Measuring and interpreting Blood hCG to Assess Pregnancy Viability Following ART Treatments

I know of no medical announcement associated with the degree of emotional anticipation and anguish as that associated with a pending diagnosis/confirmation of pregnancy following infertility treatment. In fact, hardly a day goes by where I am not confronted by a patient anxiously seeking interpretation of a pregnancy test result.

Testing urine or blood for the presence of human chorionic gonadotropin (hCG) is the most effective and reliable way to confirm conception. The former, is far less expensive than the latter and is the most common method used. It is also more convenient because it can be performed in the convenience of the home setting. However, urine hCG testing for pregnancy is not nearly as reliable or as sensitive e as is blood hCG testing. Blood testing can detect implantation several days earlier than can a urine test. Modern pregnancy urine test kits can detect hCG about 16-18 days following ovulation (or 2-3 days after having missed a menstrual period), while blood tests can detect hCG, 12-13 days post-ovulation (i.e. even prior to menstruation).

The ability to detect hCG in the blood as early as possible and thereupon to track its increase, is particularly valuable in women undergoing controlled ovarian stimulation (COS) with or without intrauterine insemination (IUI) or after IVF. The earlier hCG can be detected in the blood and its concentration measured, the sooner levels can be tracked serially over time and so provide valuable information about the effectiveness of implantation, and the potential viability of the developing conceptus.

There are a few important points that should be considered when it comes to measuring interpreting blood hCG levels. These include the following:

  • All modern day blood (and urine) hCG tests are highly specific in that they measure exclusively for hCG. There is in fact no cross-reactivity with other hormones such as estrogen, progesterone or LH.
  • Post conception hCG levels, measured 10 days post ovulation or egg retrieval can vary widely (ranging from 5mIU/ml to above 400mIU/ml. The level will double every 48–72 hours up to the 6th week of gestation whereupon the doubling rate starts to slow down to about 96 hours. An hCG level of 13,000-290, 0000 mIU/ml is reached by the end of the 1st trimester (12 weeks) whereupon it slowly declines to approximately 26,000– 300,000 mIU/ml by full term. Below are the average hCG levels during the first trimester:
    • 3 weeks LMP: 5 – 50 mIU/ml
    • 4 weeks LMP: 5 – 426 mIU/ml
    • 5 weeks LMP: 18 – 7,340 mIU/ml
    • 6 weeks LMP: 1,080 – 56,500 mIU/ml
    • 7 – 8 weeks LMP: 7, 650 – 229,000 mIU/ml
    • 9 – 12 weeks LMP: 25,700 – 288,000 mIU/ml
    • A single hCG blood level is not sufficient to assess the viability of an implanting embryo. Caution should be used in making too much of an initial hCG level. This is because a normal pregnancy can start with relatively low hCG blood levels. It is the rate of the rise of the blood hCG level that is relevant.
    • In some cases the initially hCG level is within the normal range, but then fails to double in the ensuing 48-72hours. In some cases it might even plateau or decline, only to start doubling appropriately thereafter. When this happens, it could be due to:
      • A recovering implantation, destined to develop into a clinical gestation
      • A failing implantation (a chemical pregnancy)
      • A multiple pregnancy which is spontaneously reducing (i.e., one or more of the concepti is being lost) or,
      • An ectopic pregnancy which will either absorb spontaneously (a chemical-tubal gestation), or evolve into a full blown tubal pregnancy continue and declare itself through characteristic symptoms and signs of an intraperitoneal bleed.
  •  The blood hCG test needs to be repeated at least once after 48h and in some cases it  will need to be repeated one or more times (at 48h intervals) thereafter, to confirm that implantation is progressing normally.
  • Ultimately the diagnosis of a viable pregnancy requires confirmation of the presence of an intrauterine gestational sac by ultrasound examination. The earliest that this can be achieved is when the beta hCG level exceeds 1,000mIU/ml (i.e., around 5-6 weeks).
  • Most physicians prefer to defer the performance of a routine US diagnosis of pregnancy until closer to the 7th week. This is because by that time, cardiac activity should be clearly detectable, allowing for more reliable assessment of pregnancy viability.
  • There are cases where the blood beta hCG level is extraordinarily high or the rate of rise is well above the normal doubling rate. The commonest explanation is that more than one pregnancy has implanted. However in some cases it can point to a molar pregnancy  
  • Finally, there on rare occasions, conditions unrelated to pregnancy can result in detectable hCG levels in blood and urine. They include ovarian tumors that produce hCG, such as certain types of cystic teratomas (dermoid cysts) and some ovarian cancers such as dysgerminomas.

