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.

2,823 Comments

Lynne

Dear Dr. Sher, I was waiting to start my next icsi cycle when I got a surprise positive pregnancy test. My betas have been rising slowly and I’m worried about what an u/s will show when I go in 3 days time. My betas were at 4+3: 787, 4+5: 1303, 5+6: 7800, 6+6: 21500. Do you think this could be viable? Many thanks

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Lynne

Dear Dr Sher, thank you very much for your reply. I’m very happy to say that we’ve seen a heartbeat!

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Lynne

Just to report the safe arrival of my son in May! Many thanks Dr Sher for your insight at a stressful time.

Dr. Geoffrey Sher

You are very welcome Lynne!

Congratulations!!

Geoff Sher

Ash

Hi dr,

Unfortunately i’ve had two previous miscarriage and two children . I feel as though this may be another miscarriage something strange happened :
My hcg level
13/5- 200
15/5-155 ( doctor said to prepare for miscarriage )
blood test after 5 days was

550 then 5 days after that was 4500 , 3 days after that it was 9000 my LMp was 14/4/2020
ultrasound showed gestiational sac and yolk sac but no heartbeat so again prepared for miscarriage went for hcg test 1 week from 9000 and it has come back 23,000….if i am miscarrying why is my hcg still rising some days my symptoms are so much stronger then others.

Ash

Thank you

Dr. Geoffrey Sher

I would wait 1-2 weeks and then repeat the US. You might just be too early on in pregnancy at this point, to detect a conceptus and see a HB.

Good luck!

Geoff Sher

Ash

Sorry the last two hcg numbers were 7 days apart and also i was meant to be measuring 7 weeks when i did the u/s but instead i was measuring 5 weeks days

Ash

sorry to make a new post it wouldn’t let me reply to you…. how about the fact the numbers aren’t doubling ?

Dr. Geoffrey Sher

Please restate the numbers and re-post your question and I will respond!

Geoff Sher

Dr. Geoffrey Sher

It could be! But you should repeat the test 2 days after the 1st one to see if it doubles every 48h (as it should).

Geoff Sher

Dawn Curry

Hi Dr Sher,
I went to the hospital on 7/7 due to some spotting and my beta was 1,243. The spotting stopped but came back so I went back to the hospital on 7/10 my beta was 4858, they did an US and said they couldn’t find a gestational sac. I went home had some brown spotting today (7/12) went back to the hospital and my beta was 9,111, they did an US and saw a gestational sac and yolk but no fetal pole and said the sac was measuring 4-5 weeks and the doctor said based on my hcg levels it should be measuring more than 4-5 weeks so they want me to see an OBGYN tomorrow. Does any of this sound normal to you? Also I’ve had multiple miscarriages in the past so I’m not getting my hopes up.

Dr. Geoffrey Sher

At 5 weeks you would not necessarily see a fetal HB. Yes, the hCG is high but it could still turn out OK. Wait a week and repeat the US.

Please keep me in the loop!

G-d bless!

Geoff Sher

Dominique

I had a draw on 7/6 when i was about 5weeks and 3days with results of 1840.6 then on 7/10 when i should’ve been about 6 weeks another draw with the results of 3223. Is there any hope for this baby or should I prepare myself for another miscarriage?

Dr. Geoffrey Sher

You need an ultrasound to evaluate . I suggest you do this next Monday! Results should be conclusive.

Good luck!

Geoff Sher

Chelsea

I could use some insight! I can’t find a lot of information on my situation. I had a positive pregnancy test on 7/16 (13 dpo) and my blood hcg level was 96. My next reading on 7/20 was 115…obviously bad news but then on 7/22 it was 1372 and on 7/27 8638. I am working with a RE because of 3 past chemical pregnancies. We did an ultrasound in case of ectopic but found a gestational sac in the uterus. I have a follow up ultrasound next week to look for heart beat. Is it a loss cause since that early low reading? It seems from what I read that it is…I don’t want to get my hopes up again.

Thank you

Dr. Geoffrey Sher

I think there is still hope. Your next US should be definitive.

Good luck and G-d bless!

Geoff Sher

Valara

Hi, I have highly irregular periods, like once every 6 months or so.

My last period was in February I think.

I tested faintly positive at home in July 19th, and kept retesting daily and watching the line get more solid.

On the 27th i went in for a confirmation and dating ultrasound. The obgyn could find nothing at all in the uterus. She had me do bloodwork, which I received today: 1630. I did another round of testing today and hope to hear back soon..

My question: 1630 seems higher than usual for spotting atleast the sac in the uterus? I’m 26 years old and this would be my first, but im trying to stay optimistic. Do you think this is ectopic?

Thanks.

Dr. Geoffrey Sher

Your doctor must be on the look-out for an ectopic pregnancy.

Approximately 1 out of every 100 embryos will implant and grow outside of the uterine cavity (almost always) in a fallopian tube. This is defined as an ectopic pregnancy. Infrequently, an ectopic pregnancy attaches to an ovary or to one or more other pelvic organs. On very rare occasions (1;1,000), one twin attaches and grows in the uterine cavity with the other growing outside the uterus (i.e. a heterotopic pregnancy).
There is an ever present risk that a tubal (ectopic) pregnancy might rupture causing potentially catastrophic internal hemorrhage. Accordingly any symptoms suggesting that such bleeding has started, requires immediate confirmation of the diagnosis followed by emergency treatment.
While on rare occasions, an extrauterine (ectopic) can proceed well into pregnancy, it almost always happens prior to the 8th week. There is an increase in the incidence of ectopic pregnancy after IVF conceptions where it reportedly occurs in about 3% of cases and a woman who has had one ectopic pregnancy has almost four times as great a risk of an ectopic in a future pregnancy. In fact with every subsequent ectopic this risk of a recurrence increases dramatically.

The fertilization of the human egg normally takes place in the fallopian tube. The embryo then travels into the uterus, where it implants into the endometrial lining 5-6 days after ovulation. Anything that delays the passage of the embryo down the fallopian tube can result in the embryo hatching and sending its “root system” into the wall of the fallopian tube and initiating growth within the tube. One of the most common predisposing factors is pelvic inflammatory disease (PID) in which microorganisms, such as Chlamydia, and Gonococcus damage the inner lining (endosalpinx) and eventually also the muscular walls of the tube(s) by the formation of scar tissue. The endosalpinx has a very complex and delicate internal architecture, with small hairs and secretions that help to propel the embryo toward the uterine cavity. Once damaged, this lining can never regenerate. This is one of the reasons why women who manage to conceive following surgery to unblock fallopian tubes damaged by PID, have about a 1:4 chance of a subsequent pregnancy developing within the fallopian tube (ectopic).

Congenital malformations of the fallopian tube, associated with shortening of, or small pockets and side channels within, the tube are capable of interrupting the smooth passage of the embryo down the fallopian tube, is another cause of an ectopic pregnancy.

Since the lining of the fallopian tube does not represent an optimal site for healthy implantation, a large percentage of pregnancies that gain early attachment to its inner lining will usually be absorbed before the woman even knows that she is pregnant. This is often referred to as a tubal abortion.

The advent of advanced sonographic and hormonal monitoring technology now makes it possible to detect an ectopic pregnancy much earlier than previously, …usually well in advance of it rupturing. A decade or two ago, the diagnosis of an ectopic pregnancy, ruptured or not, was an indication for immediate laparotomy to avoid the risk of catastrophic hemorrhagic shock. This often resulted in the affected fallopian tube having to be completely removed, sometimes along with the adjacent ovary. In the late 1980’s, early conservative surgical intervention by laparoscopy began replacing laparotomy (a wide incision made in the abdominal wall) for the treatment of ectopic pregnancy, often allowing the affected fallopian tube to be preserved and shortening the period of post-surgical convalescence. In the 90’s, early detection combined with the advent of medical management with methotrexate (MTX) has all but eliminated the need for surgical intervention in the majority of patients. If administered early enough, MTX will allow spontaneous resorbtion of the pregnancy and a dramatic reduction in the incidence of catastrophic bleeding. This was especially true in ectopic pregnancies arising from In Vitro Fertilization, where the early progress of pregnancy is usually carefully monitored with hormone levels and ultrasound.

Classically women with an ectopic pregnancy present with the following symptoms:

• Missed menstrual period: Although some patients will have spotting or other abnormal bleeding. The pregnancy test will be positive in such cases.

• Vaginal bleeding. When a pregnancy inadvertently implants in the fallopian tube the lining of the uterus undergoes profound hormonal changes associated with pregnancy (primarily associated with the hormone progesterone). When the embryo dies, the lining of the uterus separates. Initially, vaginal bleeding is dark and usually is quite scanty, even less than with a normal menstrual period. In some cases, of ectopic pregnancy will bleeding is more severe, similar to that experienced in association with a miscarriage. This sometimes leads to an ectopic pregnancy initially being misdiagnosed as a miscarriage and is the reason to examine the material that is passed vaginally, for evidence of products of conception.

• Pain. In the early stages this is typically cramp-like in nature, located on one or another side of the lower abdomen. It is caused by spasm of the muscular wall of the fallopian tube(s). When a tubal pregnancy ruptures the woman will usually experience an abrupt onset of severe abdominal followed by light headedness, coldness and clamminess and will often collapse due to shock. Her pulse will become rapid and thready and her blood pressure will drop. Miscarriage. Sometimes the woman will experience pain in the right shoulder. The reason for this is that that blood which tracts along the side of the abdominal cavity finds its way to the area immediately below the diaphragm, above the liver (on the patient’s right side), irritates the endings of the phrenic nerve, which supplies that part of the diaphragm. This results in the referral of the pain to the neck and the right shoulder. The clinical picture is often so typical that making the diagnosis usually presents no difficulty at all. However, with less typical presentations the most important conditions to differentiate from an ectopic pregnancy are: a ruptured ovarian cyst, appendicitis, acute pelvic inflammatory disease (PID), or an inevitable

• Vaginal bleeding. When a pregnancy inadvertently implants in the fallopian tube the lining of the uterus undergoes profound hormonal changes associated with pregnancy (primarily associated with the hormone progesterone). When the embryo dies, the lining of the uterus separates. Initially, vaginal bleeding is dark and usually is quite scanty, even less than with a normal menstrual period. In some cases, of ectopic pregnancy will bleeding is more severe, similar to that experienced in association with a miscarriage. This sometimes leads to ectopic pregnancy initially being misdiagnosis as a miscarriage and is the reason that we often want to examine the material that is passed vaginally, for evidence of products of conception.

The easiest and most common method of diagnosing an ectopic pregnancy is by tracking the rate of rise in the blood levels of hCG. With a normal intrauterine pregnancy, these usually double every two days throughout the first few weeks. While a slow rate of increase in blood hCG usually suggests an impending miscarriage, it might also point to an ectopic pregnancy. Thus the hCG blood levels should be followed serially until a clear pattern emerges.

A vaginal ultrasound examination usually will clinch the diagnosis by showing the ectopic pregnancy within a fallopian tube and if the tube has already ruptured or internal bleeding has occurred, ultrasound examination will inevitably detect the presence of free fluid into the abdominal cavity.

If there has been a significant amount of intra-abdominal bleeding, irritation of the peritoneal membrane will cause the abdominal wall to become hard tense and, depending on the amount of internal bleeding abdominal distention will be evident. Palpation of the abdominal wall will evoke significant pain and when a vaginal examination is done, movement of the cervix will produce excruciating pain, especially on the side of the affected fallopian tube.

Surgical Treatment: In questionable situations laparoscopy is usually performed for diagnostic purposes. If an ectopic pregnancy is in fact detected, a small longitudinal incision over the tubal pregnancy will allow its removal, without necessitating removal of the tube. (linear salpingectomy). Bleeding points on the fallopian tube can usually be accessed directly and appropriately ligated (tied) via the laparoscope. Sometimes the damage to the fallopian tube has been so extensive that the entire tube will require removal.

On occasions where very severe intra-abdominal bleeding heralds a potential catastrophe, a laparotomy (an incision made to open the abdominal cavity) is performed to stop the bleeding post haste. In such cases a blood transfusion is usually required and may be life saving.

Medical Treatment: The introduction of Methotrexate (MTX) therapy for the treatment of ectopic pregnancy has profoundly reduced the need for surgery in most patients. MTX is a chemotherapeutic that kills rapidly dividing cells, such as those present in the “root system” of the conceptus. Extremely low doses of MTX are used to treat ectopic pregnancy. Accordingly the side effects that are often associated with such chemotherapy used for the treatment of other conditions are seldom seen. It is important to confirm that the ectopic pregnancy has not yet ruptured prior to administering MTX.

MTX is given by intramuscular injection. Prior to its administration, blood is drawn to get a baseline blood hCG level. After the injection of MTX the patient is allowed to return home with strict instructions that she should always have someone with her and never be alone in the ensuing week. The concern is that were the patient to be on her own and an intraabdominal bleed were to occur, she might not readily be able to access someone who could get her to the hospital immediately. Instructions are also given to look for early signs that might point towards severe intra-abdominal bleeding such as the sudden onset of severe pain, light-headedness or fainting.

The patient returns to the doctor’s office four days later to check the blood hCG level. Three days later (7 days after MTX), the level is checked again. By this time the hCG level should have dropped at least 15% from the value on day 4. If not, a second MTX injection is given and the blood levels are tested twice weekly until hCG level is undetectable. Once this occurs, vaginal bleeding will usually ensue within a week or two.

It is important to note, especially in cases where more than one embryo or blastocyst has been transferred to the uterine cavity or fallopian tube (as with Tubal embryo transfer –TET/ZIFT), that implantation may occur in two sites simultaneously (i.e. in the fallopian tube as well as inside the uterine cavity). This is referred to as a heterotopic pregnancy. It is therefore important that before administering MTX, which will cause the death and absorption of any early pregnancy, that the physician makes certain that he/she is not dealing with a heterotopic pregnancy. In such cases, surgery is required to treat the tubal ectopic, while every precaution is taken to protect the pregnancy growing within the uterine cavity.

When an ectopic pregnancy occurs following infertility treatment, there is the added advantage that the physician will be on the lookout for the earliest possible signs of trouble. The performance of a vaginal ultrasound within two weeks of a positive blood pregnancy (HCG) test following IVF allows for early detection of the unruptured pregnancy and timely intervention with MTX and/or laparoscopy.

Geoff Sher

Kimberly Bunch

It has been a roller-coaster of emotions the past 2.5 weeks.
I should be 5 weeks and 4 days today going by when I ovulated using strips to track.
At 10 dpo my hcg was 8 and 12 dpo it was 32. 18 dpo my hcg was still 32. 6 days later (yesterday) my hcg was 114.
It was originally believed I was having a chemical then my levels had risen some so maybe ectopic instead. I had an ultrasound done yeterday and there wasn’t even a gestational sac. Now I have to wait for another bloodtest which isn’t until Monday. I don’t think my OB is completely sure what is even going on. Praying for a miracle and my levels will drastically jump.

Dr. Geoffrey Sher

Unfortunately the rise is very slow. Obviously one of the things your RE needs to be on the look out for is an ectopic.

Good luck!

Geoff Sher

Kathleen

Hcg levels drawn at approx 5-6 weeks
2/11 Hcg 2200
2/13 Hcg 1985
2/14 Hcg 2400 Ultrasound no heartbeat
2/17 Hcg 2424
2/18 ultrasound has heartbeat at 100 bpm size 5 weeks 6 days

The ultrasound on 2/18 was considered “normal “. The Hcg is not normal

The conflicting lab values and Positive ultrasound are not adding up.
What do you think?

