovarian androgens can also compromise estrogen-induced endometrial growth and development.

    Suppressing pituitary secretion of LH with gonadotropin releasing hormone (GnRH) agonists such as Lupron®, is particularly useful in PCOS. In that condition, serum LH levels are elevated, leading to stromal overgrowth, follicular arrests (so-called cysts) and high levels of androgens synthesis. It is therefore not surprising that these follicles often yield poorly developed (“immature”) eggs” at the time of egg retrieval (ET) and that “poor egg/embryo quality”, inadequate endometrial development and high miscarriage rates are common features of this condition. However, contrary to popular belief, this is not due to an intrinsic deficit in “egg quality”. Stimulation protocols geared toward optimizing follicle and egg development and avoiding over exposure to androgens correct these problems ad result in pregnancy rates similar to those of non-PCOS women. Whereas the overuse of LH-containing preparations such as Menopur® and Luveris® further aggravates this effect. In conclusion, to maximize ultimate oocyte maturation, we strongly recommend against the exclusive use of such products in PCOS patients, preferring FSH-dominant products such as Folistim®, Gonal F® or Bravelle® over a period of at least 9 days following pituitary suppression with Lupron®.
    PCOS women often have a family history of diabetes and demonstrable insulin resistance (evidenced by high blood insulin levels and an abnormal 2-hour glucose tolerance test).This underlying Diabetes mellitus tendency could play a role in the development of PCOS and contribute to the development of obesity, an abnormal blood lipid profile, and a predisposition to coronary vascular disease. Women with PCOS are slightly more at risk of developing uterine, ovarian and possibly also breast cancer in later life and accordingly should be evaluated for these conditions on a more frequent basis than would ordinarily be recommended to non-PCOS women.

    Most women with PCOS either do not ovulate at all or they ovulate irregularly. As a consequence thereof they in addition usually experience delayed, absent or irregular menstruation. In addition, an inordinate percentage of the eggs produced by PCOS women following ovulation induction, tend to be chromosomally abnormal (aneuploid). Rather than being due to an intrinsic egg defect being inherent in PCOS women, the poor egg quality more than likely the result of over-exposure to male hormones (predominantly, testosterone) produced by the ovarian stroma. These two factors (ovulation dysfunction and poor egg quality) are the main reasons for the poor reproductive performance (infertility and an increased miscarriage rate) in PCOS women.

    PCOS patients are at an inordinate risk of severely over-responding fertility drugs, both oral varieties (e.g. Clomiphene, Serophene & Femara) and especially the injectables (e.g. Follistim, Puregon, Gonal F, Menopur and Bravelle) by forming large numbers ovarian follicles. This can lead to life endangering complications associated with sever ovarian hyperstimulation (OHSS). In addition PCOS women receiving fertility drugs often experience multiple ovulations putting them at severe risk (40%+) of high order multiple pregnancy (i.e. triplets or greater) with often devastating consequences.

    VARIETIES OF POLYCYSTIC OVARIAN SYNDROME:

    1) Hypothalamic-pituitary-PCOS: This is the commonest form of PCOS and is often genetically transmitted and is characteristically associated with a blood concentration of Luteinizing Hormone (LH) that is uncharacteristically much higher than the Follicle Stimulating Hormone (FSH) level (FSH is normally higher than the LH concentration) as well as high-normal or blood androgen ( male) hormone concentrations (e.g. androstenedione, testosterone and dehydroepiandrosterone -DHEA).Hypothalamic-pituitary-ovarian PCOS is also often associated with insulin resistance and in about 40%-50% of the cases.

    2) Adrenal PCOS: Here the excess of male hormones are derived from overactive adrenal glands rather than from the ovaries. Blood levels of testosterone and/or androstenedione raised but here, but here, the blood level of dehydroepiandrosterone (DHEAS) is also raised, clinching the diagnosis.

    3) Severe pelvic adhesive disease secondary to severe endometriosis, chronic pelvic inflammatory disease and/or extensive pelvic surgery: Women who have this type of PCOS tend to less likely to hyperstimulate in response to ovulation induction . Their. DHEAS is also is not raised.

    TREATMENT OF INFERTILITY DUE TO ASSOCIATED OVULATION DYSFUNCTION:

    Hypothalamic-pituitary-/ovarian PCOS: Ovulation induction with fertility drugs such as clomiphene citrate, Letrozole (Femara) or gonadotropins, with or without intrauterine insemination (IUI) is often highly successful in establishing pregnancies in PCOS women. However, IVF is fast becoming a treatment of choice (see below).