2,014 Comments

MJ

I’m concerned about my levels. Last period May 26, 2020 with a 33 – 34 day approx cycle. Guessing ovulation was approx June 11 or 12. Positive pregnancy test. June 30 HCG 41. Progesterone 35.1 nmol Estradiol 368 pmol/L. July 2 HCG 52 Progesterone 48.7 nmol Estradiol 466.

Today’s results don’t seem to be good. July 6 HCG 589. Proesterone 40.9. Estradiol 167. Is there any hope?? Please help me figure out these numbers.

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Dr. Geoffrey Sher

I am not that pessimistic. Wait until 6-7 weeks and do an US for confirmation!

Geoff Sher

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Lauren

Hello Doctor,

I am hoping you can offer insight. I had my first blood test 14dpo and have had blood tests every 2-3 days since.
7/1 (14 dpo): HCG 8.1 Progesterone 11
7/3: HCG 22 Progesterone 13
7/6: HCG 95 Progesterone 19

My doctor is still concerned that it might be a chemical pregnancy. I am 4 weeks 4 days today. Since the numbers are more than doubling every 2 days, can I relax a little? I go back for another blood test on Thursday.

Thank you!

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Dr. Geoffrey Sher

It looks good to me! . Wait until 6-7 weeks and do an US for confirmation!

Good luck!

Geoff Sher

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Anastasia

Dr Sher,
Further to a 3-day 2-fresh embryo transfer on 08 June the evolution has been as follows (LMP 25 May, “Ovulation” 05 June:
β-HCG 19 June (14 days DPO): 180
β-HCG 24 June (19 days DPO): 533
β-HCG 29 June (24 days DPO): 1,455
β-HCG 03 July (28 days DPO): 2,202
Echo today 06 July (1st day of week 7?) showed:
• single embryo IUP
• small decidual sac (5mmx7mm)
• presence of yolk sac
• crown rump length 3mm
• cardiac activity yes
• presence of corpus luteum
I would be grateful to hear your insight.

Thank you and all the best,
Anastasia

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Dr. Geoffrey Sher

It is a sluggish rise in hCG. I would wait 1 week and repeat the US to look for growth.

Geoff Sher

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Jasmine

Hi Dr, I am just about 10weeks now. My BhCG was:
05/06 – 5K
19/06 – 22K
30/06 – 18K
06/07 – 14 K

I had litte spotting on 18/06 and the ultrasound on 20/06 was fine, heartbeat detected.
Hcg is dropping and I have been recommended repeat blood test in a week. What is your opinion?

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Dr. Geoffrey Sher

The hCG is on the low side for 10 weeks. Repeat it in a few days to see if it picks up. However, as long as US shows appropriate growth and the HB is normal there is reasonable hope!

Good luck!

Geoff Sher

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Malia

Hi Dr! I’d really love your opinion on this. I’m concerned about a blighted ovum.

14th- faint positive
15th- HCG 87
18th- HCG 325
22nd- HCG 1215
2nd- HCG 26,000

On the 22nd and 2nd I also had ultrasounds. The first one there was a teeny tiny gestational sac. July 2nd the sac was waaay bigger but they couldn’t see anything in it.

At this point, if we’re saying I was 4 weeks on the 14th… then on July 2nd that would make me 6.4 weeks and you should be seeing something by then. Do you think this is a blighted ovum situation or could I still be earlier than 6.4 weeks?? I have another ultrasound next Friday… I know this is just a waiting game but I’d love to hear your opinion!

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Dr. Geoffrey Sher

Malia,

It is too early to be sure. Do another US in a week from now. That should be definitive.

Good luck!

Geoff Sher

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Kaylin Perotti

Had my period start May 25th then had iud removed on the 29th. positive pregnancy test on June 25 very faint line. Then I’ve had some red/pink/brown spotting on and off since. Some days there is none and other days it’s only when I go to the bathroom. Hcg level only taken one time so far and came back at 71. Had transvaginal us and nothing seen. She did mention seeing two follicles? Not sure what that means. I have another set of bloodwork scheduled for next week.
Any insite appreciated! Thank you!

