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Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas

by Dr. Geoffrey Sher on June 14, 2016

For more than three decades, about 70% of the patients that I have performed IVF on, have journeyed to see me from out state or out of country. Over the years, I have been repeatedly asked how, given the distance separates us from our patients, we are able to provide optimal, efficient, and congenial services. This blog represents an attempt to describe how we accomplish this. It will outline the processes involved, and explain how the system we have put in place allows us to fully prepare and triage our patients at a distance, receive them in Las Vegas, monitor and treat them here, discharge them back to their home environments and then follow up with them through the diagnosis of pregnancy and post-IVF treatment (often with the welcomed and invited participation of their local primary physicians). It will also spell out how we are able to provide full and ready access to me and my team constantly, and finally, it will emphasize that the core of our success is routed in a commitment to being as accessible and affable as possible, at all times. In truth treating patients from afar is really not more complicated than is treating local patients. I am quite confident that if you were to ask those that have gone through the process, most, if not all, would tell you that we are well organized, seasoned in what we do and that the entire process is comfortable, easy and seamless.

Arranging for a Skype Consultation with me: Patients largely hear of Sher-IVF through word of mouth coming from the many thousands of women I have assisted in having babies over the years. Others reach Sher-IVF through Physician referrals, access to books and articles I have written on IVF and related topics, media and internet exposure or through personal online research by way of search engines. They then contact my wonderful “patient concierge”, Julie Dahan to set up a Skype consultation, either directly by calling 702-533-2691 or by email at julied@sherivf.com. Others access us by going to the Sher-IVF website at www.sherivf.com and making an online appointment for a Skype consultation with me that way. Regardless of how we are contacted, be assured that Julie (or her designee) will respond promptly to any such requests.


The Initial Consultation and the Report : During the initial consultation we discuss the medical and reproductive history in detail and I recommend additional testing necessary to identify the exact cause of the infertility and define an optimal approach to solving the problem. I thereupon promptly dispatch a comprehensive report by email along with a list of recommended reading of relevant articles to be found on my blog (to be found on www.sherivf.com).

 

Follow-up Administrative consultation: One or two working days later, patients receive a call from us to set up a date for a 1 hour phone consultation with our Practice Administrator, Sharon Jochman on the relevant logistical and financial considerations relating to IVF treatment with me. Thereupon, she will forward email information on such issues to patients for their review. At this point, no financial commitment to undergo treatment with me is requested or required. However, Sharon will place the patient (s) name on a tentative list for treatment in an upcoming IVF cycle batch (see below) and as that cycle draws near, she will contact the patient/couple to determine whether they wish to proceed with treatment, defer or cancel. This process protects the patient/couple from losing a chosen spot in the upcoming IVF cycle.This is because, unless in spite of best effort to contact them they are unreachable, or they expressly indicate a change of heart and wish to defer to a later cycle batch or opt out of the program, they will not lose their spot in their selected cycle of treatment. Then, subject to an expressed interest to proceed, the patient/couple would, for the 1st time, be required to make a financial commitment. 

Consultation with a Nurse Coordinator: The nurse coordinator  prepares patients for a cycle of treatment with me. She will discuss all the recommended testing and medical visits necessary.

Follow-up Consultation with me: Once the initial Clinical Coordinator consultation is completed and the requested tests and preparatory investigations have been done, the patient/couple has a wrap-up Skype or telephone consultation with me patients to discuss results advise and to finalize the protocol necessary for ovarian stimulation and fine tune the complete strategy for treatment.

The Nurse Coordinator Develops a Color-coded Calendar for the Upcoming IVF Cycle: At this point, the Nurse Coordinator generates an individualized and detailed color-coded electronic calendar that lays out the precise protocol that will be implemented. It starts with the use of a birth control pill, to be overlapped (for a few days) with a GnRH agonist (Lupron/Buserelin/Superfact), followed by all necessary medications involved in the process of preparation. She will go over the entire process and answer questions. A standard consent form will be forwarded to the patient/couple for their review and they will be invited to ask any questions on issues that are unclear. Thereupon consent form must be signed before we can proceed to treatment.

Access to us Throughout the Process: I provide all my patients with my cell phone number and encourage them to contact me with any medical issues at any time. They are informed that if they call and I am not immediately available, to leave their name and phone number on my voice mail and I will respond. Patients are also provided with Julie’s cell phone number and are invited to call her on any non-medical issue. Julie does an outstanding job of assisting patients with scheduling appointments with our staff and for testing, both locally and afar. She will also gladly assist and advise on travel/accommodation/and transportation to and from our office. I am told that rapidly Julie creeps into the hearts of my patients who rapidly bond with her and feel comfortable reaching out to her for advice and comforting.

How Long will Patients Need to Spend in Las Vegas for Treatment? For fresh IVF cycles with embryo transfer the female partner needs to plan on being in las Vegas for up to 2 weeks here. While male partners are encouraged to spend as much time with their partners in Las Vegas as possible, they are really only required to be here on the day of egg retrieval (and we can provide them with a 3-4-day advance notification of that day). Actually, if the man is perfectly fertile, he does not even need to come to Las Vegas at all. Instead we could arrange for a specimen of his frozen sperm to be delivered to the clinic. This will not prejudice IVF results in any way. In cases where we do frozen embryo transfers (FET), it is not imperative that the male be present at all. However, we do encourage the male partner to be here with his partner to provide emotional support wherever possible. In cases of embryo recipient cycles (egg donation/embryo adoption/gestational surrogacy and FET the woman is needed to be present in Las Vegas for about 7-9 days. Those times can be calendared a few months in advance. In cases involving FET, the male partner is really not needed onsite at all, although his presence is encouraged for the purpose of providing his partner with the support she needs. In cases of Staggered IVF which involves preimplantation genetic sampling (PGS) of embryos for chromosomal selection, the embryo transfer is deferred to a later cycle to allow for genetic testing to be completed. This means that the woman is only required to be present onsite with us for about 7 days. The day following the ET, both she and her partner can return home. We stay in touch with them regarding embryo development and planning for the future.