    In about 40% of cases, 3-6 months of oral Metformin (Glucophage) treatment results in a significant reduction of insulin resistance, lowering of blood androgen levels, an improvement in ovulatory function, and/or some amelioration of androgenous symptoms and signs.

    Surgical treatment by “ovarian drilling” of the many small ovarian cysts lying immediately below the envelopment (capsule) of the ovaries, is often used, but is less successful than alternative non-surgical treatment and is only temporarily effective. The older form of surgical treatment, using ovarian wedge resection is rarely used any longer as it can produce severe pelvic adhesion formation.

    Adrenal PCOS is treated with steroids such as prednisone or dexamethasone which over a period of several weeks will suppress adrenal androgen production, allowing regular ovulation to take place spontaneously. This is often combined with clomiphene, Letrozole and/or gonadotropin therapy to initiate ovulation.

    PCOS attributable to Pelvic Adhesive Disease is one variety which often is associated with compromised ovarian reserve, a raised FSH blood level and ovarian resistance to fertility drugs. In many such cases, high dosage of gonadotropins (FSH-dominant) with “estrogen priming” will often elicit an ovarian response necessary for successful ovulation induction and/or IVF. Neither steroids nor Metformin are helpful in the vast majority of such cases.

    PCOS women undergoing ovulation induction usually release multiple eggs following the hCG trigger and are thus at inordinate risk of twin or higher order multiple pregnancies. They are also at risk of developing OHSS. Many now believe that IVF should be regarded as a primary and preferential treatment for PCOS. The reason is that it is only through this approach that the number of embryos reaching the uterus can be controlled and in this manner the risk of high-order multiples can be minimized and it is only in the course of IVF treatment that a novel treatment method known as “prolonged coasting” ( see below) which prevents OHSS, can be implemented

    SEVERE OVARIAN HYPERSTIMULATION SYNDROME (OHSS):

    As indicated above, there is an inordinate propensity for women with PCOS to hyper-respond to gonadotropin fertility drugs and in the process produce large numbers of ovarian follicles. If left unchecked this can lead to OHSS, a potentially life endangering condition. The onset of OHSS is signaled by the development of a large number of ovarian follicles (usually more than 25 in number). This is accompanied by rapidly rising plasma estradiol (E2) levels, often exceeding 3000pg/ml within 7 or 9 days of stimulation, often rapidly peaking above 6,000 pg/ml prior to hCG administration. When this happens, the risk of OHSS developing is above 80%.

    Symptoms and signs of OHSS include: abdominal distention due to fluid collection (ascites), fluid in the chest cavity (hydrothorax), rapid weight gain (of a pound or more per day) due to tissue fluid retention, abdominal pain, lower back ache, nausea, diarrhea, vomiting, visual disturbances such as blurred vision and spots in front of the eyes (scotomata), a rapidly declining urine output, cardiovascular collapse and failure of blood to clot which sometimes results in severe bruising (echymosis) and frank bleeding. These symptoms and signs may appear before pregnancy can be diagnosed. If pregnancy occurs, the condition is likely to worsen progressively over a period of 3-5 weeks whereupon it rapidly resolves spontaneously over a few days. If no pregnancy occurs, the symptoms and signs all disappear spontaneously within 10-12 days of the hCG injection.

    When increasing fluid collection in the abdominal cavity (ascites) starts to compromise breathing raising the head of the bed rose slightly by placing a 4-6 inch block at the base of each head post and using a few additional pillows, will sometimes help ameliorate the problem. In cases where this does not help or symptoms become severe, all or most of the fluid can readily and safely be drained through t transvaginal sterile needle aspiration (vaginal paracentesis-performed once or sometimes twice a week) can be performed once or twice weekly . The problem will usually self corrects within 10-12 days of the hCG shot if pregnancy does not occur or, by the 8th week of pregnancy.

    Urine output should be monitored daily to see if it drops below about 500ml a day (about two cups and a half). A chest X-ray, to evaluate for fluid collection in the chest and around the heart should be done weekly along with blood tests for hematocrit, BUN, electrolytes, creatinine, platelet count and fibrin split products (FSP). If indicated on the basis of a deteriorating clinical situation, hospitalization might be needed for close observation and if necessary, to provide intensive care.