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Dr. Geoffrey Sher

I agree…it is pretty Strange! I suggest a repeat US in 1 week!

Good luck!

Geoff Sher

Kay

Doctor,
My LMP was on 03/29/2020 and I went to get my beta testing done because I just wanted peace of mind. I am approx. 5w and the hCG level was only at 59. Should I be concerned?

Dr. Geoffrey Sher

That is on the low side. However, repeat the test in 2 days to see whether it doubles!

Good luck!

Geoff Sher

Britt

My doctor said HCG was 32 at 3w 5d and the lab result said 1469 as a result…how do I interpret these two numbers being the same??

Dr. Geoffrey Sher

Perhaps it is a multiple pregnancy. But, if truth be known, a definitive opinion will require an ultrasound examination at 6-7 weeks gestation.

Good luck!

Geoff Sher

Alexa Schimmel

Good afternoon,

My first HCG 6/8-17
Second, 6/10-28
Third, 6/12-28
4th, 6/15-71

Is there a good reason why it would plateau on friday and then increase?

I would be 4 weeks and 2 days.

Could this be promising? Or could it be ectopic/chemical pregnancy.

Thank you!

Dr. Geoffrey Sher

This does not look promising to me. However, I suggest an ultrasound at 7 weeks to determine whether the pregnancy is viable.

Good luck!

Geoff Sher

Sheena

Hello!
I had IVF on June 9, 2020.
Here are my beta results

June 19- 384
June 22- 1059
June 24- 2526
July 2- 26675

Do these numbers look good for a viable pregnancy? Do you think I am lightly going to see a heart beat on July 10 with these hcg readings?

Thanks for taking the time to read and respond.

Dr. Geoffrey Sher

I think it looks very promising for you!

Good luck!

Geoff Sher

Dr. Geoffrey Sher

I think it looks very promising for you!

Good luck!

Geoff Sher

Chrissie

Good afternoon!

First 7/6 9,673
Second 7/13: 10,965

I have an appointment today for check.

Do these numbers look promising?

Dr. Geoffrey Sher

You need an US Chrissie. That would be definitive.

Geoff Sher

Amanda S

I have a history of mc. This cycle was manipulated with letrozole and trigger shot plus prog supplements.
Hcg was on the low side but doubling in the first 2 weeks so dr stopped doing quant hcg with the last one being drawn on 8/6 measuring 421-4w6d. I had first us when I was suppose to be 5w5d there was a gs measuring 4.5mm nurse said And I was measuring 4w5d. Repeat ultrasound 8 days later showed .62cm and that I was 5w1d when I should have been 6w6d on 8/20 They did a stat hcg and that came back at 4906. 5 days later 8/25 hcg went back up to 10388. Could this still be a viable pregnancy?

Dr. Geoffrey Sher

It is too early to rely on these measurements. I would take a break until 7 weeks and do an US then for a more definitive answer.

Geoff Sher

Shayna

Hi Dr. Scher,
I’m a bit worried! Had a euploid transferred on 9/17. Beta on 9/25 showed hcg was 72. Today, 9/27, hcg was 136. They’ve asked me to go back in two days to check again. I have no history of miscarriages and I gave birth to my first son naturally (I have secondary infertility, if that info helps!). Does this seem concerning to you? Levels ALMOST doubled after 48 hrs but not quite, so I’m nervous!! Any insight would be amazing. Thank you!!

Dr. Geoffrey Sher

I think it is still withing the bounds of normality!

Good luck!

Geoff Sher

Manisha

Hello Dr.

I got blood test done on 17th August and got a positive pregnancy with 1500 hcg levels. After 2 weeks, 1st September I got an ultrasound done with gestational and yolk sac visible. So based on the sac size 14mm the pathologist told it could be 5weeks 4 days but dr. Is suspicious that we should see fetal pole as it could be 8 weeks pregnancy . I have irregular cycle , so we did another hcg next day of the ultra sound and it came to 13000 level , do u think that it could be a viable pregnancy .

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Dr. Geoffrey Sher

I do think so! Have an US in a week from now. That should be definitive.

Good luck!

Geoff Sher

Caitlin

Had a miscarriage on 9/13 and took a pregnancy test on 10/2 with negative result. Had 2 positive tests on 10/14. Had beta done on 10/15 at 65 and then 10/17 at 155. Does this sound promising? No period between. How would I date this?

Rob Z

Wife’s first test

#1: 9/10 HCG of 19
#2: 9/15 HCG of 226

Blood test tomorrow to see levels but she would be 4.5 weeks today. Does this seem normal? We’ve lost a couple priors at this time and are hoping for some good news

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CarolAnn

How do these numbers look?
1st HCG 22 then another draw 48hrs laters was 51. Another draw 4 days later it was 119. Does this trend look bad?

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Dr. Geoffrey Sher

This is a slow rise. You need serial hCG measurements and ultimately an US at 6-7 weeks to give a reliable result!

Good luck!

Geoff Sher

Madison

Hi Dr. Sher,

Just thought I’d throw my numbers out there and see what you think. Based on OPK I ovulated 8/22 and this is my trend. I have had 2 miscarriages in the past so I’m no stranger to serial HCG trends and I feel this has been the weakest yet.

10/2 HCG 23 prog 20
10/5 HCG 43 prog 12.7, at this point my OB started me on prometrium 100mg
10/7 HCG 66.7 prog 11.7
10/9 HCG 138 prog 15.3
10/12 HCG 257 prog 10
They just increased my dose to 200mg. I don’t feel like this will end in a viable pregnancy but all opinions are appreciated!

They won’t schedule an US until levels are 1500 or greater, I already asked.

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Dr. Geoffrey Sher

Sadly, It looks as if you could be losing this pregnancy!

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

______________________________________________________
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

Lara

Hi Dr. I have a history of infertility. After 6 years we started with IUI and fell pregnant immediately. We had a early loss. We did 4 other IUI’s and each of them we fell pregnant. 2 ended in early loss and 2 in ectopics , leaving me without tubes. We went over to IVF and the first one was unsuccessful with no embryos to freeze. The second has been successful. We transferred 2 embabies and have 3 in the freezer now.

This pregnancy my hcg was

6dp5dt- 54
8dp5dt- 245
12dp5dt -837 (is should have been 960) doubling time 54 hrs.
14dp5dt- 1412 ( It should have neem 1654 ) doubling time 62 hrs.

Should I be concerned that its not exactly doubling?

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Dr. Geoffrey Sher

Hopefully it will be OK. However, an US at 6-7 weeks will be definitive.

Good luck!

Geoff Sher

Lara

Thank you doctor. I have an ultrasound at 6weeks and 3 days on the 2nd of November. I am praying all is ok and will update.

Kanchan

I had my IUI done on 9 September and took a trigger shot on 7th.
Took my first test on 23rd and tested a BFP. Have been having normal light brown spotting since then. Did a scan on 5 October and saw an empty gestational sac measuring 1.27cm. The doc asked me to come back after 10 days for another US.
The following day I had some bright red bleeding with clots and a tissue like thing. Not too much bleeding though.
It stopped after a while.
Tested my beta HCG on the same day (6 oct)to make sure what’s wrong and it came up to 23000.
Then again tested on 8 oct it was 34000. Again had some bright red bleeding 2 days ago and on 10th my reading was 48000.
My doctor has asked me to rest and come back next week.
If I had miscarried why would my Hcg levels keep rising? Is it some other problem or am I just being paranoid. I am currently 6 weeks and 5 days according to my LMP.

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Dr. Geoffrey Sher

I think your 1st US examination might have been done too soon. You need another US on Monday. By thenw you should be able to get a definitive answer.

Geoff Sher

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Fiona

Hello Dr. Sher this is my 3rd pregnancy. My Hcg is rising normaly i had an ultrasound when i was just 7 weeks my beta was then 15562and the tech told me she can only see the gestational sac i did repeat my Hcg after a week and it went up to 40500 what are my chances of an anembryonic pregnancy?

Dr. Geoffrey Sher

At 7 weeks and US should virtually always identify a, viable pregnancy. Unfortunately therefore I must conclude that it does not look good.

So sorry!

Geoff Sher

Shana

Very concerned. No one can give me answers. Unknown LMP.
First hcg: 3/20 -90
Repeat : 3/23 – 358
Repeat: 4/3 – 4703
Ultrasound 4/3- only showed gestational sac.
Repeat blood- 4/6-6974
Ultrasound 4/8- show yolk sac, no fetal pole.
Repeat blood 4/8- 9749
Repeat ultrasound today 4/15- showed yolk sac with fetal pole measuring 5.6 weeks- no heartbeat though.
Repeat stat labs today- 18193

Dr is preparing me for miscarriage but is confused herself as to the slow fetal growth. So assumed we would hear a heartbeat today. Going for repeat ultrasound in a week. Should I be worried? Never been more stressed out in my life.
Thanks

Dr. Geoffrey Sher

Based on the dates you provide, you are already at 7 weeks and at this stage there should be clear evidence of a viable conceptus.

This does not look promising, I am afraid!

Sorry!

Geoff Sher

Louise

Hi my l had a positive test 2nd of August. I had brown spotting on the 14th of August. Went to my doctor to get HCG levels on the 17th and they came back as 6730. Repeated the bloods on the 19th and they decreased to 5473.

Would this be a sign for a definite miscarriage?

Thanks for your time.

Christy

Hi,

I have a 31 day cycle. My last period was July 18. I ovulated the week of Aug 4. I took a bunch of pregnancy tests which all were positive. I went to my doctor and their test I only had a faint line. My doctor said this is normal due to their tests not being sensitive. He sent me for bloodwork and my beta was 220. My doctor says that is low and wants me to go for more bloodwork. If I conceived the week of Aug 4 I would only really be 3 weeks pregnant. Does this seem normal or do I have a reason to be scared?

Dr. Geoffrey Sher

No! You are about 5 weeks. You measure duration from the last period…not from ovulation. You should do an US in 10-14 vdays for a definitive answer.

Geoff Sher

Sib

Dear Dr.Sher,

I am approximately 4+2 today based on LMP (although I have short cycles of 25dats on average, I may be a few more days past this)…my first hCG test today shows as 982, but most of my early pregnancy symptoms have gone, except my headaches which worries me.
Is 982 for around my gestation ok, too low or too high ?

reply
Dr. Geoffrey Sher

Repeat the hCG test in 2 days. If it doubles you could be OK.

Good luck!

Geoff Sher

Sib

Dear Dr.Sher,

After my 1st HCG on 18th Feb coming in at 982, I had it tested again 4 days later (22nd Feb) it was 5245, it appears to be increasing at the “doubling rate”. But still I only have minor symptoms on and off… Should I be worried or would you say this number is ok?

Dr. Geoffrey Sher

It looks good to me. Remember, symptoms of pregnancy can be subjective.

Geoff Sher

Jessica

My levels jumped from 1080-3600 in 24-48hrs what’s this mean and roughly how far does this make me in weeks I’m so sick

Dr. Geoffrey Sher

That is not possible to determine reliably without accurate date for last period or an ultrasound assessment!

Geoff Sher

Ariane

Hello,

My last menstrual cycle began on April 30th. I got a positive pregnancy test 5 days ago and the tests have since gotten darker. I am not yet 5 weeks. I had my HCG tested yesterday and it was 104. My period was technically not due until today. My doctor said this is normal and is testing again tomorrow. This is my second pregnancy and I have never experienced a miscarriage. I am almost 25. Do you think the low HCG is a reason for concern?

Dr. Geoffrey Sher

It could be! Only time will tell!

Good luck!

Geoff Sher

Kaitlyn Calvert

My first beta was done at 9dp5dt – 87. Second was 11dp5dt-209 and third 13dp5d-299

Dr. Geoffrey Sher

I am concerned at the slow 3rd rise. Repeat again in 2 days!

Good luck!

Geoff Sher

Brenda

Hi Dr My LMP was July 14 took 3 home test all 3 have one dark line the second is Very light. My HCG today is at 358 I repeat in 2 days but I’m bleeding as if I was on my period with moderate cramps. I’m 1 week late from my period I’m really scared.

Dr. Geoffrey Sher

Hi Brenda,

Have another hCG test done in 2 days and then you will know what is going on. The level should double!

Thinking of you!

G-d bless!

Geoff Sher

Manisha

Hello Dr,

I got another HCG levels tested after 3 days and from 13000, it increase to 16000, we will have another US on Saturday, it didnt double though, but could it be still viable pregnancy.

Rania

Hi Dr Sher,

Please help me understand if my pregnancy could turn out normal.

I have done first hcg at 5w2d and it was 8743
Then after 48 hrs it is 10578 then i did third one after another 48 hrs 12277

I had also ultrasound at 5 w 2 d and they saw the sac and looked normal but the no. Doesnt look promising as it is slow rise. What are my chances that this could work well?

Dr. Geoffrey Sher

I would not worry. The hCG rise, slows down some time after it passes 5,000.

Good luck!

Geoff Sher

Trista Eicher

I think I’m about 5 weeks my hcg level is 800 is this a normal level for a viable pregnancy?

Dr. Geoffrey Sher

It could be! You need to repeat the hCG . It should double every 2 days!

Geoff Sher

Amanda Marshall

My blood hcg was 2400 at 4weeks 3 days, this seems very high based off the range for hcg… should I be worried… is this a indicator that I could be carrying multiples?

reply
Alynn

Hi, for 3 days I have had light bleeding with mild cramps. I am 5w4d today and yesterday I had a hcg level of 149. Am I miscarrying? Thank you

Dr. Geoffrey Sher

You should repeat the hCG test in 2 days. It should double!

That will at least give you a better idea!

Good luck!

Geoff Sher

Amanda Marquis

Is it normal for my beta hcg to quadruple in 72 hours. First draw was at 4 weeks 3 days and it was 568 and second was 72 hours later and was 2302. Could it be twins?

reply
Dr. Geoffrey Sher

Yes! But it could be a multiple pregnancy!

Good luck!

Geoff Sher

Hannah brown

Dear Dr Sheriv,

Sorry I posted this before but now I can’t find the post so sorry if I have duplicated.

My first HCG at 9dpo was 39, at 11 dpo was 104 (progesterone 71), 13dpo 186z

So my doubling time has gone from 35 to 55 hours. Is this bad news?

Thanks
Hannah

reply
Dr. Geoffrey Sher

Unfortunately, only time will tell. Repeat the hCG test in 2n days and do an US at 6-7 weeks.

Good luck Hannah!

Geoff Sher

Destiny

Dear Doctor, my hcg is rising like this:
14 dpo – 8 hcg
18 dpo – 32 hcg
21 dpo – 114 hcg
25 dpo – 395 hcg

I was on a femara/Novarel/progesterone cycle with a fertility specialist so my chances of the dates being off aren’t likely. Does this look promising or am I gearing up for my fifth loss? My RE only tells me to be cautious because of my low hcg but refuses to see me until a full week after my levels hit 1500.

– Worried Mom

Dr. Geoffrey Sher

I concur with your RE’s position. However, , to me it looks GUARDEDLY promising!

Geoff Sher

Hannah Brown

Thank you so much for your advice. I really appreciate it.

Christine

Hello!! Very concerned!! I went in Monday 9/14 8lmp hcg level was 151 progesterone 26 two days later hcg level was 236 progesterone 17. My dr put me on progesterone orally nightly. How is this looking?

Dr. Geoffrey Sher

Hard to say. It could still be OK. I am not worried about the progesterone level.