Follow-up at home: The day after embryo transfer (or following egg retrieval in cases where all eggs or embryos are frozen and no ET is contemplated in the same cycle), the woman and her partner (as applicable) can return home to be followed at a distance by us and/or locally by their own primary care physician who (under our oversite) will conduct pregnancy testing and subsequent gynecologic services and when applicable, prenatal care.


IVF Cycle Batches and how use of the Birth Control Pill Facilitates this: At Sher-IVF, we perform IVF cycles in 9-10 two, week “batches per year. This means that a number of patients arrive together at a predetermined date for treatment. These batches are prescheduled to start on set dates that are calendared for an entire year in advance. This enables patients to make travel and accommodation arrangements well in advance. In order to effect this, patients who are to be treated in a particular batch need to start their cycles (onset of menstruation) on or around the same date. To synchronize their cycles, we place each woman on a birth control pill (BCP) to lead into the cycle of stimulation. By shortening or lengthening the time on the BCP, we can ensure that menstrual bleeding starts at the required time to coincide with the start of a given cycle batch. Contrary to the erroneous belief that the BCP suppresses response to gonadotropin therapy, provided that in the last few days of using the BCP, it is overlapped with a GnRH agonist (e.g. Lupron, Superfact, Buserelin), this approach actually improves response to ovarian stimulation.

Following the launching an ovarian stimulation cycle on a BCP and the subsequent addition of a GnRH-agonist the woman will have a bleed. At this point she will be required to have a baseline ultrasound assessment and have blood drawn for measurement of estradiol (E2). If she is from out of town, this will have to be done by her primary OB/GYN. Provide that the ultrasound does not detect an ovarian cyst and her estradiol level is <70pg/ml), she will be eligible to start taking gonadotropins for ovarian stimulation under our oversight. . We will by this time have schooled her and partner in administering the shots…so this should not present a problem. Thereupon she will need to arrange to arrive in Las Vegas for me to begin monitoring her response, 7-8 days after commencing ovarian stimulation. It is unusual (and even inadvisable) for a woman undergoing controlled ovarian stimulation (COS) for IVF to be ready for triggering with hCG prior to the 8th day of stimulation so her arrival should be timely and not be too late..

The process of treating patients who journey to Sher-IVF in Las Vegas from afar, might at first glance seem somewhat complex, but it really is not. I have, over the last 3 decades, developed a system that is very easy, convenient, safe, seamless, uncomplicated and highly effective. The vast majority of the seventy percent (70%) of my IVF patients who journey from out of state and from abroad for treatment with us in Las Vegas would attest to this. In fact, many of my patients who underwent IVF in their own environments before coming to Las Vegas have commented on our availability and accessibility, in spite of the distance separating us.

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  • Stefanie - July 25, 2016 reply

    Hi Dr Sher, I am living in Canada in which most fertility clinics are very limited in their testing. I am currently 39, and did IVF last year which resulted in fetal demise at 39 weeks due to a cord aneurysm in 2 areas. Since then I have done 3 frozen transfers which have not resulted in a pregnancy. During my last frozen transfer I did 2 months of lupron/letrozole combination in order to put me in a false menopause in case I have endometriosis (did this prior to the transfer). The ultrasound after the 2 months showed big cysts on my ovaries (4 in total) which I had to aspirate before starting the frozen cycle. This same cycle I was also on Fragmin and baby aspirin while taking the estrace. The end result however was a negative pregnancy test. I would like to know are there tests that you would recommend me taking as I seem to have repeated implantation failure? Would there be any benefit to continue Fragmin while trying naturally (I do not have a clotting disorder) ? Any advise will help. Thank you in advance, sincerely Stefanie.

    Stefanie - July 25, 2016 reply

    Just to add I also did a hysteroscopy before taking the Lupron/Letrozole and the Dr did an endometrin scratch.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - July 26, 2016 reply

    Copy!