    In all case of OHSS, the ovaries will invariably be considerably enlarged. This is irrelevant to the final outcome, unless ovarian torsion (twisting of the ovary on its axis), an extremely rare complication occurs. The latter would usually require surgical emergency surgical intervention.

    It is important to know that symptoms and signs of OHSS are severely aggravated by rising hCG levels. Thus such patients should not receive additional hCG injections.

    Does PCOS cause poor egg/embryo quality? It is an undeniable fact that women with PCOS undergoing IVF are commonly found to have poorly developed (“dysmorphic”) eggs, with reduced fertilization potential and yielding “poor quality embryos”. However, in the author’s opinion (which admittedly runs contrary to popular opinion), this is unlikely to be due to an intrinsic deficit in egg quality. Rather, it more likely relates to intra-ovarian hormonal changes brought about by hyperstimulation and which compromise egg development. This effect, in the author’s opinion, can often be significantly reduced through implementation of an individualized or customized ovarian stimulation protocols that minimize exposure of the developing follicles and eggs to excessive LH-induced ovarian androgens. This can be best achieved by limiting the use of LH-containing gonadotropins such as Menopur through selective institution of “prolonged coasting” (see below).

    In the past, the onset of OHSS, heralded by the presence of large numbers of developing ovarian follicles and rapidly rising plasma estradiol levels often led the treating physician to prematurely administer hCG in an attempt to abruptly arrest the process and prevent escalation of risk to the patient. However the premature administration of hCG, while abruptly arresting further proliferation of estrogen producing granulosa cells in the follicles, unfortunately also prematurely arrests egg development. Since the ability of an egg to achieve optimal maturation upon hCG triggering is largely predicated upon it having achieved prior optimal development, the untimely administration of hCG which triggers meiosis, probably increases the risk of numerical chromosomal abnormalities (aneuploidy) of the egg. This in turn would lead to reduced fertilization potential, poor egg/embryo quality and low embryo implantation potential.

    In women with PCOS the connective tissue that surrounding the follicles (ovarian stroma) is often characteristically overgrown (stromal hyperplasia). It is the stroma that produces androgens (mainly testosterone) in response to LH. It is this, coupled with the fact that PCOS women also often have elevated blood LH concentrations (see above) results in the excessive production of androgen hormones, which is so characteristic in PCOS. While excessive exposure of developing eggs to ovarian androgens compromises follicle and egg growth it also impairs endometrial response to estrogen, which could explain the common finding of poor endometrial thickening in many PCOS women undergoing IVF.
    .
    The obvious remedy for these adverse effects on egg and endometrial development is to employ stimulation protocols that limit ovarian over-exposure to LH and allowing the time necessary for the follicles/eggs to develop optimally, prior to administering hCG through the judicious implementation of “Prolonged coasting” (PC).

    “PROLONGED COASTING”:

    In the early 90’s we were the first to report on “prolonged coasting” (PC), a novel approach that protects egg quality while preventing the development of OHSS. PC has since, gained widespread acceptance as a method of choice for preventing OHSS and has established itself as the “standard of care”. It involves withholding gonadotropin therapy while continuing the administration of the GnRHa and waiting until the plasma estradiol concentration drops below 2,500 pg/ml. Thereupon hCG is administered. In such cases, regardless of the number of developed follicles or the number of eggs retrieved, these women rarely, if ever develop OHSS. It has been reported that while PC virtually eliminates the risk of life-endangering complications associated with OHSS, there are reports in the literature that “the price to pay with PC” is often a poorer fertilization rate and reduced embryo implantation potential, compromising the pregnancy”. It is the author’s opinion an experience in the development of PC that egg/embryo quality deficit likely has little to do with the process of PC, itself and can be explained as follows: When PC is initiated too early, follicle growth and development may cease (as evidenced by the estradiol level plateauing or falling immediately, rather than showing an initial continued increase), and when PC is started too late, the follicles will often become cystic, measuring >21mm by the time the estradiol level falls below the safe threshold of 250000pg/ml, and so harbor dysmorphic eggs. Thus precise timing of the initiation of PC is critical. It should in pact be initiated preemptively in all cases when there are more than 25 follicles and the plasma estradiol reaches or exceeds 2,500pg/ml in association, provided that at least 50% of the follicles measuring 14-16mm in mean diameter. Not a day sooner or a day later. If PC is initiated with precise timing, it will usually be followed by a further progressive rise in the estradiol concentration. After a few days, the estradiol level will plateau and then it will start to fall (often rapidly). The temptation to trigger with hCG before the estradiol level falls below 3000picogtrams per milliliter must be resisted …even if the level falls below 1,000pg/ml by the time hCG is given.