All repeat the hCG test in 2 days to see if it doubles.

Good luck!

Geoff Sher

Carla

Hello ,

I am not sure how far along i am but on sep. 1 my HCG was 360 i took it again on the 14th and it was 2,000. Just want to know your opinion on this ?

reply
Dr. Geoffrey Sher

You will need an ultrasound done in 7-10 days to get the answer you seek!

Geoff Sher

Mariina

Dear Doc. I’m worried about another possibility of miscarriage my hcg today was 48,366 but they didn’t tell me how many weeks I am because I went to ER for cold they said wait for my first appointment in 3 weeks.. I am really impatient. Anyway based on my hcg you can tell me about how many weeks I am? Thanks im advance!

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MEL Sue

Dr. Sher, I have had slow, but seemingly “normal” HCG increases.
11 DPO 60 HCG
13 DPO 66 (was told to prepare for another chemical)
17 DPO 233
19 DPO 376
21 DPO 581
24 DPO 1219

Most of these levels are within the “normal” frame, but I’m scared it’s either an ectopic or will end in miscarriage. Do you have any thoughts on these betas? I am going in on Friday for an US. One doc said it looked promising and then I was called my another and said he’s not convinced it’s viable.

Dr. Geoffrey Sher

While the levels are steadily rising there is a basis for guarded optimism. However, the increase is slowish and it is impossible tomrule out an ectopic or a threatened miscarriage based on these numbers.

I suggest an ultrasound be done in a week or so to evaluate for an intrauterine gestation.

Good luck!

Geoff Sher

Emily Ekstrand

Dr Sher, I am 5 weeks 5 days, my first HCG level was 1900 and then 3500 two days later. My doc is having me come in for another HCG in 3 days time. How prepared for the worst do I need to be?

Dr. Geoffrey Sher

I am not really concerned . I think this response is quite adequate.

Geoff Sher

Becca

I am aprox 4-5 weeks

1st hcg 870
2nd hcg 2705
48hrs apart

Does this rise look too much? Or normal.

Dr. Geoffrey Sher

Looks very promising!

Good luck!

Geoff Sher

Concerned

Hi Doctor,

I am fairly certain I am almost 6 weeks due to my long cycles (35 days average with PCOS). Lmp was May 21st so obgyn believes about 7 weeks. I had spotting light pink or brownish for 3 days then had a gush of bright blood and spotted bright red for a few days Now it’s mostly dark pink or red spotting. I had hcg taken today and it was 48000. I repeat in 2 days time. I have had no intense pain or anything but the spotting coupled with high hcg level has me scared of molar. Do you see any high level hcg with bleeding that isn’t molar?

Dr. Geoffrey Sher

I doubt this is a molar pregnancy:

The older a woman becomes, the more likely it is that her eggs will be chromosomally/genetically “incompetent” (not have the potential upon being fertilized and transferred, to result in a viable pregnancy). That is why, the likelihood of failure to conceive, miscarrying and of giving birth to a chromosomally defective child (e.g. with Down Syndrome) increases with the woman’s advancing age. In addition, as women age beyond 35Y there is commonly a progressive diminution in the number of eggs left in the ovaries, i.e. diminished ovarian reserve (DOR). So it is that older women as well as those who (regardless of age) have DOR have a reduced potential for IVF success. Much of this is due to the fact that such women tend to have increased production of LH biological activity which can result in excessive LH-induced ovarian male hormone (predominantly testosterone) production which in turn can have a deleterious effect on egg/embryo “competency”.
While it is presently not possible by any means, to reverse the age-related effect on the woman’s “biological clock, certain ovarian stimulation regimes, by promoting excessive LH production (e.g. short agonist/Lupron- “flare” protocols, clomiphene and Letrozole), can make matters worse. Similarly, the amount/dosage of certain fertility drugs that contain LH/hCG (e.g. Menopur) can have a negative effect on the development of the eggs of older women and those who have DOR and should be limited.
I try to avoid using such protocols/regimes (especially) in older women and those with DOR, favoring instead the use of the agonist/antagonist conversion protocol (A/ACP), a modified, long pituitary down-regulation regime, augmented by adding supplementary human growth hormone (HGH). I further recommend that such women be offered access to embryo banking of PGS (next generation gene sequencing/NGS)-selected normal blastocysts, the subsequent selective transfer of which by allowing them to capitalize on whatever residual ovarian reserve and egg quality might still exist and thereby “make hay while the sun still shines” could significantly enhance the opportunity to achieve a viable pregnancy

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

• Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
• IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
• 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
• Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
• The “Biological Clock” and how it should Influence the Selection and Design of Ovarian Stimulation Protocols for IVF.
• A Rational Basis for selecting Controlled Ovarian Stimulation (COS) protocols in women with Diminished Ovarian Reserve (DOR)
• Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
• Controlled Ovarian Stimulation (COS) in Older women and Women who have Diminished Ovarian Reserve (DOR): A Rational Basis for Selecting a Stimulation Protocol
• Human Growth Hormone Administration in IVF: Does it Enhances Egg/Embryo Quality and Outcome?
• The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
• Blastocyst Embryo Transfers Should be the Standard of Care in IVF
• 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.
• Staggered IVF: An Excellent Option When. Advancing Age and Diminished Ovarian Reserve (DOR) Reduces IVF Success Rate
• Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation.
• Preimplantation Genetic Testing (PGS) in IVF: It Should be Used Selectively and NOT be Routine.
• Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
• PGS in IVF: Are Some Chromosomally Abnormal Embryos Capable of Resulting in Normal Babies and Being Wrongly Discarded?
• PGS and Assessment of Egg/Embryo “competency”: How Method, Timing and Methodology Could Affect Reliability
• 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
• Premature Luteinization (“the premature LH surge): Why it happens and how it can be prevented.
• IVF Egg Donation: A Comprehensive Overview

______________________________________________________
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.

Good luck!

Geoff Sher

Kay

July 13 HCG 105
July 18 HCG 795
July 30 HCG 5000

Light brown spotting yesterday, Transvaginal ultrasound showed gestational sac but could not find fetal pole or yolk sac .. after exam small amount of pink blood
Generational sac measuring at 5 weeks 4 days

Does this seem viable

Dr. Geoffrey Sher

I think you will be fine!

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

Amber Burnett

Dr Sher,
According to my LMP I should be around 4-5 weeks… my hCg level was 44.7 for the first one. Having it checked again tomorrow. No major cramping, but nothing was detected on the ultrasound. It has me worrying. Any experience with lowered hCg levels and viable pregnancies?

reply
Dr. Geoffrey Sher

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:
o 3 weeks LMP: 5 – 50 mIU/ml
o 4 weeks LMP: 5 – 426 mIU/ml
o 5 weeks LMP: 18 – 7,340 mIU/ml
o 6 weeks LMP: 1,080 – 56,500 mIU/ml
o 7 – 8 weeks LMP: 7, 650 – 229,000 mIU/ml
o 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:
o A recovering implantation, destined to develop into a clinical gestation
o A failing implantation (a chemical pregnancy)
o A multiple pregnancy which is spontaneously reducing (i.e., one or more of the concepti is being lost) or,
o 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.

Geoff Sher

Kelcie

Hey there! I had my first HCG test on 3/28- 65
I had another one done 4/1- 190.
According to my LMP I should be about 4 weeks 6 days. Does this seem right to you?

Dr. Geoffrey Sher

This sounds about right!

Good luck!

Geoff Sher

Rachel Acton

I had hcg test it came back at 173 I was 5 weeks 2 days . But I think I ovulated on 18 day of my cycle. Is this a bad number I also had a us and the dr said the sac was small

Dr. Geoffrey Sher

5 weeks is too early to interpret an US. Repeat in 10 days.

Good luck!

Geoff Sher

Ramya Aruri

Hello Sher,
I went for IVF and 2 embryos transferred on May 18th ..1st beta June 2 – 1555 & 2nd beta June 6- 3557 & 3rd beta June 15- 14465..But in Ultrasound it shows only empty gestational sac with mean sac diameter of 13.33mm and still no viability..
As per my LMP I am 6w4 days

Could you pls tell me is my pregnancy will be continuing…

Dr. Geoffrey Sher

This does not look good, I am so sorry!

Geoff Sher

Nikkole Balsewicz

First time I tested hcg. It was 360. Then tested 2 days later and went to 570. Tested a week later and it went to 550. Tested a week later to make sure it was going down since they suggested I was miscarrying and it jumped up to the 1000s. Any explanation? Thank you

Dr. Geoffrey Sher

I suggest an ultrasound at 6-7 weeks.

Geoff Sher

Dr. Geoffrey Sher

Yes! However, an US one at the 7th week will be definitive.

Good luck and please be safe!

Geoff Sher

Regie Gardener

I started spotting today. According to my last period is should be 5+6. Hcg measuring 351 US shows nothing but thickening of lining. Scheduled for second blood test Monday. I know that one measurement can not be read clearly, but should I be concerned as am also spotting? Thanks so much

Dr. Geoffrey Sher

I fear that this might not be a viable implantation. Your next hCG test done 2 days after the last should give a better indication. US at this stage might be too early to be definitive. I would repeat it in a week from now. Also please be aware that if you have any sudden pain and bleeding to go straight to the ER to rule out an ectopic pregnancy.

Good luck!

Geoff Sher

702-533-2691

Esther

Am very encouraged by this page . I’ve been tested for HCG rise in the last five days Day 1-3 weeks 6d. 2,000 (nothing on u/s Except corpus
luteum) 2nd- 4 weeks 1 day 4,000 3rd -4 weeks 3 days 9,000 U/S showed gestational sac only. Should I be worried? Next U/S scheduled for 5 weeks 6 days .

Dr. Geoffrey Sher

It is too early for a reliable US interpretation. I would wait until the 7th week!

I am guardedly optimistic!

Good Luck!

Geoff Sher

.

Charde Betton

Hello .. My hcg Numbers are 7/2/2020: 244
7/6/2020: 1377
7/8/2020: 1903
7/10/2020: 2961
7/14/2020: 3342
My doctor said this doesn’t look like it’s going to be a good pregnancy. I go for my US this Friday ..
what do you think?

Dr. Geoffrey Sher

It does not look promising , I am afraid.

Hope I am wrong!

G-d bless!

Geoff Sher

Laura

Hi, I’m so confused looking for answers. The first day of my last period was may 15th. June 15th I got a positive test.june 17th hcg was 790. The 19th it was 1,951. Today June 29th hcg is 13,000 and no yolk sac on ultrasound. Could it be too early?

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Dr. Geoffrey Sher

In my opinion, it could be too early.

Geoff Sher

Anita

Hi,
I had FET (5d) on 1st Oct. 2020, 1st Beta 123.5 on 16th Oct. 2020 and 2nd Beta was 248.9 on 19th Oct. It doesnt sound good, Wright? Quite low Beta I think. I have US booked on 4th Nov. Thank you.

Dr. Geoffrey Sher

It is a little slow. Repeat in 2 days to see if it doubles.
Good luck!

Geoff Sher

Jaci

Hi I’m measuring at 5 weeks 4 days and yesterday my hcg levels were at 158 should I worry?

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Dr. Geoffrey Sher

That is a rather low hCG for 5w 4 days. I would repeat in 2 days in the hope that it has reached or exceeded 320U.

Good luck!

Geoff Sher

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Trisha

According to my LMP I am 5 weeks 2 days. My HCG level yesterday was 740. my OBGYN said she’s concerned about this low number. I don’t understand because that appears to be a reasonable number on the chart. I follow up for a repeat HCG tomorrow. Should I be concerned? I previously had a blighted ovum in December.

Dr. Geoffrey Sher

It al depends on whether the level doubles in 2 days. If it does, you could still be in good shape!

Geoff Sher

Lindsay

Tested at about 4 weeks 3 days with an HCG of 4078 and progesterone level 21. Should this high HCG number be concerning to me?

Regina

Hi, I am 5 weeks 4 days pregnant today. I have had spotting starting 5 days ago, I got my HCG levels taken the following day (237) and again 44 hours later (421) I had a PUL (treated as an ectopic) a couple of months ago. Should I be worried with these results?

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Dr. Geoffrey Sher

I personally am not that concerned by the numbers at this stage.

Good luck!

Geoff Sher

Tara

Hi Regina – do you have an update on your journey? I have an extremely similar number to yours (234 at 5 weeks 2 days) and have pending results for my repost beta. I also have had dark brown spotting for several days. No gestational sac was seen on US at the first visit (just over 5 weeks). Do you have any updates as to how your pregnancy is progressing? I’m hoping for good things for us both! But like you, I have been concerned. Thanks so much! Any info you have would be helpful

Tara

Also – do you happen to know what your progesterone level was/is? Mine was also low at 4.8, so they are expecting that I may have had a chemical pregnancy/very early miscarriage (and hopefully not an ectopic). I am of course hoping for better news. Thanks again.

Carla

My test results are the following:

96.1, 116.9, 116.9, 189.8, 326.2 – testing every 48 hours – not sure of LMP – hcg test again tomorrow to see if it’s rising appropriately – possible disappearing twin? What are your thoughts?

Dr. Geoffrey Sher

The rate of increase in hCG is not optimal. It should double every 48h at this early stage of pregnancy. Wait about 10-14 days and do an ultrasound for a definitive answer. Any sudden pain or bleeding would mandate you going straight to an ER to exclude an ectopic (tubal) pregnancy.

Geoff Sher

Amanda

Hello,
I went in to the Dr. Thursday and had a vaginal ultrasound and saw gestational sack, no yolk sack detected. The dr. said I was measuring 5 weeks 3 days. My HCG blood was 21,988. Went back on Saturday-48 hours later and my HCG was only 26,353. I am scheduled to go back in for an ultrasound in two days. The nurse said the dr is worried about ectopic. Any positive insights would be appreciated. Thank you!

Dr. Geoffrey Sher

If an intrauterine gestational sac was seen, then it is not an ectopic. It might be too early to see a conceptus with HB. Return in 19 days and do another US.

Good luck!

Geoff Sher

Mireya

Dr. Sher I am concerned with my hcg levels.
LMP- 04/30/2020

06/01- HCG 187 progesterone 18.4
06/03- HCG 261 progesterone 12
GOT PUT ON PROGESTERONE PILLS.
06/05- HCG 389 progesterone 33

I previously had a blighted ovum and miscarried on my own at 6 weeks. I am worried that this is what is happening again. I am going in for an ultrasound soon. What are you opinions based on my hcg levels?

Dr. Geoffrey Sher

Hi Mireya,

Yes! The hCG levels are rising slower than desired. Unfortunately, it is not possible to predict confidently how this will evolve. Unfortunately you will have to wait for an US at 6-7 weeks for a definitive answer.

Good luck!

Geoff Sher

Lizzy

Hi Dr Sher,
My hcg had been rising well but not now, could my pregnancy still be viable?
My results have been:
9 Sept- hcg 23 (3 wks 3 days)
11 Sept- hcg 68
14 Sept- hcg 210
16 Sept- hcg 500
18 Sept- hcg 1100
21 Sept – hcg 3800
24 Sept – hcg 8500
28 Sept – hcg 15000
01 Oct – hcg 16000 (6 wks 4 days)
Should I be worried? I’m booked in for an ultrasound in a few days when I’ll be 7 weeks 1 day. I’ve had no bleeding. Thank you Doctor

Dr. Geoffrey Sher

I am guardedly optimistic about this pregnancy. Have a confirmatory US ASAP.