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - July 26, 2016 reply

    1. Why IVF fails:

    Whenever a patient fails to achieve a viable pregnancy following embryo transfer (ET), the first question asked is why! Was it simply due to, bad luck?, How likely is the failure to recur in future attempts and what can be done differently, to avoid it happening next time?.
    It is an indisputable fact that any IVF procedure is at least as likely to fail as it is to succeed. Thus when it comes to outcome, luck is an undeniable factor. Notwithstanding, it is incumbent upon the treating physician to carefully consider and address the causes of IVF failure before proceeding to another attempt:
    1. Age: The chance of a woman under 35Y of age having a baby per embryo transfer is about 35-40%. From there it declines progressively to under 5% by the time she reaches her mid-forties. This is largely due to declining chromosomal integrity of the eggs with advancing age…”a wear and tear effect” on eggs that are in the ovaries from birth.
    2. Embryo Quality/”competency (capable of propagating a viable pregnancy)”. As stated, the woman’s age plays a big role in determining egg/embryo quality/”competency”. This having been said, aside from age the protocol used for controlled ovarian stimulation (COS) is the next most important factor. It is especially important when it comes to older women, and women with diminished ovarian reserve (DOR) where it becomes essential to be aggressive, and to customize and individualize the ovarian stimulation protocol.
    We used to believe that the uterine environment is more beneficial to embryo development than is the incubator/petri dish and that accordingly, the earlier on in development that embryos are transferred to the uterus, the better. To achieve this goal, we used to select embryos for transfer based upon their day two or microscopic appearance (“grade”). But we have since learned that the further an embryo has advanced in its development, the more likely it is to be “competent” and that embryos failing to reach the expanded blastocyst stage within 5-6 days of being fertilized are almost invariably “incompetent” and are unworthy of being transferred. Moreover, the introduction into clinical practice about a decade ago, (by Levent Keskintepe PhD and myself) of Preimplantation Genetic Sampling (PGS), which assesses for the presence of all the embryos chromosomes (complete chromosomal karyotyping), provides another tool by which to select the most “competent” embryos for transfer. This methodology has selective benefit when it comes to older women, women with DOR, cases of unexplained repeated IVF failure and women who experience recurrent pregnancy loss (RPL).
    3. The number of the embryos transferred: Most patients believe that the more embryos transferred the greater the chance of success. To some extent this might be true, but if the problem lies with the use of a suboptimal COS protocol, transferring more embryos at a time won’t improve the chance of success. Nor will the transfer of a greater number of embryos solve an underlying embryo implantation dysfunction (anatomical molecular or immunologic).Moreover, the transfer of multiple embryos, should they implant, can and all too often does result in triplets or greater (high order multiples) which increases the incidence of maternal pregnancy-induced complications and of premature delivery with its serious risks to the newborn. It is for this reason that I rarely recommend the transfer of more than 2 embryos at a time and am moving in the direction of advising single embryo transfers …especially when it comes to transferring embryos derived through the fertilization of eggs from young women.
    4. Implantation Dysfunction (ID): Implantation dysfunction is a very common (often overlooked) cause of “unexplained” IVF failure. This is especially the case in young ovulating women who have normal ovarian reserve and have fertile partners. Failure to identify, typify, and address such issues is, in my opinion, an unfortunate and relatively common cause of repeated IVF failure in such women. Common sense dictates that if ultrasound guided embryo transfer is performed competently and yet repeated IVF attempts fail to propagate a viable pregnancy, implantation dysfunction must be seriously considered. Yet ID is probably the most overlooked factor. The most common causes of implantation dysfunction are:
    a. A“ thin uterine lining”
    b. A uterus with surface lesions in the cavity (polyps, fibroids, scar tissue)
    c. Immunologic implantation dysfunction (IID)
    d. Endocrine/molecular endometrial receptivity issues
    Certain causes of infertility are repetitive and thus cannot readily be reversed. Examples include advanced age of the woman; severe male infertility; immunologic infertility associated with alloimmune implantation dysfunction (especially if it is a “complete DQ alpha genetic match between partners plus uterine natural killer cell activation (NKa).

    2. Endometriosis:

    Endometriosis is a condition that occurs when the uterine lining (endometrium) grows not only in the interior of the uterus but in other areas, such as the fallopian tubes, ovaries and the bowel. Endometriosis is a complex condition where, the lack or relative absence of an overt anatomical barrier to fertility often belies the true extent of reproductive problem(s).
    All too often the view is expounded that the severity of endometriosis-related infertility is inevitably directly proportionate to the anatomical severity of the disease itself, thereby implying that endometriosis causes infertility primarily by virtue of creating anatomical barriers to fertilization. This over-simplistic and erroneous view is often used to support the performance of many unnecessary surgeries for the removal of small innocuous endometriotic lesions, on the basis of such “treatment” evoking an improvement in subsequent fertility.
    It is indisputable that even the mildest form of endometriosis can compromise fertility. It is equally true that, mild to moderate endometriosis is by no means a cause of absolute “sterility”.
    Rather, when compared with normally ovulating women of a similar age who do not have endometriosis, women with mild to moderate endometriosis are about four to six times less likely to have a successful pregnancy.
    Endometriosis often goes unnoticed for many years. Such patients are frequently, erroneously labeled as having “unexplained infertility”, until the diagnosis is finally clinched through direct visualization of the lesions at the time of laparoscopy or laparoscopy. Not surprisingly, many patients with so called “unexplained” infertility, if followed for a number of years, will ultimately reveal endometriosis.

    Women who have endometriosis are much more likely to be infertile. There are several reasons for this:

    • First-Ovulation Dysfunction: In about 25 – 30% of cases, endometriosis is associated with ovulation dysfunction. Treatment requires controlled ovarian stimulation (COS). The problem is that the toxic pelvic environment markedly reduces the likelihood that anything other than IVF will enhance pregnancy potential.
    • Second- Toxic Pelvic environment that compromises Fertilization Endometriosis is associated with the presence of toxins in peritoneal secretions while it is tempting to assert that normally ovulating women with mild to moderate endometriosis would have no difficulty in conceiving if their anatomical disease is addressed surgically or that endometriosis-related infertility is confined to cases with more severe anatomical disease…nothing could be further from the truth. The natural conception rate for healthy ovulating women in their early 30’s (who are free of endometriosis) is about 15% per month of trying and 70% per year of actively attempting to conceive. Conversely, the conception rate for women of a comparable age who have mild or moderate pelvic endometriosis (absent or limited anatomical disease) is about 5-6% per month and 40% after 3 years of trying. As sperm and egg(s) travel towards the fallopian tubes they are exposed to these toxins which compromise the fertilization process. In fact it has been estimated that there is a 5-6 fold reduction in fertilization potential because of these toxins which cannot be eradicated. Frankly, it really does not matter whether an attempt is made to remove endometriosis deposits surgically as this will not improve pregnancy potential. The reason is that for every deposit observed, there are numerous others that are in the process of developing and are not visible to the naked eye and whether visible or not, such translucent deposits still produce toxins. This also explains why surgery to remove visible endometriosis deposits, controlled ovarian stimulation with or without intrauterine insemination will usually not improve pregnancy potential. Only IVF, through removing eggs before they are exposed to the toxic pelvic environment, fertilizing them in-vitro and then transferring the embryos to the uterus represents the only way to enhance pregnancy potential.
    • Third-Pelvic adhesions and Scarring: In its most severe form, endometriosis is associated with scarring and adhesions in the pelvis, resulting in damage to, obstruction or fixation of the fallopian tubes to surrounding structures, thereby preventing the union of sperm and eggs.
    • Fourth-Ovarian Endometriomas, Advanced endometriosis is often associated with ovarian cysts (endometriomas/chocolate cysts) that are filled with altered blood and can be large and multiple. When these are sizable (>1cm) they can activate surrounding ovarian connective tissue causing production of excessive male hormones (androgens) such as testosterone and androstenedione. Excessive ovarian androgens can compromise egg development in the affected ovary (ies) resulting in an increased likelihood of numerical chromosomal abnormalities (aneuploidy) and reduced egg/embryo competency”. In my opinion large ovarian endometriomas need to be removed surgically or rough sclerotherapy before embarking on IVF.
    • Fifth- Immunologic Implantation Dysfunction (IID). Endometriosis, regardless of its severity is associated with immunologic implantation dysfunction linked to activation of uterine natural killer cells (NKa) and cytotoxic uterine lymphocytes (CTL) in about 30 of cases. This is diagnosed by testing the woman’s blood for NKa using the K-562 target cell test or by endometrial biopsy for cytokine analysis, and, for CTL by doing a blood immunophenotype. These NKa attack the invading trophoblast cells (developing “root system” of the embryo/early conceptus) as soon as it tries to gain attachment to the uterine wall. In most cases, this results in death of the embryo even before the pregnancy is diagnosed and sometimes, in a chemical pregnancy or even an early miscarriage. . As such, many women with endometriosis, rather than being infertile, in the strict sense of the word, often actually experience repeated undetected “mini-miscarriages”.

    Advanced Endometriosis: In its most advanced stage, anatomical disfiguration is causally linked to the infertility. In such cases, inspection at laparoscopy or laparoscopy will usually reveal severe pelvic adhesions, scarring and “chocolate cysts”. However, the quality of life of patients with advanced endometriosis is usually so severely compromised by pain and discomfort, that having a baby is often low on the priority list. Accordingly, such patients are usually often more interested in relatively radical medical and surgical treatment options (might preclude a subsequent pregnancy), such as removal of ovaries, fallopian pubis and even the uterus, as a means of alleviating suffering.

    Moderately Severe Endometriosis. These patients have a modest amount of scarring/ adhesions and endometriotic deposits which are usually detected on the ovaries, fallopian tubes, bladder surface and low in the pelvis, behind the uterus. In such cases, the fallopian tubes are usually opened and functional.

    Mild Endometriosis: These patients who at laparoscopy or laparotomy are found to have no significant distortion of pelvic anatomy are often erroneously labeled as having “unexplained” infertility. To hold that the there can only infertility can only be attributed to endometriosis if significant anatomical disease can be identified, is to ignore the fact that, biochemical, hormonal and immunological factors profoundly impact fertility. Failure to recognize this salient fact continues to play havoc with the hopes and dreams of many infertile endometriosis patients.

    TREATMENT:
    The following basic concepts apply to management of endometriosis-related infertility:

    1. Controlled Ovulation stimulation (COS) with/without intrauterine insemination (IUI): Toxins in the peritoneal secretions of women with endometriosis exert a negative effect on fertilization potential regardless of how sperm reaches the fallopian tubes. This helps explain why COS with or without IUI will usually not improve the chances of pregnancy (over no treatment at all) in women with endometriosis. IVF is the only way by which to bypass this problem.
    2. Laparoscopy orLaparotomy Surgery aimed at restoring the anatomical integrity of the fallopian tubes does not counter the negative influence of toxic peritoneal factors that inherently reduce the chances of conception in women with endometriosis four to six fold. Nor does it address the immunologic implantation dysfunction (IID) commonly associated with this condition. Pelvic surgery is relatively contraindicated for the treatment of infertility associated with endometriosis, when the woman is more than 35 years of age. With the pre-menopause approaching, such women do not have the time to waste on such less efficacious alternatives. In contrast, younger women who have time on their side might consider surgery as a viable option. Approximately 30 -40 percent of women under 35 years of age with endometriosis will conceive with in two to three years following corrective pelvic surgery.
    3. Sclerotherapy for ovarian endometriomas.: About 10 years ago I introduced “sclerotherapy”, a relatively non-invasive, safe and effective outpatient method to permanently eliminate endometriomas without surgery being required. Sclerotherapy for ovarian endometriomas involves needle aspiration of the liquid content of the endometriotic cyst, followed by the injection of 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
    4. The role of selective immunotherapy Women with antiphospholipid antibodies (APA’s) experience improved IVF birth rates when heparinoids (Clexane/Lovenox) is administered from the onset of ovarian stimulation with gonadotropins until the 10th week of pregnancy.
    a. About Intralipid (IL) and steroid therapy: Intralipid (IL) is a solution of small lipid droplets suspended in water. When administered intravenously, IL provides essential fatty acids, linoleic acid (LA), an omega-6 fatty acid, alpha-linolenic acid (ALA), an omega-3 fatty acid.IL is made up of 20% soybean oil/fatty acids (comprising linoleic acid, oleic acid, palmitic acid, linolenic acid and stearic acid) , 1.2% egg yolk phospholipids (1.2%), glycerin (2.25%) and water (76.5%).IL exerts a modulating effect on certain immune cellular mechanisms largely by down-regulating activated natural killer cells (NKa). This effect is enhanced through the concomitant administration of corticosteroids such as dexamethasone, prednisone, and prednisolone which enhance the therapeutic effect by suppressing cytotoxic/activated T-lymphocytes (CTL). This effect of IL might is likely due to its ability to
    5. In vitro fertilization is the treatment of choice for women with endometriosis. This is especially true for women more than 35 years of age or where surgery and treatment with fertility agents has proven to be unsuccessful. We anticipate that approximately 75 percent of such women will achieve the birth of one or more babies within three IVF attempts performed at SIRM.
    6.
     suppresses pro-inflammatory cellular (Type-1) cytokines such as interferon gamma and TNF-alpha. In-vitro testing has shown that IL successfully and completely down-regulates activated natural killer cells (NKa) within 2-3 weeks in 78% of women experiencing immunologic implantation dysfunction. In this regard it is just as effective as Intravenous Gamma globulin (IVIg) but at a fraction of the cost and with a far lower incidence of side-effects. Its effect lasts for 4-9 weeks when administered in early pregnancy.