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Dr. Geoffrey Sher

IT is much too early for US confirmation of pregnancy. I suggest you do follow-up hCG tesats and an UD in abut 2 weeks.

Vaginal bleeding occurs in about 25% of all pregnancies. When it happens, it almost invariably raises the concern of pregnancy loss (miscarriage). Bleeding can also be a sign of a tubal (ectopic) pregnancy, and in cases where the distended Fallopian tube ruptures it can precipitate a life-threatening crises. However, a small amount of painless vaginal bleeding can also be the result of normal embryo implantation (i.e. implantation bleeding) or it can result a local erosion of the vagina or cervix and/or trauma during intercourse.

Geoff Sher

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Kaylin Perotti

What would two follicles mean on the US? And how long does implantation bleeding last? How do I know how far along I am, nc if I go by my last period it would be 5 almost 6 weeks, and we know that’s not right.

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Dr. Geoffrey Sher

Implantation bleeding is usually very brief. No more than a day or so and it is mild without any pain.

You would need to wait about 10-14 days and then do an US to get the information you seek!

Geoff Sher

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Candace

Hi Dr. Sher,

I’ve had a previous ectopic pregnancy and a chemical pregnancy and I am currently pregnant.

Naturally because of previous losses I had my HCG levels checked at 17 and 19 DPO. The results were 404 and 1014 respectively. This means my levels almost tripled in a 42 hour period. I decided to get another blood draw exactly a week later which came back at 14, 000. This shows the same doubling time as before however the levels and rate of doubling seem worrisome. Are they to you?

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Tara Smith

Hello,

On June 8th 2020 my hcg was 350, had heavy bleeding on morning of June 12th and doctor told me it was definitely a miscarriage as hcg was 105 that day.

Heavy bleeding lasted 5 days and then stopped. Then light bleeding came back 7 days later and has been going on for 4+ days (bright red blood, but not very much).

I am still testing positive for pregnancy tests as of July 2nd, 2020. The HCG test strips have actually been getting darker over the past three days (potentially meaning increasing HCG??). I still have light bleeding today.

I am so confused. Shouldn’t the test be negative by now if it was only at 100 3 weeks ago? If HCG was increasing what would this mean?

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Dr. Geoffrey Sher

Go in and see your doctor for a quantiative hCG test and for an ultrasound .

Good luck!

Geoff Sher

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Alana

Hi from Australia Dr Sher!
Hoping you can help me.
LMP 5/10
12/6 HCG 77
15/6 HCG 187
19/6 HCG 343
22/6 HCG 588
25/6 HCG 829
2/7 HCG 1809
3/7 US today showed baby with heartbeat measuring 6+2, sac measuring 5+2.
Is there any chance this could be viable?

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Dr. Geoffrey Sher

Only time will tell! Do an US next Monday to see if a gestational sac with a viable conceptus can be seen.

Geoff Sher

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B

Hi Dr.

I’m worrying about the doubling rate not quite doubling. On 6/29 (5 weeks) my HCG level was 411, today 7/1 (48 hours late – 5w+2d) my HCG level is 741. I have had two previous miscarriages (blighted ovum and chemical pregnancy) so naturally I’m very nervous…

Do you think there’s cause for concern here? Does this 80% HCG rise fall out of normal?

Thank you for any insight.

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Dr. Geoffrey Sher

This is concerning. Only time will tell. Repeat the hCG test in 2 days! Hopefully it will start doubling and thereby alleviate some concern.

Good luck!

Geoff Sher

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Val

So I’ve had spotting all week on and off I finally started some mild bleeding after an intravaginal us and found out I had a bad uti I’m supposed to be 7 weeks based off lmp but I’m measuring 5 weeks and my hcg was 404