    Since when using agonist ( Cetrotide/Ganirelix/Orgalutron) pituitary suppression throughout the stimulation phase with gonadotropins, the plasma estradiol level often under expressed follicle growth, this method of pituitary blockade should not be used in cases ( such as with PCOS) where PC might be required.,

    If you are interested in having a Skype consultation with me, please call 1-702-699-7437 or 1-800-780-7437 to set it up

    Finally, perhaps you would be interested in accessing the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores.

    Geoff Sher
    .

  • Kemi - December 3, 2015 reply

    Hi Dr Sher,

    My NK cells where elevated because of autoimmune issue. We don’t have a DQ Alpha match.

    Am negative for anti thyroid antibodies, APA, Factor V Lieden. The only mutation I have is the MTHFR C677T Heterozygous.

    We are still currently trying naturally after both my miscarriages in February and June 2015. I also have thrombophilia and MTHFR C677T Heterozygous mutation, I am due to go on holidays on the 21st of December to come back on the 2nd of Jan 2016. Flight is 6hrs 30mins. if I find out am pregnant before the 21st of December, is it safe to fly with my previous miscarriages and MTHFR. C667 gene mutation and thrombophilia.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - December 3, 2015 reply

    I am pleased that there was no alloimmune component. That works in your favor. And yes, if you conceive, you would be safe to travel (in my opinion).Read my article on Thrombophilia posted on this blog asnd you realize that and why I do not believe this condition is an important cause of EARLY pregnancy loss. It does cause later loss and probably also plays a role in the genesis of placental insufficiency, placental abruption, preeclampsia an intrauterine death.

    Good luck!

    Geoff Sher

  • Kemi - December 3, 2015 reply

    HI Dr Geoffrey Sher,

    I had raised NK Cells and TH1/TH2 cytokines and after 2 rounds of intralipids it has brought my TH1/TH2 levels down from

    TNF a – 39.6 to 28.9 and
    IFN – 15.5 to 11.5

    We are still currently trying naturally after both my miscarriages in February and June 2015. I also have thrombophilia and MTHFR mutation, I am due to go on holidays on the 21st of December to come back on the 2nd of Jan 2016. if I find out am pregnant before the 21st of December, is it safe to fly with my previous miscarriages and MTHFR gene mutation and thrombophilia.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - December 3, 2015 reply

    Hi Kemi,

    I think you are on the right track taking intralipid and steroids and they seem to be having the desired effect on NK cell activity. It would be helpful to know whether they were elevated because of an autoimmune or an alloimmune cause because this would alter the approach to treatment . I suggest that your blood be tested for autoimmune factors such as antiphospholipid antibodies (APA), antithyroid antibodies (ATA) and immunophenotype. In addition, your blood and your partner’s should both be tested for alloimmune matching. (for DQalpha and HLA genetic similarities (see below).

    Below please find several articles that I wrote and have posted on my blog, hosted on this website, http://www.DrGeoffreySherIVF.com. To access any of these articles go to the home page of the blog and look for the “search bar” to be found at the top of the page. Then type the selected topics or any other infertility-related topic of your choice. One click will take you to the relevant articles posted there. I continue to contribute fresh material at a rate of two articles per month.

    Here are a few of the topics on my blog for your consideration:

    •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)
    •Recurrent Pregnancy Loss (RPL): Why do I keep losing my Pregnancies?

    If you are interested in having a Skype consultation with me, please call 1-702-699-7437 or 1-800-780-7437 to set it up
    Finally, perhaps you would be interested in accessing the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores.