    I strongly recommend that you visit http://www.DrGeoffreySherIVF.com. Then go to my Blog and access the “search bar”. Type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.
    • Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • The Fundamental Requirements For Achieving Optimal IVF Success
    • Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
    • Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
    • Human Growth Hormone Administration in IVF: Does it Enhances Egg/Embryo Quality and Outcome?
    • The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
    • Blastocyst Embryo Transfers Should be the Standard of Care in IVF
    • Secondary Infertility: Addressing the Root Causes
    • Blastocyst Embryo Transfers Done 5-6 Days Following Fertilization are Fast Replacing Earlier day 2-3 Transfers of Cleaved Embryos.
    • Frozen Embryo Transfer (FET) versus “Fresh” ET: How to Make the Decision
    • Frozen Embryo Transfer (FET): A Rational Approach to Hormonal Preparation and How new Methodology is Impacting IVF.
    • Preimplantation Genetic Testing (PGS) in IVF: It Should be Used Selectively and NOT be Routine.
    • Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
    • PGS in IVF: Are Some Chromosomally abnormal Embryos Capable of Resulting in Normal Babies and Being Wrongly Discarded?
    • PGS and Assessment of Egg/Embryo “competency”: How Method, Timing and Methodology Could Affect Reliability
    • IVF Failure and Implantation Dysfunction:
    • The Role of Immunologic Implantation Dysfunction (IID) & Infertility (IID):PART 1-Background
    • Immunologic Implantation Dysfunction (IID) & Infertility (IID):PART 2- Making a Diagnosis
    • Immunologic Dysfunction (IID) & Infertility (IID):PART 3-Treatment
    • Thyroid autoantibodies and Immunologic Implantation Dysfunction (IID)
    • Immunologic Implantation Dysfunction: Importance of Meticulous Evaluation and Strategic Management:(Case Report
    • Intralipid and IVIG therapy: Understanding the Basis for its use in the Treatment of Immunologic Implantation Dysfunction (IID)
    • Intralipid (IL) Administration in IVF: It’s Composition; How it Works; Administration; Side-effects; Reactions and Precautions
    • Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
    • Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • Vaginally Administered Viagra is Often a Highly Effective Treatment to Help Thicken a Thin Uterine Lining
    • Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF

    Please call or email Julie Dahan, my patient concierge. She will guide you on how to set up an in-person or Skype consultation with me. You can reach Julie at on her cell phone or via email at any time:
    Julie Dahan
    • Email: Julied@sherivf.com
    • Phone: 702-533-2691
     800-780-7437

    Geoff Sher

  • hogan - July 6, 2016 reply

    Hello. I am 39, (40 in September,) and have been trying to conceive 10 mths. Got preg at 7 mths, had a miscarriage at 6 wks. After ultrasound, found I have an enlarged retroverted uterus, and a fibroid, 6.1 cm in size and left fundal, intramural in position. Endometrial lining was 12mm. I’ve had the following tests: TSH-2.030, Estradiol – 56.4pg/ml, LH – 6.5, FSH-8.2, AMH – 2.8ng. Do you think the fibroid will be an issue for me getting pregnant and carrying to term? Is it time to possibly consider fertility procedures or should I continue to try on my own? Thank you in advance. Best regards.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - July 7, 2016 reply

    This is a large fibroid but provided it does NOT encroach on the uterine cavity it should not interfere with implantation. However, it will increase in size by several fold during pregnancy and that can cause significant problems. I would thus seriously consider having it removed.