Geoff Sher

Debbie Slater

Think I’m very early into pregnancy, had mild to heavy bleed for 2 days, now very light pink when I wipe, slight aching at bottom of my back, had vaginal examination and was told cervix closed, no blood clots can be seen but some blood visable. Had hcg checked and was 60 then a day later 75, I’ve had 4 miscarriages already.

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Dr. Geoffrey Sher

Repeat the hCG in 2 days. It should double. If not, there could be a problem and perhaps we should talk!

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

Mariela

Hi! I went to my OB yesterday for my first ultrasound. They thought I was at 7 weeks but only measured 6 weeks and no heartbeat yet. Initial hCG levels were 4000 about 2 weeks and today it’s at 26,000. I have to go back Monday for another ultrasound. Does everything seem ok? I am worried next week will be too early to see a heartbeat.

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Dr. Geoffrey Sher

I am not so much concerned at the 1 week difference between US measurement and dates, that sometimes happens. However, there should be a clear HB by now. I would get a 2nd opinion immediately.

Geoff Sher

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leticia sims

I did ivf. I thought hcg looked good now worried.

11dp5dt 171
14dp5dt 448
16dp5dt 994
18dp5dt 2243
22dp5dt 6697

Between last 2 i dont seen the doubling eveey 48hrs. Should i be concerned?

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Dr. Geoffrey Sher

Once the beta gets > 5,000, it will no longer double every 2 days! I would not be overly concerned. It looks promising to me!!

Be safe!!

Geoff Sher

Duha

Sorry I forgot to put this in my first post! I’m also a little worried about my progesterone. On the day I got a postive Sep 10th my progesterone was 79. Sep 14th it went down to 50, so then I was told to take progesterone 400mg twice daily. Sep 17th my progesterone went up to 86.4. Sep 21st went down to 81.4. Today, Sep 25th it went up to 82.1. Is my progesterone level normal at the moment and is it normal for progesterone to fluctuate?

Duha

Naty

Hi! My hcg were as follows
19 dpo – 3369
21 dpo – 7744
23dpo – 11289
26dpo – 16291
The last couple are not doubling just rising should I be worried? I have an ultrasound scheduled in two weeks. Thank you.

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Dr. Geoffrey Sher

Once the hCG goes above 6,000, the rate ofv increase slows down.

This is probably OK!

Good luck!

Geoff Sher

Naty

**Update – Had an ultrasound and baby was just fine!
Thank you again Dr for your answers.

Emma

Hi, I am 6 weeks 6 days and had transvaginal scan yesterday with no yolk sac or fetal pole. hCG levels are 9000 and my Dr says they aren’t rising as much as they should be – does this look like a non viable pregnancy. I also had a scan at 6 weeks and only saw gestational sac then. Thanks!

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Dr. Geoffrey Sher

It could be, but I would give it 1 more week and re-scan before taking action.

Geoff Sher

Caitlyn

Hi, I’m 11 days post 5 day embryo transfer and my HCG test came back at 19. Do I have any hope this won’t be a chemical pregnancy? My HPTs on day 9 and 11 appear to be the same darkness.

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Dr. Geoffrey Sher

It is on the low side. Repeat in 2 days to see if it doubles.

Geoff Sher

Aimee

Had my hcg levels taken:
24/06 – 3957
26/06 – 5506
I had a transvaginal ultrasound which sac measured 4 weeks and 2 days on 24/06. Doctors concerned of possible ectopic as they aren’t doubling, but my levels seem really high. Any advice?

Dr. Geoffrey Sher

If they saw a sac in the uterus it is not an ectopic. I recommend repeating the US in 2 weeks!

Geoff Sher

Katie

Hello! I’m very concerned about a molar pregnancy.
Yesterday 7/28 had blood draw results of hcg were: 49,376 (extremely high)
Dr. put me at 5 weeks 5 days based on date of last menstrual period.
On the scan she identified the fetal pole, but no heart beat. She said it was too early and that everything looked just as it should.
I read this could be indicative of a molar pregnancy. I am due to go back for another blood draw 7/30 and another us one week from tomorrow.
This is my first pregnancy and I’m extremely worried. The nurse said she was not concerned based on what they saw via us. Any thoughts?

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Dr. Geoffrey Sher

The detection of a fetal pole makes a molar pregnancy unlikely but does not completely rule out a partial molar pregnancy. Unfortunately only time will determine this.

I empathize with your concern, but all you can do is wait and see what transpires.

Geoff Sher

Kaitlynne Jagneaux

Ok so this is going to be a long post. So I got a positive test on 7/20. I had been bleeding so I went to er assuming MC they did beta and said it was only 16 and nothing on ultrasound and said I wasn’t pregnant. A week late I was still getting positive urine tests so I went to my ob they check and it had went up to 640. Well bleeding started again the next day and went to er. Had beta done (at a different lab that what I’ve been going to) and it showed it had dropped to 508. So went to ob a week later. They didn’t give me the beta because their machine was down but did an ultrasound and saw nothing so they said MC and told me to come back in three weeks. Well they called Monday and said beta jumped to 800 and wanted me to come in again. So I went back today and beta jumped to 3000. They couldn’t do an ultrasound today so they have me scheduled for Monday. Has anyone had this happen but still have a healthy pregnancy? Doctor says he’s optimistic but I’m still concerned.

Edit, I didn’t wait three weeks the day the hcg machine was down they still took my blood, the results just didn’t come back until later in the week. So the jump from 508 to 800 was only within 3 days

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Dr. Geoffrey Sher

I am concernedthat this might not be a healthy implantation in the uterus and even a possible ectopic. Repeat the US in a week and if you have any sudden onset of pain and/or bleeding , go to the ER stat.

Good luck!

Geoff sher

Megan D

Good Morning,

I started spotting brown approximately 1 week ago. It has ebbed and flowed, starting browns and going to red but it is pink now. Majority of the time it’s when i wipe and has only made it to a pad a few times.

7/9 -I had an US done and measured 5W4D (I thought I was 6w5d) a gestational sac was only seen. HGC that day was 5916. Progesterone was 8.4. Started progesterone cream 7/10. Seems to have slowed the bleeding to more pink and much lighter.
7-/10 – HCG repeat was 7995.

Does this sound promising or a likely miscarriage coming?

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Dr. Geoffrey Sher

It still sounds promising. After the hCG level reaches 5,000, it often does not risen as rapidly as before.

Good luck!

Geoff Sher

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Kathy

Hi Dr, my hcg is rising but not doubling. 127, 202, 300, 427. They saw a small gestational sac measuring over a week behind. Can this be viable at all?

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Dr. Geoffrey Sher

If these are measurements don at least 2 days apart, it does not bode well for a normal,viable pregnancy!

Sorry!

Geoff Sher

Kimberly Bunch

Hey Kathy just wondering if you had an update? I am in a similar situation, my HCG has risen very slowly. I have an US Friday to see if they see anything.

Sinéad

Hi Dr Sher
I had a FET on July 8th. I had blood taken two days ago on 22nd July; Beta hcg was 5.4. Is there any chance I could be pregnant? Should I have blood test repeated?
Thank you.

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Dr. Geoffrey Sher

Sadly…if the hCG level is due to an implantation, it probably is not a viable one. Repeat the hCG 2 days later to see!

G-d bless!

Geoff Sher

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Dr. Geoffrey Sher

Too early for US; You should wait another 2 weeks and do another US.

Good luck!

Geoff Sher

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Rits 123

Hi.
I have my last periods on 10th September. And yesterday i.e. 16th October I take urine test and it is positive. Then I take blood Hcg test, it’s count is 650.80, my doctor suggested to re test blood hcg tomorrow.

Is it confirm pregnancy or have some issues.
How much hcg count it should have as per my dates.
Can some one please suggest it.

Thanks

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Dr. Geoffrey Sher

A repeat test two days afte the 1st one and an US done in 10-14 days later should be definitive.

Good luck!

Geoff Sher

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Michelle

I’ve found out I’m pregnant. My beta hcg was 5400 on 6th 8500 on the 8th & 13400 on the 10th and then 25000 on the 15th. I had an ultrasound on the 10th and saw a sac and yolk. I’m worried my hcg isn’t rising enough. Can it still be a viable pregnancy?

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Dr. Geoffrey Sher

I’m am not unduly concerned with the slower rise here.

Geoff sher

Cindy

Hi I had my first hcg test which 14 next day did it was 20 I’m bleeding a little have a ultrasound and a blood test Monday I have bad feeling it’s not going to get any better am I right what could it be

Dr. Geoffrey Sher

No! many women have mild bleeding in early pregnancy…without consequence. You need to repeat the test in 2 days to see if the level doubles

Good luck!

Geoff sher

Stephanie Moore

I have had irregular periods and also 3 miscarriage i recently found out im pregnant no ideal how far along but had hcg levels of 59.9 than 7 days late 80.9 should i be worried for another miscarriage

Dr. Geoffrey Sher

This is not good Stephanie. It sure looks like this could be another disappointment.

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

______________________________________________________
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

Misty

I had a timed IUI with letrozole and Hcg shot. I got a positive pregnancy test before my period was due and the Hcg levels were doubling all the way until at least 5 weeks when I no longer had testing. The progesterone level on 200 mg promethium did drop from 37 to 29 then 26 and back to 28 before I stopped testing. I went in for my 6 week scan and Sac was measuring 5 weeks 4 days the tiny tiny little dot they measured that Looked like the static from the ultrasound machine supposedly measured 5 weeks 5 days. No heartbeat was found the tech said it was just too small. I live out of state from my fertility clinic so my on did the ultrasound. They have me doing more Hcg tests to see if it continues to double if not it’s considered a miscarriage. Any hope for this pregnancy?

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Dr. Geoffrey Sher

5w 4 days is too early. You need to repeat the US in a week from now.

Good luck!

Geoff Sher

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Laura

Dear Dr Sher,

I have Hashimoto’s thyroiditis and have been undergoing blood tests for pcos which my doctors are struggling to diagnose due to the hashimotos. However the start date of my lmp was August 22nd and I got a positive pregnancy test on sept 20th. I had some brown spotting last week so and had a scan on Friday where they saw a sac but no yolk or foetus. Hcg went from 9000 something to 13,000 something today and they have said they would expect it to be 18000. Does this sound like it is not developing? I am waiting to hear what they want to do next, I am praying that it will be successful, but at the minute I feel it will be bad news.
Many thanks, Laura

Dr. Geoffrey Sher

With an hCG that high, the viability of the pregnancy should be able to be clearly apparent!~

Good luck!

Geoff sher

Amber

Dear Dr. Sher
My LMP was 4/21/2020
Got a positive pregnancy test on 5/25/2020
Been experiencing some pinkinsh/brownish spotting with intermittent cramping. Went to the ER (my doctors office suggested so) my HCG level was 25000 but ultrasound shows gestational sac only. The doctor said they are unable to tell how far along I am, should I prepare myself for the worst? I had a miscarriage in January.

Dr. Geoffrey Sher

Only time will tell. Do an US in about 10 days for a definitive answer.

Good luck!

Geoff Sher

Gitta

Hi Dr Geoff,

I know my questions are similar to everyone else’s but of course I still have to ask. I found out September 13th that I was pregnant ( first pregnancy ) , I got ultrasound sept 23 and they saw yolk and sac and said I am measuring 4 weeks 3 days ( based on my last period date that seems off but I also had a very strange cycle before my recent cycle where I had my period almost 40 days. On sept 23 they said my HCG level was 4224 and progesterone 8.9, I went back again to check blood sept 28 and it was 5880 With 9.0 progesterone . I’ve had no cramps, no bleeding . Also my pregnancy symptoms were sever aches and some fatigue but now I don’t really have the aches anymore . Since my HCG didn’t double does this seem like a miscarriage based on the timing ? Also, if it turns out to be that way when does the process of the miscarriage typically begin . As you know from your experience with patients , just hoping for some thoughts based on the above. Thanks so much for your help.

Dr. Geoffrey Sher

Women usually menstruate 2 weeks following ovulation. So, if your cycle was 40 days, you probably ovulated on around the 26th day of your cycle. This could explain the discrepancy between your dates and the US findings. I do not think you should write off this pregnancy yet. Wait 2 weeks and get another US for final deliberation.

Good luck!

Geoff sher

Kailee

Hello
5/20-20
5/22-91
5/26-708
5/28-1296

Is this normal? I had an ectopic 3 years ago and am worried.

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Gitta

Thank you so much Dr Geoff, to add to the above comment, could it be possible to seem 4 weeks 3 days with HCG at those levels but in all actuality the growing has just stopped at about that time and my body is preparing to miscarriage ? My last period was July 31 and they said I look to be 4 weeks 3 days on sept 23 US and then on sept 28 blood showed 5800 HCG. My last period before the July 31 was the 40 day. Thanks again. It is very nice that you have this forum and answer questions for people. It is very much appreciated, more than you know!

Dr. Geoffrey Sher

You need an US in about 1 week, to establish the viability status of this pregnancy.

Good luck!

Geoff Sher

Sara Stokes

Progesterone at 16.6 normal for 9dpo positve pregnancy test? Beta was 13

Dr. Geoffrey Sher

You need to repeat the hCG test every 2 days to make sure it doubles each time!

Good luck!

Geoff Sher

Megan Edwards

Hi Dr. Sher,
I’m currently 5w5d with an hcg if 43,000. At 5w3d hcg was 28,000. My levels were doubling/tripling before this last check and now I’m panicked that I’ve had a demise. Any input? Thanks!!!

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Dr. Geoffrey Sher

I strongly doubt this. However, have an ultrasound for a definitive answer.

Geoff Sher

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Chris

Dear Dr. Sher,

We recently had IUI performed and then 3 HCG tests.
First test 13DPO- 39.5
Second test 15DPO-65.3
Third test 17 DPO- 107.3

At first the doctor didn’t seem concerned but now he wants to see us back again for another hcg test. Does this hcg growth rate seem concerning, in your opinion?

Thank you so much for your thoughts!

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Dr. Geoffrey Sher

It is somewhat concerning that the hCG level is not rising optimally. BUT only time will tell!

Good luck!

Geoff Sher

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Emily P

Hi! Found out I was pregnant on 2/1. I would have been 3+2. Found out super early! Since then I’ve had pink/brown spotting. First beta was done on 2/3 HCG was 59 and Progesterone was 18. Second beta was done on 2/5 HCG was 127 and Progesterone was 21. Had more spotting so I have a third blood draw on 2/10 HCG was 404 and Progesterone dropped to 13. Doctor doesn’t seem concerned and thinks everything is fine, however it’s not doubling appropriately and my Progesterone dropping is very concerning to me. Does this sound like a viable pregnancy or is my instinct probably right?

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Monica

Hi Dr. Sher.

I am 33 ttc for 2 years. Last year in March I had a hsg and then became pregnant. Unfortunately in April we found out that it was an ectopic. Went for repeat hsg in summer and seemed as though right tube (ectopic) was blocked. Decided to do ivf –
1st transfer (August) chemical – low beta
2nd transfer (September) – negative pregnancy test – untested embryo
(Did an ERA – came back receptive)
3rd transfer (October) –
hcg 1 = 63
Hcg 2 = 71
Hcg 3 = 78
(Done 48 hours apart)
I was taken off progesterone and my body continued to produce it on its own. My hcg continued to then climb and eventually had hcg in 2000s but miscarried at around 7 weeks. Never saw on US.