reply
Dr. Geoffrey Sher

Vaginal bleeding occurs in about 25% of all pregnancies. When it happens, it almost invariably raises the concern of pregnancy loss (miscarriage). Bleeding can also be a sign of a tubal (ectopic) pregnancy, and in cases where the distended Fallopian tube ruptures it can precipitate a life-threatening crises. However, a small amount of painless vaginal bleeding can also be the result of normal embryo implantation (i.e. implantation bleeding) or it can result a local erosion of the vagina or cervix and/or trauma during intercourse.
Notwithstanding, in virtually all cases the occurrence of early pregnancy vaginal bleeding congers concerns or even alarm regarding the possibility of miscarriage. And when this happens to women who conceived following infertility treatment, the alarm often turns into panic. However, the truth is that in most such cases the bleeding soon stops and the pregnancy proceeds unabated to the birth of a healthy baby. However, because some do progress and end in miscarriage, and in most cases, only time will tell how things will ultimately turn out, we use the term “threatened miscarriage” to describe such early bleeding. The term “inevitable miscarriage” is used once symptoms and signs confirm a miscarriage is in progress. The term “complete miscarriage” is used if all products of conception are passed, leaving the uterus “empty”. An “incomplete miscarriage” refers to cases where some products remain retained in the uterus.

Geoff Sher

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Nervous

Hi Dr. Sher, I’m back and more nervous than ever. Using a chromosomally normal 5 day blast, I got the following HCG results:

9dp5dt HCG 27
11dp5dt HCG 54
13dp5dt HCG 129.5
15dp5dt HCG 269.5

At that point, we started to relax a bit and your reply was hopeful too.

Now, at 23dp5dt (presumably 6 weeks) I got a transvaginal ultrasound and the tech said she could see a small spot of fluid but could not tell if it was a gestational sac and, if it was, that it was measuring smaller than it should. My HCG today was 2035. I am booked for a repeat ultrasound on Monday. What do you think? We are sick with worry!

Thank you!

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Dr. Geoffrey Sher

It is still early. Repeat the US in 1 week. That will be definitive!

Good luck!

Geoff Sher

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Nervous

So you believe there is some hope? We are just heartbroken thinking this will be our fourth loss. Thank you, Dr. Sher!

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Dr. Geoffrey Sher

Only time will tell!
I really think we should talk.

call Patti at 702-533-2691 ans set up an online consultation with me to discuss!

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.
I strongly recommend that you visit http://www.SherIVF.com. Then go to my Blog and access the “search bar”. Type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.
• The IVF Journey: The importance of “Planning the Trip” Before Taking the Ride”
• Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
• IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
• The Fundamental Requirements For Achieving Optimal IVF Success
• Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the “Conventional” Antagonist Approach
• Ovarian Stimulation in Women Who have Diminished Ovarian Reserve (DOR): Introducing the Agonist/Antagonist Conversion protocol
• Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
• Human Growth Hormone Administration in IVF: Does it Enhances Egg/Embryo Quality and Outcome?
• The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
• Blastocyst Embryo Transfers Should be the Standard of Care in IVF
• IVF: How Many Attempts should be considered before Stopping?
• “Unexplained” Infertility: Often a matter of the Diagnosis Being Overlooked!
• IVF Failure and Implantation Dysfunction:
• The Role of Immunologic Implantation Dysfunction (IID) & Infertility (IID):PART 1-Background
• Immunologic Implantation Dysfunction (IID) & Infertility (IID):PART 2- Making a Diagnosis
• Immunologic Dysfunction (IID) & Infertility (IID):PART 3-Treatment
• Thyroid autoantibodies and Immunologic Implantation Dysfunction (IID)
• Immunologic Implantation Dysfunction: Importance of Meticulous Evaluation and Strategic Management:(Case Report
• Intralipid and IVIG therapy: Understanding the Basis for its use in the Treatment of Immunologic Implantation Dysfunction (IID)
• Intralipid (IL) Administration in IVF: It’s Composition; How it Works; Administration; Side-effects; Reactions and Precautions
• Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
• Endometrial Thickness, Uterine Pathology and Immunologic Factors
• Vaginally Administered Viagra is Often a Highly Effective Treatment to Help Thicken a Thin Uterine Lining
• Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
• A personalized, stepwise approach to IVF
• How Many Embryos should be transferred: A Critical Decision in IVF.
• The Role of Nutritional Supplements in Preparing for IVF

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ADDENDUM: PLEASE READ!!
INTRODUCING SHER FERTILITY SOLUTIONS (SFS)
Founded in April 2019, Sher Fertility Solutions (SFS) offers online (Skype/FaceTime) consultations to patients from > 40 different countries. All consultations are followed by a detailed written report presenting my personal recommendations for treatment of what often constitute complex Reproductive Issues.