    Fibroids or leiomyomas are non-malignant muscle tumors that grow in the uterine wall. They can be found in about one out of every five (1:5) women >30Y of age. Fibroids are far more prevalent in African Americans and women and less frequent in other ethnic groups (i.e. Caucasians and Asians).
    Fibroids, enlarge and/or distort uterine configuration. They can produce symptoms such as heavy, painful and prolonged menstrual periods. Other symptoms include pain with intercourse, backache, severe abdominal pain when large fibroids run out of blood supply or when superficial fibroids on a stem (pedunculated) undergo twisting (torsion). Sometimes fibroids will protrude into the uterine cavity, cause severe cramping and bleeding and so irritate the uterine lining as to compromise embryo attachment (anatomical implantation dysfunction). Women with fibroids are also at greater risk of miscarriage, premature delivery, malposition of the baby (mandating cesarean delivery) and an increased risk of bleeding after birth (post-partum hemorrhage)
    Diagnosis can be made by one or more of the following symptoms/presentations: Symptomatology, pelvic examination pelvic ultrasound, hysterosalpingogram (HSG), sonohysterogram (HSN), CT-scan or MRI..
    Fibroids are classified as:
    • Submucosal: Here the fibroid grows just under the lining of the uterine cavity (mucosa) or protrudes into the uterine cavity. They might mold into the underlying uterine muscle (sessile) or be on a stalk (pedunculated). Submucosal fibroids can change the shape of the uterine cavity, irritate the lining and prevent implantation, cause miscarriage. These lesions must be removed in their entirety prior to undertaking embryo transfer, usually hysteroscopically. (see below)
    • Subserosal: – Here the tumors grow under the outer layer (serosa) of the uterus. These fibroids will not compromise implantation, but if they are large, causing severe pain, and especially if they are multiple, pedunculated and thus at risk of undergoing torsion (twisting) the3y should be removed, usually laparoscopically. (See below).
    • Intramural: – when the fibroids develop within the muscular wall of the uterus. This is the commonest presentation. Unless they are large and multiple and do not encroach on the uterine cavity, they can be left alone Surgical removal is usually by laparoscopy or laparotomy/abdominal open incision (See below)
    The uterus is composed of a thick layer of smooth muscle (myometrium) surrounding the endometrial lining into which the embryo implants and which serves to protect and nourish a growing pregnancy. These tumors are rarely malignant (see below). Fibroid tumors, even large ones, can occur without producing any symptoms at all.
    For the most part, only those fibroids that impinge upon the uterine (endometrial) cavity (submucosal) affect fertility. Exceptions include large fibroids in the muscle wall of the uterus (intramural) that can block the openings of the fallopian tubes as they enter the uterus, and where multiple fibroids cause abnormal uterine contraction patterns.
    In some cases multiple uterine fibroids may so deprive the uterine lining (endometrium) of blood flow, that the delivery of estrogen to the endometrium is curtailed to the point that the lining cannot thicken sufficient to support a pregnancy. This can result in early 1st trimester (prior to the 13th week of pregnancy) miscarriages. Large or multiple fibroids, by curtailing the ability of the uterus to stretch in order to accommodate the spatial needs of a rapidly growing pregnancy, may precipitate 2nd trimester (beyond the 13th week) miscarriages and/or trigger the onset of premature labor.
    Sizable fibroid tumors are usually easily identified by simple vaginal examination. However, even the smallest fibroid can be identified by transvaginal ultrasound. Sometimes it is difficult to tell if the fibroid is impinging on the uterine cavity. In such cases, a hysteroscopy (where a telescope like instrument, inserted via the vagina into the uterine cavity) or a sonohysterogram where injected fluid, distends the uterine cavity allowing for examination of its inner configuration can help distinguish between intramural and submucosal fibroids. CT scan and MRI can also be used to distinguish between fibroid tumors and another condition that also involves affects the uterine muscular wall, known as adenomyosis. This condition is characterized by endometrial tissue growing deeply into the uterine wall.. Given the often-diffuse nature of adenomyosis, it can be very difficult to remove surgically. This contrasts with fibroid tumors, which are well defined and are usually easily removed.
    Surgical Treatment: The mainstay for the treatment of fibroid tumors is surgical removal (myomectomy). Small, asymptomatic fibroids that do not impinge upon the endometrial cavity will usually not require treatment other than observation and vigilance. Large fibroids and submucosal fibroids should be removed prior to starting fertility treatments such as In Vitro Fertilization (IVF) in order to decrease the chance of implantation failure, miscarriage, pregnancy complications and premature labor. Intramural and subserosal fibroids are readily removable by laparoscopic resection or via an abdominal incision. The former allows for a more rapid convalescence and is ideal for the removal of small and accessible superficial fibroid tumors, while the latter approach is preferred for treating larger and less accessible fibroids.
    Myomectomy can affect fertility in several ways. If the endometrial cavity is entered during the surgery, there is a possibility of post adhesions forming within the uterine cavity. This should always be checked by the performance of a hysteroscopy or through a \sonohysterogram, prior to beginning fertility treatment. Because myomectomy can be bloody, there is a high likelihood of post-operative abdominal adhesion formation, which could bind down or encase the ovaries, preventing the release of the eggs, or block the ends of the fallopian tubes. For this reason, it is important that myomectomies be formed only by accomplished surgeons, who are familiar with techniques to limit blood loss and prevent adhesion formation.
    Regardless of whether the laparoscopic or abdominal approach is employed, adequate closure of the uterine wall is essential in order to reduce the subsequent risk of uterine rupture during pregnancy or labor. This is one of the main arguments used against the use of laparoscopic removal of large, multiple or remotely situated fibroids. While laparoscopic myomectomy requires but a few days (at most) for post-operative convalescence, abdominal myomectomy usually requires 6-8 weeks of recovery time. When myomectomy necessitates or results in the uterine cavity being entered (purposefully or inadvertently), it should always be followed up with a “2nd look” hysteroscopy to rule out scar tissue formation, which occurs frequently in the presence of submucosal fibroids.
    Uterine polyps (and in some cases, also submucosal fibroids), can usually be removed hysteroscopically (through the vagina). This eliminates the need for abdominal surgery and greatly reduces the recovery time. Hysteroscopic surgery is only useful if the majority of the fibroid protrudes into the endometrial cavity, ensuring that the tumor defect will not be too large. This surgery is often done under laparoscopic guidance, to reduce the risk of uterine perforation. After hysteroscopic surgery it is often advisable to prescribe cyclical hormonal therapy for a few months to encourage regeneration of the endometrial lining over the area of tumor defect and healing of the uterine muscle. A 2nd look hysteroscopy should be performed a few months later in all cases, to rule out scar tissue formation even if it means delaying or deferring the initiation of definitive fertility treatment.
    Medical Treatment: The growth of fibroid tumors is estrogen-dependent. Thus when a woman enters menopause and stops making female hormones, fibroids tend to shrink in size on their own. Conditions that mimic menopause can also reduce the size of fibroid tumors. The most common of theses treatment is with a medication such as leuprolide acetate (Lupron), which shuts off the communication of the brain with the ovaries, preventing hormone production. However, this type of medication can only be taken for a limited period (usually 6 months) and once the medication is stopped the fibroids will usually regain their original size within a few months. The medication is therefore only a “temporary fix,” used mostly to decrease the size of large fibroids in order to make their ultimate surgical removal easier, or to help a woman bridge the gap until spontaneous menopause sets in. For the majority of women there is no major benefit from Lupron therapy prior to surgery.
    Embolization of Fibroid Tumors: Myomectomy always carries the small (although infrequent) risk that severe, uncontrollable intra-operative bleeding could require the performance of a hysterectomy (complete removal of the uterus) as a life saving measure. Moreover, some women are poor candidates for surgery. This is where a new procedure known as embolization comes in. Embolization is a procedure in which small particles are injected into the arteries of the uterus under radiological guidance to shut off the blood supply to the fibroids, in the hope that they will “shrink” and perhaps, even disappear.
    Embolization is relatively new to the field of gynecology and little is known about its potential effects on future fertility. We are concerned that in the process of shutting off the blood supply to the uterus, it will permanently so reduce endometrial blood flow, as to compromise embryo implantation. For this reason, I do not currently recommend this therapy for women who still wish to conceive and carry a baby in their uterus. At present, it seems best suited for symptomatic women who are finished with their childbearing or who are planning to use a gestational surrogate.
    Malignant Change in Fibroid Tumors: Fibroids rarely undergo malignant change. The reported incidence is less than 1 in 2000 cases. Fibroids usually grow very slowly (over a number of years). However, when growth occurs rapidly over a month or two, especially in older women who have large fibroids, it should raise the suspicion of this very rare but extremely serious complication.