Tried new treatments before most recent transfer – lupron (2 months prior)baby aspirin, immunotherapy, progesterone, prednisone, Claritin, lovonox and a lot of prenatals and supplements.
Did a transfer on 6/8 Of a tested normal embryo
hcg on 6/17 -53
Hcg on 6/19 – 88
Hcg on 6/23 – 63
Progesterone has been above 45 the entire time.

My husband and I am at a complete loss and do not know what else to do. Can you provide any feedback, treatment, recommendations, thoughts that could maybe help us? I don’t know how much more I can take. We’ve invested so much time, emotion, not to mention money into this.
Are there women who’s numbers fluctuate always in the beginning? Should I do anything? We’re desperate.

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Dr. Geoffrey Sher

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 15y 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
e. Ureaplasma Urealyticum (UU) Infection of cervical mucous and the endometrial lining of the uterus, can sometimes present as unexplained early pregnancy loss or unexplained failure following intrauterine insemination or IVF. The infection can also occur in the man, (prostatitis) and thus can go back and forth between partners, with sexual intercourse. This is the reason why both partners must be tested and if positive, should be treated contemporaneously.
Certain causes of infertility are repetitive and thus cannot readily be reversed. Examples include advanced age of the woman; severe male infertility; immunologic infertility associated with alloimmune implantation dysfunction (especially if it is a “complete DQ alpha genetic match between partners plus uterine natural killer cell activation (NKa).
I strongly recommend that you visit http://www.DrGeoffreySherIVF.com. Then go to my Blog and access the “search bar”. Type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.

• The IVF Journey: The importance of “Planning the Trip” Before Taking the Ride”
• Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
• IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation (COS)
• The Fundamental Requirements for Achieving Optimal IVF Success
• Use of GnRH Antagonists (Ganirelix/Cetrotide/Orgalutron) in IVF-Ovarian Stimulation Protocols.
• Ovarian Stimulation in Women Who have Diminished Ovarian Reserve (DOR): Introducing the Agonist/Antagonist Conversion protocol
• Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
• Human Growth Hormone Administration in IVF: Does it Enhances Egg/Embryo Quality and Outcome?
• The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
• Blastocyst Embryo Transfers should be the Standard of Care in IVF
• IVF: How Many Attempts should be considered before Stopping?
• “Unexplained” Infertility: Often a matter of the Diagnosis Being Overlooked!
• IVF Failure and Implantation Dysfunction:
• The Role of Immunologic Implantation Dysfunction (IID) & Infertility (IID): PART 1-Background
• Immunologic Implantation Dysfunction (IID) & Infertility (IID): PART 2- Making a Diagnosis
• Immunologic Dysfunction (IID) & Infertility (IID): PART 3-Treatment
• Thyroid autoantibodies and Immunologic Implantation Dysfunction (IID)
• Immunologic Implantation Dysfunction: Importance of Meticulous Evaluation and Strategic Management 🙁 Case Report)
• Intralipid and IVIG therapy: Understanding the Basis for its use in the Treatment of Immunologic Implantation Dysfunction (IID)
• Intralipid (IL) Administration in IVF: It’s Composition; how it Works; Administration; Side-effects; Reactions and Precautions
• Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
• Endometrial Thickness, Uterine Pathology and Immunologic Factors
• Vaginally Administered Viagra is Often a Highly Effective Treatment to Help Thicken a Thin Uterine Lining
• Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
• A personalized, stepwise approach to IVF
• How Many Embryos should be transferred: A Critical Decision in IVF?
______________________________________________________
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
Maja

Hello,
I had ovulation on June 14th
My hcg was:
29.6. – 363
1.7. – 1060
3.7. – 3113
7.7. – 13.011
9.7. – 14.370 🙁
First, I was worried because my betas were tripling every 48h, then doubling. Now, the last hcg had only 10% increase over 48h.

Please, share your thoughts on this.
Thank you!

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Dr. Geoffrey Sher

This may or may not be an issue because when the hCG rises above 5,000, the rise usually slows down. Do an US for definitive information on the viability of the pregnancy!

Good luck!

Geoff Sher

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Cheyenne

Hello.
My LMP was Jan 27th. I should be right at 8 weeks, but had an ultrasound today and baby is measuring at 6 weeks. HCG levels are at 25000. I never have regular periods, and even bled for 2 weeks last January because I didn’t ovulate in that month. Is my baby okay?

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Dr. Geoffrey Sher

Repeat the US in a week to see if growth is appropriate.

Good luck!

Geoff Sher

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Maddie D

Hi Dr. Sher,

My HCG results came back this morning and I am worried because they seem to be rising slow. My level at 5w3d was 3098, and at 5w5d they measured at 4573. I had a miscarriage several months ago so I’m anxious that the slow rise means that another one is on the way.

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Dr. Geoffrey Sher

At this stage, doing additional hCG measurements wont really help !Have an US done in about 1 week. This will provide a definitive answer.

Good luck!

Geoff Sher

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Ashley Kidd

9-8 hcg 69
9-11 hcg 335 (3 day increase)
9-17 hcg 2368 (6 day increase)

Are these increases good?

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Kendra

I found out I was pregnant on 5/14 Had blood drawn on 5/15 Hcg levels was 13.6 and my progesterone was 2.1 went back on 5/25 hcg level was 41 went to the er because I wanted to make sure my hcg level was going up on 5/21 my hcg level is 47 I’m assuming that I’m 5 weeks and 5 days should I be worry

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Dr. Geoffrey Sher

This does not look good for a viable pregnancy, I am afraid!

Sorry!

Geoff Sher

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Nicole Ramos

I’m not sure how far along I am I got a positive home pregnancy test on 4/7 the day I was suppose to get my period went to the hospital 4/10 hcg was 186, went back to the hospital on 4/14 hcg now 1158 , but I did have very light spotting g with no clots 2 times so far , doesn’t last all day just a few hours, I also experienced a miscarriage a year ago, how does this look. I have 1 live birth and 1 miscarriage this is the 3rd pregnancy

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Dr. Geoffrey Sher

I think it is rather promising.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.
Miscarriage: Mild painless vaginal bleeding (often referred to as “spotting”) is usually due to hormonally induced eversion of the glandular cells that line the inner cervical canal, such that erosion develops on the outer part of the cervix that protrudes onto the vagina. The everted glandular tissue is fragile and susceptible to contact trauma, brought about sexual penetration or the insertion of vaginal suppositories. Since such local bleeding does not involve the developing conceptus located inside the uterus it is almost always innocuous. The diagnosis of a local cause of bleeding requires visual inspection of the vagina and cervical inlet a speculum examination. Thereupon, provided that the pregnancy has advanced beyond 5-6 weeks, a concomitant sonogram could confirm the presence of an unaffected pregnancy. Patients are advised to be more careful in inserting vaginal suppositories and to avoid sexual penetration until the bleeding has stopped for at least 1 week.

Good luck!

Geoff Sher

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Nicole Ramos

With the spotting that I’ve had I have had no cramping once so ever , so you think that it could look like a successful pregnancy?

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Nicole Ramos

When I went to hospital the dr checked my cervix and it was closed

Vidushi

dear Dr,Sher. my LMP was 6th April 2020. as i had pregnancy symptoms i took a beta hcg test on 30.04.2020 and the result was 17.9. I then again repeated the result today 02.05.2020 and the result was 6.6. What does that mean? Am I too early to test or am I miscarried?

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Dr. Geoffrey Sher

It could be too early! I would repeat the test on Monday to see if/how the level rises. However, an hCG of 6.6u is a low number and I would prepare for the worst while hoping for the best.

Good luck!

Geoff Sher

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Vidushika

thank you doctor. I did not check again yet. still no bleeding. still have the pregnancy symptoms. i think it is better to wait till tomorrow as it is my expected period date. however still the HPT’s are negative.

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Worried and Expecting

Hi Dr. Sher,

I am presently 11w5d pregnant (Conceived naturally at age 44). I’ve been concerned for some time now as my roughly 6w4d hcg result was 69,000. I had an u/s at 9w4d and measurements were. Spot on and heart rate was 163. U/s a week later (10w3d) had a heart rate of 158 and appropriate growth. I’m concerned about chromosomal issues due to my high hcg coupled with bring AMA (it is a singleton). Any reassurance? Thank you!

Dr. Geoffrey Sher

I do not agree. However, discuss this with your RE and do an amniocentesis in about 2 weeks for prenatal testing.

Geoff Sher

Dr. Geoffrey Sher

You are very welcome Vidushi!

Stay safe!

Geoff Sher

Christina

My hcg levels today 16/7 in New Zealand are 35000 on Monday 13/7 they were 18000 I have my first us tomorrow and I’m scared they will tell me there is no heartbeat, this is my last baby and my husbands first and last my lmp was the 7/6 and lasted 3 days my midwife says I’m about 7+2 based on my hcg but when I look it up it says 6+2 What would you think I’m so scared!

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Dr. Geoffrey Sher

You count from the 1st day of your last menstrual period.

I am optimistic that you will get good news!

Geoff Sher

Jennifer

Based off LMP I should be 5w4d and yesterday hcg was only 100!! I go back tomorrow for 2nd hCG. I have history of 4 miscarriages. Is there any hope or should I prepare my heart for miscarriage number 5?

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Dr. Geoffrey Sher

That is very low and does not (in my opinion) bode well for a viable pregnancy. BUT let’s first see what the next hCG level is.

Sorry!

Geoff Sher

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Jessica Knight

I am 8 w but hCG level is 11,000 48 hrs. Later 13,000. Is this a viable pregnancy?

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Dr. Geoffrey Sher

It could well be! The reason I say this is because hCG levels often do not double every 2 days after they exceed 6,000.

Have an ultrasound done for confirmation.

Good luck!

Geoff Sher

Sarah

Hi,
I’m 7 weeks pregnant, after a miscarriage at 13 weeks. My HCG levels in the last two tests (48 hrs apart) have gone up – but not doubled. I’ve had a scan which detected a heartbeat and confirmed dates/sac/embryo. Is there chance that despite the scan looks good – my hormone levels are predicting a miscarriage? Which results should I ‘trust’ more?

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Dr. Geoffrey Sher

The ultrasound is the most reliable. Repeat in 1 week to re-evaluate growth and progress!

Geoff Sher

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Jenna

Hi- I had a positive pregnancy test at 4 weeks and my initial HCG level through the blood test was 33. I had it repeated two days later and it was 37. I am trying to gauge how likely it is that I am going to miscarry or if there is a chance it could progress normally. I would love to know your thoughts.

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Brandi Overhuls

I’m measuring 8 w baby measured 6w3d I could be off on lmp hcg dropped from 34222-28884 I’m so scared to see second ultrasound

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Dr. Geoffrey Sher

When it fluctuates at such a high level, it often does not signal an impending loss!

Good luck!

Geoff Sher

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Leigh Fitz

Hi, I am 6 weeks and 4 days and the T US showed cardiac activity however my hcg levels last week dropped from 4177 to 3774 and this week rose back up to 4200 but my progesterone dropped from 15 to 10. Is this pregnancy viable? Is this a signature of a chromosomal issue?

reply
Dr. Geoffrey Sher

Not necessarily so! Do an US in 1 week to determine health of pregnancy!

Geoff Sher

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Kelly

Hello. I have history of ectopic, left tube removed 7/14. Pregnant again. LMP 8/17. LH surge detected 9/4 so suspected ovulation 9/5. Here is the history of my HCG levels:
9/19 94
9/22 324
9/24 695
9/26 1565
9/28 3948
9/30 7986
10/5 34025
I had US on 10/5. Gestational sac measured I think 18mm? Visible yolk but tech said she couldn’t see a baby. I have another US 10/9. I know that US will be the ultimate answer but wanted to know your thoughts of which way this pregnancy was leaning towards? I don’t know which way to think because hcg is doubling so I don’t know if that’s a good thing or it’s bad because the numbers are high but no baby showing in US. I know it’s not for certain but your thoughts are much appreciated. Thank you.

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Dr. Geoffrey Sher

You are beyond 7 weeks so there should be a clear fetus seen. Unless there was a technical error with regard to the procedure, it sounds as if this could be a pending loss!

Repeat the US using a 2nd opinion.

Good luck!

Geoff sher

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Jess

Hello Dr Sher,
I thank you for considering this question as we’ve just moved out of town and I have no doctor at the moment. I am 38 years old with a history of infertility, one loss, and one full-term baby, born when I was 35 years old.
I have been following my hcg numbers by using request a test lab orders which you can order online.
At 4w3d hcg was 557
At 4w5d hcg was 1697

I was pleased with this increase but my anxiety brought me back to the lab at 5w3d and hcg was lower than I’d hoped at 6356. I know hcg does slow its doubling time, but I thought not until after 6 weeks. Does this level seem appropriate to you? I will be waiting in agony until my ability to receive an ultrasound. I’d appreciate any insight you can share as I work to figure out which provider I will be seeing in our new home.

reply
Dr. Geoffrey Sher

Unfortunately Jess, it will require an US for a definitive answer. Good luck!

Geoff Sher

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Yogita

Hi Doc,

We did 1 frozen embryo(6AA) transfer on Sep 22. my HCG level on 5 days after was Sep 27 was 495 and on Oct 2 (10 days after) was 3000. I am really worried because hcg level is quite high(abnormally high?) for single embryo . Do you see any problems or issues? I have ultrasound scheduled on Oct 17.
Thanks
Yogita

reply
Mary Clark

I had a blood test for my pregnancy & it came back 452 miu. How many weeks would that make me ?

reply
Dr. Geoffrey Sher

Probably 5 + weeks but it is not possible to say with certainty!

Good luck!

Geoff Sher

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Dr. Geoffrey Sher

I am not too concerned at this stage. However, the dye has been cast and what will be will be!

Good luck!

Geoff Sher

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Cheryl Grantham-Hill

I’ve had the most oddest experience and the hospital is flummoxed.
I had a postive pregancy test 10dpo a few days later I started experience right handed pain and pain in my shoulder. I went to a&e and was told that the pregnancy test was negative however bloods eventually came back as postive at a low HGC of 70 was told to come back 24hours later for a scan to see if i had a cyst etc. They said everything looked normal except i had thrush and to come back in another 24 hours for repeat bloods. The HGC was then 125. They said to come back 2 weeks later for a scan as i was to early to see anything. Within a week i had started to experience further pain and spotting so went to hospital who said unortunately my levels had only risen to 824 when they should of been around 2000 so it could of been ectopic or a miscarriage. I was told to come back in for a scan following day. They could not see a sac or anything so said ot was a PUL. Was told to come back for follow up bloods. The next set of 3 bloods where all static rising and dropping by between 100 and 200. I had then been spotting blood for around 7 to 10 days. I had another scan and they said they saw any empty tiny sac but wasn’t sure if it was real or not. I then started expelling bright red blood and clots for around 4 to 5 days and passed a weird greyish tissue which we thought was the sac. When i went back for another scan the sav had dissaperaed and i was told i only had 4 to 5 mil of blood left to expel. That night i experienced severe pain when trying to pass stool and was in and out of consciousness. I was taken to hospital and I had green poo and my white blood count was about 16. They said they thought i may have a stomach infection but sent me home the next day. The next week I had repeat bloods the levels had risen from around 1000 to 1600 we was all so shocked as the blood had returned to brown and we thought it was all over. When they did a scan they saw a small 4mm sac again !! I should of been 8 weeks and hadn’t had sex again in this time. I have had right sided pain the whole time on and off which is increasing and US does not show anything in my tube. Please HELP x

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Cheryl Grantham-Hill

Where i have written rising and falling over those 3 days that was by 100 to 200 each time so was 824 then 910 then 890 then 924 the 1040 then eventually up the 1600 a week later

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Dr. Geoffrey Sher

It could still be a misdiagnosed ectopic pregnancy or a threatened miscarriage. However, the raised WBCC concerns me. I just hope you do not have appendicitis. Either way you need a thgorough evaluation which might include a D&C and Laparoscopy.