    Geoff Sher

  • Krista Whitley - December 2, 2015 reply

    Hello Dr. Sher! First, thank you for your help having our beautiful baby girl, who is now a thriving seven year old. Second, I have dear friends who are considering PGD expressly for the goal of having a girl, as they already have two boys and don’t want more than 3 children. What do you recommend?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - December 3, 2015 reply

    Couples have for centuries sought to influence the gender of their offspring. More than seven centuries ago the ancient Chinese developed a birth calendar said to be able to predict gender on the basis of when conception occurred. Later, the ancient Greeks suggested that by lying on her right side during intercourse, a woman could improve the likelihood of having a male child. And 300 years ago, the French suggested that placing a ligature around the right testicle would improve the chance of having a male child.
    More recently in the U.S., methods such as timing intercourse, assuming different positions during sex, and (relatively recently) employing rapid sperm centrifugation in an attempt to separate male chromosome-bearing sperm from female sperm prior to artificial insemination were proposed. The fact is that none of these (as well as many other) such anecdotal assertions have been shown to have any real validity.
    Currently, in spite of several well described medical approaches, the indisputable fact has emerged that it is only by way of IVF that reliable sex selection can be achieved. This allows for embryos to be screened for gender through preimplantation genetic diagnosis prior to transferring the embryo(s) of the desired gender to the uterus.
    Nevertheless, it is an inescapable reality that the very idea of medical sex selection challenges moral and ethical beliefs at their very foundation. Many hold that the growing popularity of gender selection solely for the convenience of altering a family’s gender balance represents an unwanted example of how assisted reproductive technology is subject to abuse…and thus it should be outlawed. They also see it as an example of a disturbing trend towards “designer babies” where genetic engineering could be used to manipulate the intellect, body configuration, build, height, and the talents of future offspring. This assertion is commonly followed by the tantalizing question as to where all this would end and whether we as a society “would really want to live in such a world.”

    There is, however, one clear exception to the apparent across-the-board opposition to sex selection that is well worthy of mention. This applies in cases where sex selection is used to avoid the occurrence of a serious medical disorder that selectively affects one gender or the other (e.g., Hemophilia, a life threatening bleeding disorder that selectively affects male offspring).

    EVALUATING CURRENTLY USED METHODS FOR SEX SELECTION

    SPERM GRADIENT METODOLOGY (discredited because of a lack of reliability)

    This is one of the simplest methods that still (unfortunately) remains in widespread use. Here sperm is rapidly spun down (centrifuged) in the hope of separating the male sperm (those with Y-chromosomes) from the female sperm (those with X-chromosomes). It relies on the assumption that the X chromosome makes sperm heavier, allowing for separation of male from female chromosome-bearing sperm. Though this method is often touted as a low cost method for sex selection, the truth is that it simply does not work!

    LOW CYTOMETRIC TESTING BY THE MICROSORT METHOD (discredited because of a lack of reliability)
    This method which is now somewhat discredited by the FDA employedthe use of a fluorescent dye that adheres to genetic material within the sperm. It was based on the premise that because X-bearing sperm contain more genetic material, these sperm were supposed to pick up more dye than Y-bearing sperm. Thereupon, X and Y bearing sperm are then separated into two groups and used for intrauterine insemination (IUI) or IVF. This method was touted as yielding a 60% to 70% accuracy rate with IUI. This has not been adequately confirmed and in my personal experience its reliability in the IVF setting has been questionable to say the least. The Microsort technique is to my knowledge not presently being offered in the United States.
    IVF using PREIMPLANTATION GENETIC DIAGNOSIS (PGD)
    Preimplantation Genetic Diagnosis (PGD) involves the removal of one or more cells from an embryo, for chromosomal or genetic analysis. The most widely used and he most reliable PGD method for gender selection is fluorescence in-situ-hybridization (FISH). However, this technique does not identify all 23 pairs of chromosomes in the embryo’s cells. At best it can well identify 12. Thus, while FISH provides an excellent method for gender selection and for identification of structural chromosomal aberrations, it is not a reliable method for diagnosing embryo aneuploidy (“competency”). Conversely, another PGD method, next generation gene sequencing (NGS) which does assess all the embryo’s chromosomes can be used for both detecting all the embryo’s chromosomes and thus can determine embryo “competency” reliably. It also reliably identifies gender. However, while NGS is very bit as reliable as FISH for gender selection, FISH can be done in fresh cycles (i.e. the ET is done in the same cycle as that in which the ER is done), while NGS requires time for testing that requires Staggered IVF (St-IVF) in which the embryos are biopsied on day 3 or day 5-6 (post-fertilization) and the blastocysts are ultrarapidly frozen (vitrified) and allowed to proceed in culture to blastocysts whereupon they are ultra-rapidly frozen (vitrified) and are then held for transfer in a subsequent cycle.
    Upon completion of FISH, which takes about 24-36 hours, the couple can select which embryo(s) they will transfer to the uterus. If pregnancy results, there is almost a 100% chance it will result in the desired gender. If NGS is used, the degree of accuracy in diagnosing gender, is as reliable as is FISH but in addition, NGS provides information on the entire karyotype (all 23 pairs of chromosomes) which is extremely beneficial because it assesses embryo “competency, while FISH does not.