    Please call or email Julie Dahan, my patient concierge. She will guide you on how to set up an in-person or Skype consultation with me. You can reach Julie at on her cell phone or via email at any time:
    Julie Dahan
    • Email: Julied@sherivf.com
    • Phone: 702-533-2691
     800-780-7437

    Geoff Sher

    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.

  • marie - June 27, 2016 reply

    hi Doc,

    I just want to know the meaning of this result:
    NK (NK CELLS)

    Observation

    Values

    FLO* CYTOMETRY FOR ACTIVATED NATURAL

    Sample Type: peripheral Blood

    Lymphocytes

    total (CD3-56+)

    Total NK cells (CD3-S6+)

    @CDS6 ‘Bright’ NK cells CDS 6 ‘Bright’ NK cells

    SCD56 •Dim’ NY. cells

    CD56 ‘Dim’ NE cells

    . Dim

    Bright NK

    Activated (CD69+) CD36 ‘Dim’ Activated (CD69•) CDS6 ‘Dim’ NKs

    Cornents :

    normal

    Lymphocytes

    elevated

    S Total ceils

    •Abnormal activated natural killer

    KILLER CELLS

    3.6

    21.6

    0.79

    0.49

    0.018

    20.9

    0.76

    0.02 1.7

    12.7

    X 10 g of x10

    x10

    x10

    x10

    1 ymphocytes lymphocytes lymphocytes

    -6 11,

    Units

    (1.5-4.0)

    12.0)

    12.0)

    cell count •

    (Reference ranges derived from ‘How to improve

    An evidence—based review of adjuncts to I VF

    your ART success rates:

    killer cell analysis

    Results may be affected by certain conditions including acute stress, pregnancy, infection, hormonal medication, I VF stimulation, and herbal medication.

    While studies have demonstrated an association between an increased test result and difficulties in reproduction such as miscarriage or infertility, a causal relationship has not been established.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - June 27, 2016 reply

    These results, while they do not show activation of NK cells, are not the tests that I would have ordered and thus for me, are difficult to interpret. In my opinion, the gold standard test for NK cell activity is the K-562 target cell test which is best performed in about a half dozen Reproductive Immunology Reference Laboratories in the United States. The one I prefer is Reproductive Immunology Associates in Van Nuys, CA. (RIA). Another test that might in time prove to be of value and the results of which in most cases seem to correlate with those derived from the K-562 test, is measurement of uterine Cytokine activity.

    • The Role of Immunologic Implantation Dysfunction (IID) & Infertility (IID):PART 1-Background
    • Immunologic Implantation Dysfunction (IID) & Infertility (IID):PART 2- Making a Diagnosis
    • Immunologic Dysfunction (IID) & Infertility (IID):PART 3-Treatment
    • Thyroid autoantibodies and Immunologic Implantation Dysfunction (IID)
    • Immunologic Implantation Dysfunction: Importance of Meticulous Evaluation and Strategic Management:(Case Report
    • Intralipid and IVIG therapy: Understanding the Basis for its use in the Treatment of Immunologic Implantation Dysfunction (IID)
    • Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
    • Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • Vaginally Administered Viagra is Often a Highly Effective Treatment to Help Thicken a Thin Uterine Lining
    • Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF

    I invite you to arrange to have a Skype or an in-person consultation with me to discuss your case in detail. If you are interested, please contact Julie Dahan, at:

    Email: Julied@sherivf.com

    OR

    Phone: 702-533-2691
    800-780-7437

    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

  • LC - June 24, 2016 reply

    Hello. We live in Amman Jordan. Does your clinic offer donor embryo cycles? Thanks.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - June 24, 2016 reply

    We do, but frankly donor embryos are VERY hard to come by and the waiting list is extraordinarily long.