Good luck!

Geoff Sher

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Christina

I had two 5 day frozen embryos transferred on March 27. On 10/6 my blood test showed 114. Then on 10/9 the number was 173. Is it possible both embryos took initially and now just one is continuing to produce HCG? I am testing again 10/11 and I am hoping to see double of 173.

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Christina

Blood test on 10/11 was 165 – the Dr wants me to test again on Monday 10/16 so maybe there is still hope by some chance.

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Christina

My blood test results came back at 340 today 10/16 so really great news. Hopefully the final test on 10/19 will be even higher numbers.

Nicole S.

I hope it worked out for you! I had a 4AA 5 day FET on 12/21/18. On 12/30 my hcg was 75. On 1/3/19 my hcg barely rose only up to 85. I’m not very optimistic but go back for more bloodwork on 1/5/19. I’m hoping that my number doubles but I’m sure it’s not likely. But thanks for giving me some hope!!

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Dr. Geoffrey Sher

I am afraid this sounds like a chemical pregnancy. So sorry!

Geoff Sher

Jessica

Had an initial transvaginal US at 5w4d and only the Gestational sac was visible. Number are doubling nicely and beta on day of US was 5600. Is there hope?

Dr. Geoffrey Sher

You need to give it more time. This is too early to be conclusive. Wait another 10 days and retest.

Geoff Sher

Sarah oliver

Hello! My first hcg lvls were 1074. Progesterone 7.
Started progesterone supplements immediately. 3 days later – hcg 1624 5 days later next hcg 2891 progesterone 58.7. Had a scan showing a sac 5w0d. 7 days later hcg only increased to 5891. repeat scan not for another 5 days 🙁 should be 6w5d then. Not looking promising is it?

Not looking so good is it?

Dr. Geoffrey Sher

Only time will tel. An ultrasound done 10-14 days from now should be definitive.

Geoff Sher

Cierra Kozak

I started to miscarry on May 11th. And passed a whole fetus May 14th. I didn’t know I was pregnant until the fetus came out. Wasn’t able to go to the ER until the Wednesday after. They said my HCG was 173. And nothing was on the ultrasound except fluid on my right side. The Friday after that my HCG was over 250. I’m told I couldn’t have been more than 3 to 5 weeks pregnant. May 27th or 28th I’m told I’m pregnant. I am very confused. And I’m treated like I’m stupid or something. If a fetus with arms and legs with tinny digits on them came out of me, how can I have been 3 to 5 weeks when I lost the baby and now be pregnant?

Dr. Geoffrey Sher

Cierra, you could be correct but I cannot respond authoritatively without much more information.

Sorry!

Geoff Sher

Anna

Hello Dr Sher,

I am 35 and my first pregnancy. Today is 6 wks +2 of my pregnancy. We got pregnant 3rd cycle of letrozole/ovidrel 250 injection. My levels have been rising like this:

May 2 – 301
May 4 – 713
May 7- 2168
May 13 – 25173

They seem to be rising faster than doubling every 48-72 hrs. Is this normal? Also at my first bloodwork (may 2nd) my progesterone level was at 222 (canadian measurements). We have an ultrasound next thursday at 7 weeks. Any input would be much appreciated, thank you

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Dr. Geoffrey Sher

I think this is likely to be a healthy singleton implanting! I could be wrong and it turns out to be twins, but I do not think so.

Geoff Sher

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Anna

Thank you for your quick response, I hope you have a wonderful day!

Cheryl Grantham-Hill

Thank you.
Would a threatened miscarriage HGC rise that slowly?
The pain is increasing but they still wont scan me until Thursday. I am terrified of rupture.
Have you ever heard of a sac passing or disappearing and then reappearing on another scan?
I feel so alone and am getting no help from the hospital so appreciate your help.

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Dr. Geoffrey Sher

If the sac was truly in the uterus, it would not disappear and then reappear. That could simply be a technical glitch of poor visualization.

I too am concerned that this could be an ectopic. You need to discuss your concern openly with your RE who should be amenable to following up more frequently…given the issue at hand.

My thoughts are with you!

Geoff Sher

Fay

Dr Sher,
I am currently 6weeks 3 days and my numbers were than doubling until my draw yesterday. On the 19th it was 14491 two days prior to that it was 8654. I had bloods drawn yesterday and it was 31777. I’m really worried as it’s taken nearly 6 days to double. Should I start worrying?

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Dr. Geoffrey Sher

An US done this coming week will be definitive.

Good luck!

Geoff Sher

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Aisling

Hi there. I’m 6 plus weeks. My hcg was 21786 then 24159 -48 hours later. We saw a heart beat on Monday but I know the hcg should double and it didn’t. Will near… Does this mean I will lose this baby,? I have to go back in ,2 weeks for another scan. Thanks a mill

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Dr. Geoffrey Sher

The rise in hCG does not continue to double all along. I am not really concerned here!

Good luck!

Geoff Sher

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Hira

Hello I wanna know my due date was 27 on 28th my hcg was 94 n on 30 it was 186 is it normal? As one de said wait n other said Mai b uncertain viability

Dr. Geoffrey Sher

So far so good. If all remains OK, you should be due in the 1st 2 weeks of April 2021.

Good luck!

Geoff Sher

Heather Anderson

Hi doctor, I’m on my 6th round of IVF, 3 miscarriages… I got a positive from this last transfer. On Monday 1/27 my hcg was 178, on 1/29 it was 316. So only rose 77%. I go in for another test tomorrow. But I have also had a lot of cramping yesterday and today. Any thoughts? Thanks!

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Dr. Geoffrey Sher

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

______________________________________________________
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.

Patients are encouraged to share the information I provide, with their treating Physicians and/or to avail themselves of my personal hands-on services, provided through batched IVF cycles that I conduct every 3 months at Los Angeles IVF (LAIVF) Clinic, Century City, Los Angeles, CA.

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

Dr. Geoffrey Sher

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

______________________________________________________
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.

Patients are encouraged to share the information I provide, with their treating Physicians and/or to avail themselves of my personal hands-on services, provided through batched IVF cycles that I conduct every 3 months at Los Angeles IVF (LAIVF) Clinic, Century City, Los Angeles, CA.

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

Kara Thomas

I’m currently 12 weeks pregnant. I went to the ER yesterday because I felt a gush of fluid. Luckily they did an ultrasound and everything looks great. They also did an Hcg quantitative for some reason. I’m concerned about the low number. It was 1097. My doctor said that hcg doesn’t matter at this point but I still feel that is very low. What do you think?

reply
Dr. Geoffrey Sher

I agree with your doc0ctor to a point. However, it is definitely on thge low side. Repeat the US and hCG in about 1week and follow up with me please.

Geoff Sher

reply
Cindy

On the 27/03 HCG = 70
07/04 HCG = 2900
14/04 HCG = 8500
Does that sound normal ? Just had another test done today.

reply
Nancy

My HCG on 5 w 3 days is 2500. Saw the yolk sac of 2mm. I repeated the blood work since I stopped getting pregnancy symptoms. It is only 8800 in 6 w 1 day. Should I be worried as the numbers are not doubling?

reply
Dr. Geoffrey Sher

Have another US. It should be definitive.

Good luck!

Geoff Sher

reply
Yogita

Hello Dr,

We did 1 frozen embryo(6AA) transfer on Sep 22. my HCG level on 5 days after was Sep 27 was 495 and on Oct 2 (10 days after) was 3000. I am really worried because hcg level is quite high(abnormally high?) for single embryo . Do you see any problems or issues? I have ultrasound scheduled on Oct 17.
Thanks
Yogita

reply
Dr. Geoffrey Sher

It means that implantation has commenced. How it turns out…remains to be seen through follow-up blood tests and ultimately in about 2-3 weeks , through ultrasound evaluation.

Geoff Sher

Mary Jane

I had a fresh 5 day blastocyst transfer on March 27th. My hcg at 12 days post transfer was 80, and then 14 days post transfer it went up to 135. I am worried this is low or is rising too low, but my dr didn’t see a need for me to get another level drawn. Any suggestions?

reply
Dr. Geoffrey Sher

Respectfully, I would repeat the hCG test in 2 days to see if it doubles (or better). If so, then I would have less concern.
___________________________________________________________
ADDENDUM:
INTRODUCING SHER FRERTILITY SOLUTIONS (SFS)
Hitherto I have personally performed the actual hands-on treatment of all patients who, seeking my involvement, elected to travel to Las Vegas for my care. However, with the launching of Sher-Fertility Solutions (SFS), I will as of March 31st take on a new and expanded consultation role. Rather than having hands-on involvement with IVF procedures I will, through SFS, instead provide fertility consultations (via SKYPE) to the growing number of patients (from >40 countries) with complex Reproductive Dysfunction (RD) who seek access to my input , advice and guidance. In this way I will be able to be involved in overseeing the care, of numerous patients who previously, because they were unable to travel long distances to be treated by me, were unable to gain access to my input.

Anyone wishing to schedule a Skype consultation with me, can do so by: Calling my concierge (Patti Converse) at 1-800-780-7437 for an appointment,enrolling online on my website, http://www.SherIVF.com, or 702-533-2691; or emailing Patti at concierge@SherIVF.com or . sher@sherivf.com .
I was very recently greatly honored in receiving an award by the prestigious; International Association of Top Professionals (IAOTP). For more information, go to the press release on my website, http://www.sherIVF.com .

PLEASE HELP SPREAD THE WORD ABOUT SFS!

Geoff Sher

reply
guna889

hi Dr Sher. Im 12dp3dt with 1st beta of 16.6. i have not spotted or started bleeding. Will this be a viable pregnancy?

reply
Dr. Geoffrey Sher

It is a low start but repeat in 2 days to see if it doubles!

Good luck!

Geoff Sher

Kate

Hello Dr Sher. I had a pgs tested transfer on august 24th. My betas have been doubling normally. Yesterday we saw a heart beat and I am 6 weeks. My beta HCG was rechecked and its only 7600 from 3600 5 days ago. Should I be concerned?

reply
Dr. Geoffrey Sher

The beta levels rise more slowly at this stage. Sounds as if all could be fine here.

Good luck!

Geoff Sher

reply
Kate

Thank you Dr Sher. I really appreciate you answering back. I am worried because the doubling time is about 110 hrs, which seems a lot. My RE does not want to retest hcg now but wait for a repeat ultrasound in a week.

reply
Concerned

My husband and I have been trying to conceive for a long time. I am probably about 10 days past ovulation. My Dr sent me for blood work. 2 days ago my hcg was at 4.5. 2days later it is at 5.8. She is sending me for more bloodwork to be done in a few days. I am hoping that these low levels mean that I am very early on but I’m afraid I am getting my hopes up. From what I have read it says anything over a 5 is pregnant. But if I am shouldn’t my levels have increased more than that over 2 days?

reply
Concerned

Thanks for your reply. I suspected as much. Is it at all possible that the outcome will be positive?

reply
Mui

I am 5 + 4 weeks Pregnant.
My betaHCG at 4weeks on
5/8 – 490
5/11-1500
5/12-1840
5/15-2820
5/18-3510
and progesterone level went from 101nmol/L to 75 to 81 to 70 and then dropped to 45
Is there a chance my pregnancy is still viable? I am going get get an ultrasound in 3 days at 6 weeks gestation. I am so worried!!

reply
Dr. Geoffrey Sher

This is not a promising rise. You need an ultrasound to see what is happening.

Geoff Sher

reply
Mui

I had my ultrasound today, they saw a gestational sac measuring equivalent 5w+2d, I am 6 weeks by date. No yolk sac or embryo.
My HCG today 5/22 is only 4190 from 3510 (5/18).
My obstetrician basically said I will miscarry in a couple of weeks and there’s no need for further ultrasound. I don’t have any symptoms. What’s your opinion?

reply
Dr. Geoffrey Sher

I respectfully disagree. The assessment could be off. I suggest you repeat the US in 1 week!

Good luck!

Geoff Sher

reply
MandyJohnson

I am scared first HCG 13 told to not have hope. Second HCG 82 told all was okay third HCG 91 told to wait and see 4th beta needed. Is there a chance?

reply
Dr. Geoffrey Sher

The last rise in beta hCG points towards a possible chemical pregnancy! Let’s hope the 4th reading bounces back but I am not very optimistic.

So sorry!

Geoff Sher

Geoff Sher

Gab

Hello – I had a positive at home pregnancy test 6/14. HCG 105 6/16 then 672 on 6/20. Does this look promising?

reply
Sharon Born

Hi, I’ve just found out I’m pregnant at 46! Completely shocked and now worried about something being wrong with my baby. I was pregnant at 41 but unfortunately had to have termination as an amniocentesis found out my baby had downs. My HCG levels at 4.5 weeks was 776 and now just over 48 hrs later gone up to 1386. They were hoping to see them double so I have to get my bloods done again in 48 hrs plus have an internal scan. I did have an internal scan at 4.5weeks but they couldn’t see anything but it could’ve been done too early. Do you think I should be worried given my age?

reply
Dr. Geoffrey Sher

Congratulations!

You meed to see a high-risk Obsterician and have chorionic villus sampling or amniocentesis to evaluate for developmental problems.

Good luck!

Geoff Sher

reply
jaishree

I’m of 44yrs and had done day 5 blastocyst transfer on 23 Aug. My first hcg is 228 on 10 th day I.e on 1 Sep. On 13 th day I.e on 4 Sep it is 1558. 2 blastocyst were transferred. Does this super rise in count indicates possibility of twins? Pl reply.

reply
Andrea

Hi Dr. Sher,
I did a 5 day transfer on July 31st. My beta values were 17 on 08/11, then 47 on 08/15, then 56 on 08/17, and finally 187.8 on 08/21.
My RE is concerned about the slow rise and has discussed chemical and ectopic with me. Is there any chance that this could be a viable pregnancy?
Thank you so much for your time.

reply
Dr. Geoffrey Sher

I have to concur with the opinion by your RE.

But…only time will tell!

Geoff Sher

reply
Andrea

I was told to stop my progesterone after my third beta. I checked back in after my fourth beta and was told I should still not be taking it. Do you agree with this?

Dr. Geoffrey Sher

If your pregnancy is a chemical gestation, there would be no purpose continuing the progesterone therapy.

Geoff Sher

Andrea

My fifth beta is 445 …that’s 48 hours after my last beta of 187.8. My clinic is still not hopeful at all. Am I wrong to think that there is a chance for this pregnancy?

Dr. Geoffrey Sher

I have not given up on you. This could still be OK. Have an ultrasound done in about 10 days.

Good luck!

Geoff Sher

Jenny

Dear Dr,
– 14 dpo hcg level 150 @ 9.00 a.m.
– 19 dpo hcg level 860 @ 8.30 a.m.
Here are my numbers after transferring 2 embryo’s 2 days after egg collection. I am so nervous after years of fertility treatment and several early losses that I am anxious to be hopeful. Bust just based on these numbers, would you agree it looks positive? Thank you.
Jenny

reply
Kammi

Hello, first beta at 12dpiui was 4992, second beta 48 hours later dropped to 3527, 3rd beta 72 hours dropped to 1735…doctor has now called me in for ultrasound. Is there still hope for me???

reply
Dr. Geoffrey Sher

This is not very encouraging, I am afraid!