    A PERSONAL OPINION:
    Sex selection done purely for family balancing is somewhat controversial, raising concern that if widely accessible and freely available, such practice could distort the natural sex ratio, leading to a population gender imbalance. However, for this to happen, there would have to be a significant population preference for sex selection. In reality, the contrary seems to apply, since studies conducted in western societies discount these concerns. In fact, the relatively high cost of IVF with the added cost of gender selection in the United States makes it unlikely that the demand would ever become large enough to impact overall population gender balance. In addition, several studies done in Western countries have shown that the majority of people do not seem to be concerned about the gender of their offspring, and that with a few notable exceptions, gender preference does not appear to be slanted in the direction of either male or female. Thus, from a practical standpoint, such concerns are overstated.
    Given that in the United States most couples do not care about the gender of their offspring, and only a minority are interested in selecting the sex of their children there is currently no risk that IVF sex-selection will impact the population gender balance. Thus, in my opinion by and large, freedom of choice should prevail and a service for sex selection should be freely available
    So, in my personal practice, I absolutely do offer gender selection in the following circumstances.
    • Medical Indications for Gender Selection:
    o For cases associated with
     sex-linked genetic disorders or,
     serious genetic disorders that are more likely to occur in one gender or the other.
    • Non-Medical Family balancing
    o For couples who have at least one child of the opposite gender to that which they choose for their IVF embryo transfer and,
    o For those women who do not have any children at all but prefer to have a child of one or the other gender.

    Below please find several articles that I wrote and have posted on my blog, hosted on my new website, http://www.DrGeoffreySherIVF.com. To access any of these articles go to the home page of the blog and look for the “search bar” to be found at the top of the page. Then type the selected topics or any other infertility-related topic of your choice. One click will take you to the relevant articles posted there. I continue to contribute fresh material at a rate of two articles per month.
    • Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
    • Preventing Severe Ovarian Hyperstimulation Syndrome (OHSS) with “Prolonged Coasting”
    • Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
    • Unexplained IVF Failure
    • 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)
    • Recurrent Pregnancy Loss (RPL): Why do I keep losing my Pregnancies?
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
    • The Role of Nutritional Supplements in Preparing for IVF
    • Frozen Embryo Transfer (FET): What Does it Involve?
    • Hereditary Clotting Defects (Thrombophilia)
    • Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
    • PGS-Biopsy for the Assessment of Embryo Numerical Chromosomal integrity (Ploidy): Should it be done on Day 3 or on Day 5-6 post fertilization?
    • Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
    • Launching Ovarian Stimulation with a BCP: How Does it Affect Response?
    • Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
    • Male Factor Infertility
    • Endometriosis and Infertily
    • Implications of “Empty Follicle Syndrome and “Premature Luteinization”
    • Fertility Preservation (FP) Through Freezing/Banking Human Eggs
    • Selective Banking of Genetically Tested Donor Eggs:
    • IVF Egg Donation: A Comprehensive Overview
    • IVF-Gestational Surrogacy: An Overview
    • Understanding Polycystic Ovarian Syndrome (PCOS) and the Need to Customize Ovarian Stimulation Protocols.
    • Intrauterine Insemination (IUI): Who Needs it & who Does Not: Pro’s & Con’s!
    • The Role of Gender Selection in IVF
    If you are interested in having a Skype consultation with me, please call 1-702-699-7437 or 1-800-780-7437 to set it up
    Finally, perhaps you would be interested in accessing the 4th edition of my book ,”In Vitro Fertilization, the ART of Making Babies”. It is available as a down-load through http://www.Amazon.com or from most bookstores.

    Geoff Sher

Alert ! - Dr. Sher will not have access to the internet, and will therefore be out of reach, from June 5 until June 25. Please re-submit this comment after that date. Until then, please explore the Sher IVF website and his Facebook videos archived on his page.

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