    I strongly recommend that you visit http://www.DrGeoffreySherIVF.com. Then go to my Blog and access the “search bar”. Type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.

    • Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • The Fundamental Requirements For Achieving Optimal IVF Success
    • Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
    • Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
    • Blastocyst Embryo Transfers Done 5-6 Days Following Fertilization are Fast Replacing Earlier day 2-3 Transfers of Cleaved Embryos.
    • Frozen Embryo Transfer (FET) versus “Fresh” ET: How to Make the Decision
    • Frozen Embryo Transfer (FET): A Rational Approach to Hormonal Preparation and How new Methodology is Impacting IVF.
    • Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF
    • How Many Embryos should be transferred: A Critical Decision in IVF.
    • The Role of Nutritional Supplements in Preparing for IVF
    • IVF Egg Donation: A Comprehensive Overview

    Please call or email Julie Dahan, my patient concierge. She will guide you on how to set up an in-person or Skype consultation with me. You can reach Julie at on her cell phone or via email at any time:
    Julie Dahan
    • Email: Julied@sherivf.com
    • Phone: 702-533-2691

    Geoff Sher

    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.

  • Tiffany Raats - June 23, 2016 reply

    Thank you for your reply….do YOU do the TESE or TESA?….if not, which Dr in Vegas do you use? Also, if the sperm is “mature” enough, would she be a candidate for artificial imsemination? OR, does she have do to invitro?

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - June 23, 2016 reply

    We do both TESE and TESA.
    You cannot use TESE/TESA derived sperm for artificial insemination.
    Please call 702-892-9696 and talk to Tina. She will give you the names of the urologists we use.

    Geoff Sher

  • Tiffany Raats - June 22, 2016 reply

    Hi, I am inquiring for my daughter who now lives in Canada. She is very healthy, and has had many fertility tests showing that she is good ( she is 26) her husband (41) had a vasectomy, then had a reversal. For a short period of time, his SA was showing around 7 million sperm, but the last 3 samples are unfortunately showing zero……we have to believe there is scar tissue/obstruction. My first question is, do you do extraction of sperm? And my second question, would this sperm be mature enough/ strong enough for artificial insemination OR would she require IVF?…….thank you very much

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - June 22, 2016 reply

    Men with no sperm in their ejaculates (azoospermia) whether due to non-obstructive or obstructive (usually post-vasectomy) causes, can have their sperm accessed surgically and still propagate pregnancies. There are 2 methods by which this can be achieved. : 1) TESE (testicular sperm extraction), where a biopsy of the testis is done or, 2) TESA (testicular sperm aspiration), which involves introducing a needle into the testis and aspirating fluid and tissue. Both methods can be conducted under local anesthesia and both will provide sperm-containing tissue and fluid for immediate processing and fertilization (using ICSI) or cryostorage for future use. However, the question is: Which method yields better results. An Israeli study performed on men with non-obstructive azoospermia, conducted about a decade ago, compared the results of TESE with those from TESA in the same patients and found TESE to be the preferred approach.
    TSE/TESA is the preferred method for accessing sperm in men with azoospermia. By far the commonest indication for using this approach is post-vasectomy obstructive azoospermia where the use of TESE/TESA is far more successful and uncomplicated than is the alternative of having the man undergo surgical reversal. In fact, TESE/TESA yields a comparable IVF birth rate as for controls where normal sperm derived through masturbation is used. The approach is simple, relatively low-cost, and safe. In most cases, it is relatively painless and has a low complication rate. Moreover, in post-vasectomy men, it avoids the need for riskier and painful surgery designed to reconnect sperm ducts (vasa deferentia) while enabling the man to retain his chosen method of contraception after having propagated another pregnancy. In addition surgical vasectomy often fails to successfully reestablished duct patency and even when successful it often results in the subsequent reocclusion of the sperm ducts due to scar tissue formation. Moreover, in a large percentage of cases where vasectomy reversal was performed > 5 years after the vasectomy antisperm antibodies develop and this will almost always preclude subsequent natural conception even in cases where surgery had reestablished duct patency.

    While in some cases of non-obstructive azoospermia, TESA/TESE will yield sperm capable of achieving fertilization through ICSI and also subsequent viable pregnancies, success rates are low. However, in such cases, this approach yields the only possibility of the male partner participating genetically in propagating pregnancy.

    There is no reason to believe that the sperm we extract would not be mature.

    I strongly recommend that you visit http://www.DrGeoffreySherIVF.com. Then go to my Blog and access the “search bar”. Type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.

    • Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
    • The Fundamental Requirements For Achieving Optimal IVF Success
    • Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
    • Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
    • Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
    • Traveling for IVF from Out of State/Country–
    • A personalized, stepwise approach to IVF
    • How Many Embryos should be transferred: A Critical Decision in IVF.
    • The Role of Nutritional Supplements in Preparing for IVF
    • Routine Fertilization by Intracytoplasmic Sperm Injection (ICSI): An Argument in FavorHormonal Treatment of Male Infertility
    • Antisperm Antibodies, Infertility and the Role of IVF with Intracytoplasmic Sperm Injection (ICSI)
    • Testicular Sperm Extraction (TESE) and Testicular Sperm Aspiration (TESA): Surgical Approaches for Accessing Sperm from men who have no sperm in their ejaculates (Azoospermia)

    Please call or email Julie Dahan, my patient concierge. She will guide you on how to set up an in-person or Skype consultation with me. You can reach Julie at on her cell phone or via email at any time:
    Julie Dahan
    • Email: Julied@sherivf.com
    • Phone: 702-533-2691
     800-780-7437

    Geoff Sher

    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.

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