If you wish to schedule an online consultation with me, please contact my assistant (Patti Converse) by phone (800-780-7437/702-533-2691), email (concierge@SherIVF.com) or, enroll online on then home-page of my website (www.SherIVF.com).

PLEASE SPREAD THE WORD ABOUT SFS!

Geoff Sher

reply
Nervous

Hi again, ultrasound today at 6+2 (IVF so dates are precise) showed a small, 4mm gestational sac with possibly something inside. Do you still think we have a chance? It has apparently grown from 1.5 to 4mm in 2.5 days. Thank you!

Sahra

Sehr geehrte Dr. Geoffrey Sher,

bei meinem ersten Text wurden merkwürdigerweise einige Wörter verdreht. Deshalb noch einmal.

ich befasse mich seit seit einigen Tagen mit Schwangerschaften. Ich plane schon seit einiger Zeit schwanger zu werden, aber wollte damit noch ein wenig warten. Ich wollte ein wenig mehr über die einzelnen Schwangerschftsnachweismethoden erfahren, dass nimmt mir ein wenig die Angst. Ich habe gehört, dass die neuen Urintests alle nach dem selben Prinzip funktionieren. In allen wird hcg auch Beta hcg nachgewisen. Das funktioniert nach dem Lateral Flow Tests. Wie ist das mit dem Bluttest? Welches Prizip wendet man bei einem quantitaiven Bluttest bei einem Arzt an? Die sollen viel genauer sein und man kann Sie sogar früher als einen Urintest anwenden. Ich finde leider nichts im Internet.

Vielen Dank im Voraus.

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Dr. Geoffrey Sher

Hi Sahrah,

Please re-post this question in English and I will respond promptly!

Geoff Sher

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L Tocco

Hi there! Hoping you can offer some insight. At just about 5 weeks pregnant I shared my concern of no pregnancy symptoms with my midwife. She recommended a serial hcg test. A day after speaking with her morning sickness and breast tenderness kicked in, but I decided to do the testing anyway. At 6 weeks pregnant I got an hcg test done to check levels and it was at 43,119 mIU/mL. A day after getting my 1st hcg done I spotted a little (tan with a touch of brown) and my pregnancy symptoms vanished overnight (after having them for 7 days straight). I tried to hold off and see if spotting was going to progress or if pregnancy symptoms were going to come back. I decided to do another hcg at 6 weeks, 6 days pregnant and the results came back at 52,801 mIU/mL. The spotting only happened for 2 days (very mild) and I think I had a slight return of nausea yesterday (3 days after initial spotting incident). Does this hcg increase seem normal? I’ve read that they are supposed to increase more, but I’ve also read that they aren’t as reliable at 6/7 weeks or when the values exceed 6,000. Any insight would be helpful.

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L Tocco

Thank you! So to clarify, is it normal for hcg to rise that slowly at 6-7 weeks?

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Dr. Geoffrey Sher

Once it rises above 5000 (or so), the rise usually slows down.

Geoff Sher

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JS

My first reading 9DP5DT was 17.4 and 11DP5DT was 31.1. Going in for a retest in 3 days.

Looking pretty unlikely, right?

Thanks for all the assessments you’ve been providing.

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JS

Thanks, Dr. Sher. Got another reading this morning at 15DP5DT. Now it’s at 236. They said to come in for another test in 6 days and do early ultrasound in 8 days. Nervous, but at least it’s looking more hopeful.

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Ashley smith

Hello my hcg level went from 156.9 to 140.0 is there a chance I will have a miscarriage?

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Dr. Geoffrey Sher

This does not look good…I am afraid!

So sorry!

Geoff Sher

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Jeanine Smith

Hello I am currently 7 weeks pregnant today and had a trans vaginal scan at my fertility clinic today. Additionally Last week I had a six week scan and we saw a 6 week baby with a HR of 131 and an appropriately sized Yolk sac and a gestational sac measuring 2.66cm. This week at the 7 week scan we saw the baby measuring at 7 weeks with a HR of 138 a normal sized yolk sac but the gestational sac measured at 2.24 cm. I asked if this drop meant anything and I was told that the sac is three dimensional and the ultrasound just takes one image measurement so it can vary slightly time to time and it was nothing to worry about and that the heart rate was appropriate and the growth was on target. Do you agree with these findings? Is a gestational sac measuring 2.24cm in size appropriate for 7 weeks? I had two previous losses where the gestational sac was very small way too small to be viable and the heart rates were not viable. This is where my concern is coming from. Thank you Jeanine

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Dr. Geoffrey Sher

I concur with the explanation and advice given.