___________________________________________________
ADDENDUM: PLEASE READ!!
INTRODUCING SHER FERTILITY SOLUTIONS (SFS)
Hitherto I have personally performed IVF- treatment and related procedures on patients who, elected to travel to Las Vegas to be managed by me. However, with the launching of Sher-Fertility Solutions (SFS) in April 2019, I have taken on a new and expanded role. Now, rather than having hands-on involvement I confine my services to providing hour-long online Skype consultations to an ever-growing number of patients (emanating from >40 countries), with complex Reproductive problems, who seek access to my input, advice and guidance. All Skype consultations are followed by a detailed written report that meticulously describes and explains my recommendations for treatment. All patients are encouraged to share this report with their personal treating doctor(s), with whom [subject to consent and a request from their doctor] I will, gladly discuss their case with the “treating Physician”.
Through SFS I am now able to conveniently provide those who because of geography, convenience and cost, prefer to be treated at home or elsewhere by their chosen Infertility Physician.
“I wish to emphasize to all patients with whom I consult, that in the final analyses, when it comes to management, strategy, protocol and implementation of treatment, my advice and recommendations are always superseded by that of the hands-on treating Physician”.

Anyone wishing to schedule a Skype consultation with me, can do so by: Calling my concierge (Patti Converse) at 1-800-780-7437 (in the U.S.A or Canada) or 702-533-2691, for an appointment. Patients can also enroll online on my website, http://www.SherIVF.com, or email Patti at concierge@SherIVF.com .
I was very recently greatly honored in receiving an award by the prestigious; International Association of Top Professionals (IAOTP). For more information, go to the press release on my website, http://www.sherIVF.com .

PLEASE HELP SPREAD THE WORD ABOUT SFS!

reply
Miamo

Hello!
I was 6w2day 1st hcg ( monday)= 35623 came bak to do blood test 2 days later ( wed) dropped to 33598 also have u/s same day ( wed) result as 17mm maybe gestational sac and 2mm Echogenic focus possible represents early Fetal pale
Is that a good sign?
Cheer

reply
Dr. Geoffrey Sher

Give it 1 more week and repeat the US. That should be definitive!

Good luck!

Geoff Sher

reply
Aparna

Dear Dr Sher, I am 42 years old, this was my third fresh IVF after repeat failed IVFs and FETs. This time I got PGS normal embryos and Endometrial receptivity test done to locate the window of implantation. 13 days since transfer, my B-hcg levels came out at 41. The doctor rules this as a chemical conception that failed to develop further. I am go back for a second blood test on 7/28/2017. Do you think this cycle has any future? Should I check for immunological issues now? I did develop a sore throat and cold 8-9 after transfer. Please let me know your thoughts. Thank you.

reply
Dr. Geoffrey Sher

It does not look encouraging, I am afraid!

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

• The IVF Journey: The importance of “Planning the Trip” Before Taking the Ride”
• Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
• IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation (COS)
• The Fundamental Requirements for Achieving Optimal IVF Success
• Use of GnRH Antagonists (Ganirelix/Cetrotide/Orgalutron) in IVF-Ovarian Stimulation Protocols.
• Ovarian Stimulation in Women Who have Diminished Ovarian Reserve (DOR): Introducing the Agonist/Antagonist Conversion protocol
• Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
• Human Growth Hormone Administration in IVF: Does it Enhances Egg/Embryo Quality and Outcome?
• The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
• Blastocyst Embryo Transfers should be the Standard of Care in IVF
• IVF: How Many Attempts should be considered before Stopping?
• “Unexplained” Infertility: Often a matter of the Diagnosis Being Overlooked!
• IVF Failure and Implantation Dysfunction:
• The Role of Immunologic Implantation Dysfunction (IID) & Infertility (IID): PART 1-Background
• Immunologic Implantation Dysfunction (IID) & Infertility (IID): PART 2- Making a Diagnosis
• Immunologic Dysfunction (IID) & Infertility (IID): PART 3-Treatment
• Thyroid autoantibodies and Immunologic Implantation Dysfunction (IID)
• Immunologic Implantation Dysfunction: Importance of Meticulous Evaluation and Strategic Management 🙁 Case Report)
• Intralipid and IVIG therapy: Understanding the Basis for its use in the Treatment of Immunologic Implantation Dysfunction (IID)
• Intralipid (IL) Administration in IVF: It’s Composition; how it Works; Administration; Side-effects; Reactions and Precautions
• Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
• Endometrial Thickness, Uterine Pathology and Immunologic Factors
• Vaginally Administered Viagra is Often a Highly Effective Treatment to Help Thicken a Thin Uterine Lining
• Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
• A personalized, stepwise approach to IVF
• How Many Embryos should be transferred: A Critical Decision in IVF?
• The Role of Nutritional Supplements in Preparing for IVF

If you are interested in seeking my advice or services, I urge you to contact my concierge, Julie Dahan ASAP to set up a Skype or an in-person consultation with me. You can also contact Julie by phone or via email at 702-533-2691/ Julied@sherivf.com You can also apply online at http://www.SherIVF.com .

*FYI
The 4th edition of my newest book ,”In Vitro Fertilization, the ART of Making Babies” is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

Geoffrey Sher MD

reply
Siobhan

Dear Dr Sher,

With regards to the FET, my clinic said they would thaw the embryo in the morning of the day of transfer, but said the transfer could take place anytime between 10-3.
Would it be better to have the transfer done on the earlier side if its thawed in the morning, or better to be done in the afternoon?
I am also planning on 48hours of bed rest (ish) after it’s been done, is this a good idea?

Thank you

reply
Dr. Geoffrey Sher

I personally do not advocate absolute bed rest. As to the timing of the FET…it should not matter. I concur with the propsed timing of the FET.

Geoff Sher

reply
Susan

Dear Dr. Sher,

I did IVF and Frozen embryo transfer day-5 blastocyst was done on 06/05 and on 06/19 hcg level was 39. On 06/21 hcg level was 184. My doctor has asked to come for a US one week later. I asked him whether I should repeat the hcg test again and his answer was no. I am worried whether this a sign of positive pregnancy? Do I need to repeat the hcg test?

Thanks

reply
Dr. Geoffrey Sher

I agree with your doctor! Just do an US in a week. Things are actually looking quite promising for you!

Good luck!

Geoff Sher

reply
Hannah

Many thanks for your swift reply. Sorry to start a new comment but I can’t seem to reply to your post. The want to measure hcg again to see if it has doubled, am I right in thinking though that hcg this high wouldn’t necessarily double in 48 hours? This has caused a lot of worry after years of trying to conceive and I don’t want to be worried without due cause.
Thanks again

reply
Alexa

Hi!

Commenting again after my lab work. So I got my HCG done today. It was 185.

So 6/8-17
6/10-28
6/12-28
6/15-71
6/17-185

They still think it will be an abnormal pregnancy, but I have such a good feeling. I would be 4 weeks 4 days.

Any thoughts?

Thank you!

reply
Dr. Geoffrey Sher

Again. I suggest you wait until an US at 7 weeks which should be definitive.

Geoff Sher

reply
Alexa

Dr. Sher,

My fertility specialist is convinced it is an ectopic and wants me to get in with him to have a biopsy of the uterus to see if it was intrauterine or ectopic, but I feel as tho this is too soon to do this and we should track the HCGs a bit longer and then do the US before doing any definitive treatment?

He also, recommend I not restart my progesterone, but my
Regular OB said it can’t hurt and recommended that I restart it…what are your thoughts with the jump of 71 to 185 with an possible ectopic?

I did start spotting a bit today.

Thank you!
Alexa

Dr. Geoffrey Sher

Very Respectfully,

I personally would recommend taking the progesterone, then wait about 10mdays and then do an US to see whether there is an intrauterine sac. In the meanwhile I would be on the be on the lookout for any severe abdominal pain or bleeding and go directly to see your doctor or to the ER if it occurs.

Geoff Sher

Good luckQ

LaDawn

Dr. Sher,

I’m feeling a bit defeated!
9dp5dt HCG 17
11dp5dt HCG 35
13dp5dt HCG 104

To me, they are doubling which is what I’ve understood to be the most important factor. However, my doc said 17% chance of this being a viable pregnancy and seems to be convinced it is ectopic. I’ve been through this nine times over, accusing pregnancy twice. The first I miscarried at 6.5 weeks, and this pregnancy.

Are these levels really so low to be concerned? Do you agree with the assessment of only 17% viability?

Thank you!

reply
Dr. Geoffrey Sher

I do not see a problem. I think the hCG levels are rising adequately.

Geoff Sher

reply
LaDawn

Thank you for your response! So, your opinion is that a low initial beta does not necessarily mean a poor prognosis?

reply
Hannah

Dear Dr Sher,
I am wondering if you can help me. My beta hcg was measuring 18,000 at 6 weeks pregnant. 48 hours later it had risen to 22,015. A live foetus with a heartbeat was also seen on scan. My doctor said as hcg has not doubled in 48 hours that this indicates a miscarriage but I was under the impression that doubling slows down once levels are this high. Can you shed any light?
Many thanks

Dr. Geoffrey Sher

I do not necessarily agree. However, I would repeat the US in 1 week and asceratain whether alll is OK.

Good Luck!

Geoff Sher

LaDawn

Hello,

Hoping you might ease my mind. My follow up HCG Levels were as follows, in addition to the three previous levels provided:

16dp5dt HCG 367
20dp5dt HCG 1157
I am now 5w 4d pregnant. My major concern is now that my doubling time is increasing and my HCG is still at such a low level.

Do you consider this to be an appropriate increase?

Is it of concern that my doubling time is slowing at such a low level?

Do you think this level is suggestive of a viable pregnancy given that I have (combined) a lower HCG that seems to be slowing in its rise?

reply
Dr. Geoffrey Sher

At this point, I would not be over-concerned. Wait a week and do an ultrasound for a definitive answer.

Geoff Sher

LaDawn

Thank you for some reassurance:). So, in your opinion, having a low initial beta doesn’t indicate a poor prognosis for this pregnancy?

reply
Dr. Geoffrey Sher

It is of course more reassuring when it starts off higher. However a doubling effect (every 2 days) bis equally encouraging in my opinion.

Geoff Sher

reply
Luana

Hi,
5 day transfer was on October 30th. On November 11th HCG was 13, on the 13th was 27, and on the 15th 83. I know that’s really low…. but it is doubling. Thoughts?
I just had an anembryonic loss in February.
Thank you!

reply
Dr. Geoffrey Sher

It is impossible to say for certain, but given the doubling of hCG level every 48h, I do see hope for you here.

Please keep me in the loop!

Geoff Sher

KAR

I did IVF and embryo transfer was on 05/25 and on 3rd of Jun hcg level is zero what des its mean

reply
Dr. Geoffrey Sher

I am afraid this does not bode well. The cycle has probably not worked.

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).
My answer to patients who ask me when is the time to stop undergoing IVF is ….Aside from the weight of the financial burden, the time to stop is when in spite of thorough and comprehensive evaluation, there is no remediable and treatable explanation for repeated failure.

Geoff Sher

reply
MARIA ROHAZE Te

i had a scan done at 6weeks and 3days but no heartbeat yet. a day later i bled and i thought i miscarried. the scan showed a sac w a yolk and my hcg was 25000. my cervix was also closed. 2 days later my hcg came up to 48000. is there hope for a viable pregnancy still? no more bleeding since that night.

reply
Dr. Geoffrey Sher

I would definitely repeat the US after the weekend!

Geoff Sher

reply
Rachel

I had a HCG test at 14 dpo which was 50.7 and repeated on 19dpo with a result of 97. The levels aren’t increasing will this pregnancy fail or is it an indicator it’s ectopic?

reply
Dr. Geoffrey Sher

I am afraid this does not look very promising. Repeat the hCG test in 2 daily intervals . It should double each time .

Geoff Sher

reply
Destiny

My obgyn called last Thursday said my HCG was 9000 I haven’t had a period since March 10 and she doesn’t know how far along I am. Everything I read says 6-8 weeks could this be true?

reply
Kate

Dear Dr Sher,
My hcg at 16po was only 24, and I have been spotting since 14 dpo, with a brief period of light/moderate bleeding and cramping yesterday at 18dpo. I was figuring I was probably starting to miscarry, but just found out my betas more than doubled in 44 hours (hcg 63 at 18dpo), and now the bleeding has slowed to light spotting again. Does the doubling of hcg mean there is hope for this pregnancy? Can a pregnancy start with low hcg and 5 days of spotting/light bleeding and still be viable?

reply
Anna

My RE transferred (FET) a 6day blast and on 9dp6dt my beta was only 70. Then two days late 101. They want me to continue meds and come back in two days. If the numbers aren’t doubling and the pregnancy isn’t viable do you know why they want me to come back and continue meds? It seems like it’s just delaying the inevitable.

reply
Dr. Geoffrey Sher

You absolutely should repeat the beta hCG in 2 days. That one lowish second beta could be an aberration.

Good luck!

Geoff Sher

reply
Jasmine

Hi, Dr. Sher:

Here are my numbers:
12/11/19 – 4 weeks, 2 days (17 DPO): HCG – 898, Progesterone – 15.3
12/13/19 – 4 weeks, 4 days (19 DPO): HCG – 2,065

I miscarried before, and I am fearful it is because of low progesterone. My doctor refuses to put me on prometrium but I don’t think it would hurt.

What do you think about my HCG numbers with progesterone levels? Do you think I should advocate for the prometrium? I have an ultrasound on Monday, 12/23 @ 6 weeks.

Dr. Geoffrey Sher

I am rather optimistic about this pregnancy. I hope I am proven correct!

Good luck!

Geoff Sher

laxmi karki

Hi,Dr.i am 6w4d pregnant according to LMP. My hcg on 14/04/2020 aas around 2000 and hcg on 22/04 was 13000. I had on and off dark pink to brown spotting for 2 weeks and previous history of 2 early miscarriage.i had done dating US on 17/04 but didny see anything.I am just concerned with my pregency.

Dr. Geoffrey Sher

There is cause for concern here. You need to do an US to determine definitively what is going on.

Geoff Sher

Naty

Dear dr. Sher,
I have had a transfer of 2 frozen blastocysts on 8 March 2017. On day 15 after transfer (23 Mar.), my HCG was 7000. Do this numbers mean that I have twins? thank you in advance for the answer!

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Marianne

Dear Dr Sher

I recently had a 5day FET. I had me beta tested at 15dpt so approx 4 weeks 5 days and hcg was 1010. They said they were happy with this result and so wouldn’t retest. I am now waiting for my scan but so anxious that my levels might not be increasing and although pleased with my result really wished they’d retested for peace of mind! Once levels have reached over 1000 does this indicate more chance of a healthy pregnancy? Thank you!

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Dr. Geoffrey Sher

I agree that it would perhaps have been reassuring to repeat the hCG test 2 days later to see if it has doubled. This having been said, an ultrasound examination should soon be able to reveal tangible evidence of a developing pregnancy.

Good luck!

Geoff Sher

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Mariam

Dear dr. Sher,
I have had a test of the natural killer cells of my endometrium before I started IVF. This test show no significant immunological alterations. I have had 2 miscarriages and I am going for my third IVF attempt. After my first miscarriage I have had Methylprednisolone 4 mg per day. My doctor suggests Intralipids (and Methylprednisolone 4 mg and Clexane 40 mg) for my third attempt. If I had elevated NK cells I would understand this suggestion. I am in doubt. Would Intralipids improve the chance?