Good luck!

Geoff Sher

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Mrs Peers

Dear Dr Sher,

I am currently pregnant (approx 5 weeks 4 days) and due to regularly suffering from anxiety and having a miscarriage 3 months ago, I requested for my hcg levels to be checked for reassurance. Unfortunately, despite having no other symptoms my levels on 21.06.20 were 788 and increased to 1056 48 hrs later. Due to the slow rising levels I have been booked in for a transvaginal ultrasound tomorrow. The doctor is optimistic as I have no other symptoms however I’m getting increasingly worried it may be another miscarriage or possibly eptopic. Do you think these levels are concerning at the moment? I have had a successful pregnancy prior to my miscarriage.

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Dr. Geoffrey Sher

It could be a little early for a definitive US. I personally would give it about 1 more week before doing this.

Geoff Sher

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Alexis

I was breast feeding for 1 year and I had a cycle in April and the last one was around May 3rd. I am pregnant but my levels are rising slow and they have no answers for me as to what’s going on! I passed 2 blood clots on the 23rd and went back to the ER still no answers. Here were my levels
6/10 – 60
6/19 – 120
6/22 – 360
6/24 – 460
I also have an unexplained rash across my stomach.
What do you think?

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Dr. Geoffrey Sher

Impossible to predict, but this is a cause for some concern. I suggest an US be done in about 10-14 days from now. That should be definitive. I do not think the rash is related.

Good luck!

Geoff Sher

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Ashley

Last period start date was May 27/20
2 positive at home tests
Hcg level tested June 22 at 157, and 48 hours later only 261 should this be of concern.

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Dr. Geoffrey Sher

Not possible to say for certain. Repeat it in 48 hrs and then do an US at 6-7 weeks.

Good luck!

Geoff Sher

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Krystina Geyer

Dear dr Sher ,
I had my hcg levels taken 6/18 they were 29 on 6/22 they were 166 then 6/24 they where 445
Ultrasound was done on 6/30 they seen normal gestational sac with yok sac measuring at 5.5 weeks but no fetal pole . Hgc was 5,011 next hcg was done 7/2 was 7,855 . My dr said she would have liked it to be in the low to mid 8,000 range is this normal or concerning? Thank you for your help

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Dr. Geoffrey Sher

It is still too early for an US to be reliable. I am not pessimistic! This looks reasonably OK to me! Wait until 6-7 weeks and do an US for confirmation!

Good luck!

Geoff Sher

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Maz

Dr. Sher – My first beta at 9dp5dt was 210 and second beta at 12dp5dt was 1,274. Third beta on 19dp5dt is 16,176. I transferred one embryo. The numbers seem good, but I’m slightly concerned because they are a bit high it seems. Should I be worried? Thank you.

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Dr. Geoffrey Sher

The embryo could have split. However, I think it will probably turn out to be one. An US done at 6-7 weeks will likely be definitive.

Geoff Sher

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chirali

I had my bhcg done on 6/3/20 and it was 1263, and my first ultrasound done on 6/17/20, they were able to see gestational sac and yolk sac measuring 17 mm but no fetal pole. Is there anythings to worry? I have a repeat ultrasound on 6/29/20 but this wait is killing me. I have been pregnancy symptoms and they are worsening day by day. Any input would be appreciated.

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Dr. Geoffrey Sher

Without knowing how far along you were at the US, I cannot comment authoritatively.

Geoff Sher

PS: If you re-post, please also include this original post as a point of reference.

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Cassie Ruth

Hi Dr. Sher,

Is it normal for HCG levels to more than double every 48 hours. I am approx 4-5 weeks pregnant (LMP 5/21/20). Also, should my levels be higher in general?

6/19 (8:30 AM) HCG 111
6/22 (7:45 AM) HCG 705

Thank you in advance, and thank you for taking the time to help us all.
Cassie

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Dr. Geoffrey Sher

This looks normal to me! Do an US 1n about 2 weeks from now.

Good luck!

Geoff Sher

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heather

Dr,
I found out 2 weeks ago I was pregnant, two days after that I started to bleed so I went to the er, they ran an hoc lever which was a 78, two days later another test it was a 74, then two days later a 95, then another 48 its at 146, does this mean a good thing, and how many weeks would this mean I am….

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Hayley

I had my first HCG at 11dp5dt and it was 45. The nurse said that this was too low and that it should be at least 70 for the day that they tested. There is repeat blood testing in two days to see if it has progressed, but the nurse was not hopeful.
What do you think?

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Dr. Geoffrey Sher

Repeat the hCG test in 2 days. It needs to double. Ultimately an US done at 7 weeks will give a definitive answer.

Good luck!

Geoff Sher

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AM

My partner has undergone a frozen embryo transfer on June 10th and tested positive (hCG level 811) on Monday June 22nd. Today (2 days later) her hCG level was 1200. Is this cause for concern?

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Dr. Geoffrey Sher

It could be a cause for concern, but it could also be a spontaneous reduction from a twin pregnancy down to 1. I suggest another test be done 2 days after the most recent one. It should be >2000. Ultimately, an ultrasound test done about 1 week from now should be definitive.

Geoff Sher

AM

My partner’s third bloodtest (48hrs) after the second showed hcg of 2182. Hcg production seems to have sped up somehow? We only transferred one embryo.

12dp5dt: 811
14dp5dt: 1219
16dp5dt: 2182

Is it more likely to be ectopic or can the percentage that hcg rises fluctuate in a normally progressing pregnancy?

AB

I had a miscarriage around May 27th & found out I was pregnant again June 18th! My levels went down completely after the miscarriage & are now 556, is that a good number?? I go back tomorrow (blood was drawn yesterday meaning it’ll be 2 days later)!

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AB

I’m confused, this is a separate pregnancy. My levels from the miscarriage in May went to 0 Memorial Day weekend, I was just wondering if 556 was a good HCG number for a new pregnancy!

Dr. Geoffrey Sher

It could be, but the level 48h later will be more revealing!

Geoff Sher

Amanda

Im 35 and haven’t had a child since 2007. I recently had a positive home test on 6/5 and on 6/15. I went in on 6/15 and my hcg level was 114. I went back on 6/17 and it was 101. Is this reason to worry?

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Dr. Geoffrey Sher

Not necessarily, but you do need a thorough evaluation ASAP.

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Geoff Sher

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Nonia Minhas

Hi!

I have h/o recurrent m/c and had an IUI on 05/14/2020, HCG was 801 mIU/mL (June 1), HCG 7139 mIUmL (June 11) at 5 weeks and 3 days (Transvaginal U/S showed gestational sac), repeat HCG at 6 weeks 3 days 9473 mIU/mL (transvaginal U/S showed progression with heartbeat flutter). Are these numbers still okay? I’ve heard to go by u/s results more than lab values after weeks. Thanks!

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Dr. Geoffrey Sher

The hCG levels tend to rise more slowly after the level reached 4000-5000. Follow weekly US examinations for the next few weeks. That will be more indicative.

Geoff Sher

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Olivia

Dr Sher,

I feel like I am going crazy here. My FS seems to think everything is progressing fine, but I cannot see how with the following numbers.
4+2 weeks: HCG – 1300
5+2 weeks: HCG – 23,000
6+ Zero weeks : HCG – 68,000

Shouldn’t it be around 100,000 by now ?

Also, and perhaps more importantly, Progesterone is going down, not up.. every single person I ask says the progesterone needs to be increasing more and more during pregnancy. mine is going down each time and once again the FS says as long is it is above the threshold, it is okay.

Progesterone went from 17.6 to 15.0 and now to 13.8..

Please Dr Sher if you could let me know what you think that would be greatly appreciated. I’ve been trying for a very long time and I suspect the FS is not being proactive and providing something for progesterone.

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Dr. Geoffrey Sher

I personally do not believe there is a problem with the hCG level or your progesterone. have an US done to confirm the viability of the pregnancy.

Good luck!

Geoff Sher

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Olivia

Thank you Dr Sher, that gives me reassurance. I’ve booked my US for next week just now 🙂
(I’ve never had a miscarriage, but I’ve been unexplained primary for 4 years, this is natural/miracle pregnancy hence the cautiousness)

Why is it that Progesterone is trending downwards though? Could it be caused by a transition of the corpus lut ceasing production of progesterone while the placenta is slowly taking over.

I’ve seen many flipcharts and hormone graphs in my Fertility Clinics and online that show Progesterone trending upwards from implantation and onwards, hence the concern.

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Dr. Geoffrey Sher

I think the trend in blood progesterone level is still in the acceptable range but I urge you to discuss this with your personal doctor as to whether he/she wishes to supplement with progesterone therapy.

Geoff Sher

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Nervous

Hi Dr. Sher, We are so nervous. We had one chemical pregnancy, a missed miscarriage discovered at 16 weeks (Trisomy 21), and a missed miscarriage discovered at 8 weeks (Trisomy 22) using non-PGS tested embryos given male factor infertility (all 5AA, ICSI). We then tested the remaining embryos and transferred a chomosomally normal 5AA from the same retrieval. 9 days past the 5 day FET, my HCG was only 27. Exactly 48 hours later it doubled to 54. The nurse seems hopeful about the increase but concerned about the low numbers. What do you think? Thank you!

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Dr. Geoffrey Sher

I wish I could reassure you, but all I can say is that there hope because of the 48h doubling time of hCG level.You need another us done in 48H . It should be >100. If so, then an US done at 6-7 weeks should provide a more definitive answer.

Good luck!

Geoff Sher

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Nervous

Thank you, Dr. Sher. We now have one more data point:

9dp5dt HCG 27
11dp5dt HCG 54
13dp5dt HCG 129.5

What do you think???

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Nervous

Thank you! Last blood draw showed another doubling:

9dp5dt HCG 27
11dp5dt HCG 54
13dp5dt HCG 129.5
15dp5dt HCG 269.5

Do you think this is a viable pregnancy? Praying and hoping!

Dr. Geoffrey Sher

Yes! Likely it will be viable. do an US at 6-7 weeks to confirm.

Geoff Sher

Kate

Good Day Dr Sher,

Your opening paragraph of this blog is so incredibly apt. Im really afraid to be optimistic regarding my most recent IVF. (fresh 2 x AA embryos) would greatly appreciate your views if this is a viable pregnancy?
8DP5DT – 24.3hcg was told inconclusive pregnancy.
9DP5DT – 33.4 hcg
10DP5DT – 44 hcg (3 test 48 hrs later)

I feel it’s too slow to be a healthy pregnancy but really don’t know. Thank you for answering so many questions on this platform. Your honesty is refreshing.

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Dr. Geoffrey Sher

The rise is rather slow. I am not vey optimistic!

Sorry!

Geoff Sher

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Kate H

Thanks Dr. Sher,
My HCG dropped from 44 to 36; then 3 days later rose again to 40. I’m assuming these numbers are completely unrealistic for a good pregnancy, but unsure why it dropped and rose again. should i continue with progesterone or let this end naturally?

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Dr. Geoffrey Sher

Sadly, it looks as if this is a failing implantation!

Sorry!

Geoff Sher

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Christine

I have had four early losses (one of them ectopic) and then I had my son. I’m pregnant again and these are my numbers. Doesn’t seem promising since the doubling times are decreasing but my RE says they are “within range” so I’m going for an ultrasound on June 30th. What do you think? Are decreasing doubling times this early always a bad sign? My cycle started May 21.

6/16: 79
6/18: 170
6/20: 289
6/22: 407

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Dr. Geoffrey Sher

It looks suspect. My bigger concern is that this might be another ectopic. If you have any bleeding with severe pain go straight to your doctor or to the ER if he/she is not immediately available.

Good luck!

Geoff Sher

PG

Hello Doc,
Thanks for your previous response. I did few more tests since last week and here are the HCG results
1) 4W 3 Days -> 625
2) 4W 6 Days -> 991
3) 5W 1 Day -> 991
4) 5W 2 Day -> 1053 . Got vaginal ultrasound done as well. They see IUP with a sac and yolk.
My doc says its non-viable pregnancy and will wait for it to naturally end until 7th Week and then based on another ultrasound will take further action.
I don’t have any symptoms either of being pregnant or miscarriage. What are your thoughts onn this?

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Kasey

I had a single FET with 5day female blastocyst, On 5/28, my hcg was 143. 4 days later on 6/1, it was 1123. That jump seemed significantly higher than I was expecting… Is it possible to have a molar pregnancy with FET? Or is this increase normal?

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