Kind Regards, Mariam

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Dr. Geoffrey Sher

Uterine cytokine analysis is in my opinion often wrong and the NK cell concentration is irrelevant. You need to be tested for uterine NK cell activation, using the K-562 target cell test.

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

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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Amanda

Transfered 2 5 day blasts
8dp5dt 15
10dp5dt 36
15dp5dt 293
US & beta in 1 week
Thoughts on this being a viable pregnancy please!

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Brigitte Adams

I had FET of 1 PGS normal (day. 6 5bb) embryo . My 1st beta was 90…then 48 hours later 86 and 72 hours later 78. Is there any hope at all? This was my only surviving embryo from eggs I froze 5 years ago at well known clinic in CO. Not getting any feedback from my Doctor. I had a myomectomy 5 months ago so should be no issues with there and my lining was 10 triple. Any feedback you have would be great… I am a wreck.

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Dr. Geoffrey Sher

I am afraid that on the face of it, this does not look good.

Good luck!

Geoff Sher

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Amanda

Ty for the fast response! My last transfer of 2 embryos ended in a cp due to possible chromosome abnormalities. (testing wasn’t available when retrieval was done.) With my successful cycle at 15dp5dt my hcg was 1,000. Why so low this time around? Do you think this is a low start? All embryos were 5d, frozen, and from same retrieval.

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Amanda

Results are in!

8dp5dt 15
10dp5dt 36
15dp5dt 293
22dpd5t (5w6d) 4,366
Ultrasound showed a gestational sac & yolk sac measuring on the small side, 5w2d (4 days behind.)
Any concerns? us & beta again in a week.

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Amanda

Ty. Isn’t being behind in size alarming since the exact conception is known with IVF. Also loss of preg symptoms for 3 or 4 days now. Going crazy from all the worrying.

Dr. Geoffrey Sher

Just hang in there Amanda. there is nothing you can do except wait it out.

Good luck and G-d bless!

Geoff Sher

Amanda

I can finally relax as yest we not only saw, but heard a strong heartbeat! Just want to say thank you for creating this site & taking time to answer people’s questions. For anyone starting out on the slow side with hcg levels keep the faith and stay off the internet!

Dr. Geoffrey Sher

So happy for you Amanda!

Good luck and G-d bless!!

Geoff Sher

shailey

Hi Dr,
I am trying to conceive through natural way. This is my 8 DPO and my beta hcg is only 8.37 mIU/ml. Is it a pregnancy or not because I have learned that any level below 10 mIU/ml is considered non pregnant?

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Dr. Geoffrey Sher

It is too early to reach any definitive conclusions. Wait 7 days and repeat the beta.

Good luck!

Geoff Sher

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shailey

Thanks Doctor. But is it true that anything below 10 mIU/ml is considered non-pregnant?

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Dr. Geoffrey Sher

Not true! What is more important is to see a (roughly) doubling every 2 days nis early pregnancy and ultimately a few weeks later, ultrasound confirmation of a potentially viable pregnancy.

Geoff Sher

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Janet

LMP May 27
Faint Positive home tests June 20-23
Blood test hcg zero today June 25, but then another faint positive home test this evening. 200 mg daily progesterone support since day 17 of cycle.

Any insight on the conflicting pregnancy test results? Can you have a false negative blood test?

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Dr. Geoffrey Sher

Doesn’t make sense. Repeat the blood test in 2-3 days!

Good luck!

Geoff Sher

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Elisa

Dear Dr.
I had two three day embryos transfered 19/12/16, my first beta 12/30/16 was 83 and the second 01/05/17 has been 749. Do you think the value is increasing correctly?

Thank you very much for your answer.

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Rohan

Dear Doc, we conducted iui on 14th Dec. Our last lmp was on 28th nov. Hcg level on 30th dec was 67, on 2nd Jan was 161 & on 6th Jan was 858. We would like to request your opinion about how do you think it is growing & any insights that you can help us with. Regards, Rohan Dodal

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Rohan

Dear Doc, are there any concerns due to low hcg values. Also, my wife had vomiting & pain below today in morning.

Dr. Geoffrey Sher

I cannot answer that question authoritatively without MUCH more specific information. …Sorry!

Geoff Sher

Mariam

Dear dr. Sher,
My third frozen transfer failed. I have a question. I have had a test about endometrial receptivity in a mock cycle on day 22. The test advises to do the transfer in the same conditions: day 22 and P+5.5 (five and a half day of progesterone). My hospital has done the transfers (frozen transfer on which assisted hatching was performed) on day 22 and P+4 or P+4.5 (four and a half or four days of progesterone). How important for my window of receptivity is this one day less or more of progesterone. What would you advice?
Kind regards, Mariam

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hannah

mybeta hcg 14dpo was 37 then 16dpo beta was 120 is that good? ive had backcramps no bleeding i have ultrasound on 28th is there a goodchance normal pregnancy pregnant through ivf

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Maria

Dear dr. Sher,
I have had a transfer of 3 frozen blastocysts on 10 November. On day 15 after transfer (25 Nov.), my HCG was 209. I have had morning sickness from 15 till 22 Nov., but the nausea is totally gone from 23 Nov. I don’t have a positive feeling about this. What is your opinion?
Kindest regards, Maria

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Dr. Geoffrey Sher

Symptoms are subjective….Repeat the beta hCG and if it is >1,00MIU/ml, get an ultrasound done.

Geoff Sher

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Maria

Dear dr. Sher, thank you for your reaction. I requested a second Beta yesterday 29 November. The HCG was 359. The HCG has risen 72% in 96 hours. This will be a miscarriage? Kind regards, Maria

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Savannah

Hello.

My LMP was 5/31. They’ve been normal. 5-6 days of bleeding and then starting again exactly 28-30 days later.

Had some bright red bleeding early morning of 7/12. Then spotting then nothing. Had U/S measuring me at 5weeks0days. According to my lmp I should have been 6weeks0days. Just a gestational sac. No yolk. No fetal pole.

HCG on 7/12 was 9,360.

Today on 7/14 came back 17,400.

So hcg rising but no yolk and measuring a week behind. Your thoughts?

Dr. Geoffrey Sher

Repeat the US in 1 week. It might be a little early for certainty one way or the other.

Good luck!

Geoff Sher

Nadie

Dear Dr. Sher,
I just did an FET on 11/11 and my first beta was 11/23 at 158. The repeat was two days later and came back at 415. I asked for a third, which was scheduled for 3 days after the second and it is 1046. Should I be concerned that my doubling times have slowed down?

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Nadie

Thank you so much! You’ve put my mind at ease, so I can relax and wait for my ultrasound.

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Vik

Dear Dr. Sher, We’re a couple of Indian descent (wife: 39, me: 41) and have been trying to conceive via IVF for a year or so. On Oct 31 we transfered 2 frozen 3 day embryo’s (8 cells, between the “best and second best grade”)

On Nov 11 we did our first HCG and it was 485
On Nov 13 HCG was 1735
We’re scheduled for a 3rd HCG and doctor’s appointment on Nov 15th.

While we’re excited about good HCG numbers and a great increase rate, we’re worried that it might be too fast growing. Does this bring us within the potential of Molar Pregnancy possibilties?

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Judy

Dear Dr. I had an iui with trigger shot. Having hcg test every 48 to 72 hours. My levels are as follow: 13dpo 15, 16dpo 88, 18dpo 150 does this seem like a viable pregnancy? Is there any hope with low hcg numbers?

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Sherelle

Hi Dr. Sher,
I had a frozen embryo transfer 14 days ago. My first bhcg test was done 10dpt and my level was a 4. The nurse said that she was sorry but it probably wasn’t a viable pregnancy but come on 10/22 and do another hcg level. I went back on 10/24 and my level was 11 so the nurse said to come back on 10/26 to do another hcg level. Now I have seen the hcg blood level chart that you posted in an earlier comment and that some pregnancies start off with low bhcg levels. I am encouraged by that and I believe God has the last say in this situation but would like to get your thoughts on this being a viable pregnancy.

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Alexandra Harvey

Hi Dr. Sher –
I transferred a single five day embryo on October 11th. 6 days after transfer my HCG levels were 35. At 9dpt, rose to 190. At 11dpt, rose again to 487. At 7 days after transfer I started experiencing some spotting that continued to the 11th day that turned into light to moderate bleeding. I had my HCG drawn again this morning at 13dpt and my HCG had plateaued at 486.
Is this a chemical pregnancy? Is there a reason why my numbers continued to rise so well despite experiencing spotting early on? Is there any chance this pregnancy is viable?

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Dr. Geoffrey Sher

Repeat the beta in 48H to see if it doubles. If so, arrange for US confirmation in 2 weeks or so. If not, it could be a chemical pregnancy or a tubal pregnancy.

Good luck!

Geoff Sher

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Kelsey

Hi! I just went through my 4th IVF cycle but it was the first FET we have ever done. Yesterday (13 days past 3 day transfer of 2 embryos) I did an HCG blood test (it didn’t indicate it was a beta, just said HCG) the result was 40.9 U/L, and at the bottom of the paper it says anything over 30 means positive pregnancy test. We were over the moon yesterday and so excited to finally be pregnant first time in our lives. But I called my doctor this morning and he said the number is low and to go into the clinic and do a beta HCG test to see what’s up tomorrow. He also said that lab might have different range of what is a positive HCG level. I don’t understand, what is the difference between plain HCG and beta HCG? Is that number really low of 13dp3dt? Is there still hope? We are hoping it will double by tomorrow. Thank you for your help!

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Dr. Geoffrey Sher

I think guardedly that this is good news. The hCG test and beta hCG test is one and the same thing. Repeat the test in 48H. It should double. Good luck!

Geoff sher

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Tsitsi Chitiza

I did IVF and embryo transfer was on 11 Sept 2016. My first beta on 21 sept 2016 was 17. Whats your opinion.

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Dr. Geoffrey Sher

You need to repeat it in 2 days. It should more or less double every 48H .

Geoff Sher

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Maja

Thank you!
I did US yesterday and it showed 14mm gestational sac with yolk sac and there were signs of fetus pole, still no heart activity. Dr says it’s normal for 5w5d and that I should do another US in 10 days.

Forgot to say that I’m 42, no kids and got pregnant naturally… so I’m worried because of age and everything. First time when I got pregnant, 6 months ago, it was a blighted ovum, but beta was low from the beggining and not doubling.
Thank you for your time ones again 🙂

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Tiffany Langford

Hello. I’m a hopeful gestational carrier for my friends and am 5w1d pregnant. We had our 5 day blastocyst transferred on July 5th followed by a positive test on the 14 and my first hCG beta at 135. The next was 48 hours later at 173. Not a good rise. The next two were 351, then 613. Appropriate rises. They are still very concerned about that initial rise and said ectopic is a possibility. Today my 5th beta at 17dp5dt was 1224-finally doubled. I’m scheduled for an ultrasound next week right at 6wks. What would you suggest might be going on here?
Thank you.

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Dr. Geoffrey Sher

Hi Tiffany,

Yes this is an abnormal rise in beta hCG and indeed a failing uterine implantation or an ectopic needs to be ruled out. However, it could still be OK… so until the US examination it is not possible to tell will any degree of confidence.

Sorry!

Good luck.

Geoff Sher

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Tiffany Langford

Thank you for your response. Could you explain what “A recovering implantation, destined to develop into a clinical gestation” means?

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Tiffany Langford

I found a different explaination in your reply to someone on April 28. I hadn’t considered a chemical pregnancy since my numbers are still rising. Thanks.

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James Kemp

My business partner acquired a sample a form form using this http://goo.gl/qhoxAJ

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tracy bullis

Great Article. comments ! I loved the facts , Does anyone know where my assistant can access a template a form version to use ?

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Dr. Geoffrey Sher

Not sure I understand precisely what you are looking for.

Geoff Sher

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Gloria

Hi! I had an IVF with 2 day 5 blastocysts transferred on June 27,2016. My first hcg value 14 days after transfer was 1,046 (July 11, 2016) with repeated test (July 13, 2016) at 2,241. Did ultrasound at 5 weeks 2 days with only one gestational sac identified. Is it still possible to be a twin pregnancy with another sac still not showing? I was really hoping for twins as crazy as it may sound.
Thanks!

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Dr. Geoffrey Sher

Unlikely Gloria! It might have started oof with >1 but with all but one absorbing.

Good luck!

Geoff Sher

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Celeste Rojas

A few positive at home tests and after my first blood draw I am only at a 35. I’ve been scheduled for a first visit a month and a half from now and no follow up blood draw has been ordered. Is this normal? They believe I am roughly 4-5 weeks. This seems so low (I did find out very early one when pregnant with my first daughter and I tested 27 at 4 weeks) and also a very long time to wait for any follow up confirmation. They pretty much asked that I wait til my scheduled appointment and notify them if I start bleeding or have any one sided pain.

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Dr. Geoffrey Sher

I respectfully suggest that you do 1 or two additional hCG tests spaced 2 days apart to see if the hCG is doubling every 48h as it should. It is in my opinion not reasonable to make you wait that long.

Geoff Sher

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Lauren W

Dr. Sher,
My beta at 13dp5dt was 257. Beta #2 scheduled for 15dp5dt. Do you think 257 is low for 13dp5dt?

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Dr. Geoffrey Sher

No I think it could be OK provided the next beta shows a doubling over 2 days.

Geoff Sher

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Lauren W

Update:
13dp5dt: 257
15dp5dt: 258
17dpt5dt: 316
19dp5dt: 624
21dp5dt: 1,012
Crazy numbers. Ultrasound scheduled for Monday (26dpt5dt). We’re told to be cautiously optimistic and possibly both embryos took and one did not make it. Realistically – any hope?

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Courtney

Good Evening,
At 5 weeks ish- I was at 4012 and 51 hours later I was at 6221. It didn’t double but I heard after a certain value it can slow down. Should I be concerned with this level?

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Y&D

I just completed my first IVF CYCLE. Ive never been on any fertility meds before until this cycle. We transferred 1 frozen embryo (grade 4ab) 5day blastocyst . My first beta was on 10dp5dfet and my hcg is at 5.8. Is there still hope for a positive pregnancy?

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Rebecca

After a miscarriage at 9 weeks a years ago, I had a positive home pregnancy test on a natural cycle. My first beta at 14 dpo was 452 and my second 73 hours later was 2070. While I am happy about these high numbers I am now concerned they are too high. Do you think these are signs of a Molar pregnancy or Downs Syndrome?

Thank you,

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Dr. Geoffrey Sher

No I do not think there is reason for concern…..

Good luck!

Geoff Sher

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EYA

Dear Dr

i have nk cells at 19% and slight sticky blood. upon BFP i started duphaston and 10mg prednisone.
my 1st hcg was 982.
96 hours later it was 3296.
96 hours later it was 5445. Upped to 20mg prednisone. Cervical scan three days later showed a gestational sac and yolk sac that measured ard 5 weeks gestation. by LMP i should be 6 weeks. I started my clexane.

Could be it recovering implantation? I am due to see my dr in 3 days time.

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EYA

why i said its recovering implantation is cos the first scan, my dr cant even make out if thats a sac. But 3 days later we saw a gest sac and yolk sac..
Could it be possible?

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Dr. Geoffrey Sher

Please give me the entire statement where this was mentioned so I can see what you are referring to.

Geoff Sher

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EYA

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.

Dr. Geoffrey Sher

Thank you. What was implied is that it could be possible for an embryo to get off to a slow start or go through a regression with regard to its implantation status and thereafter recover and improve its implantation performance. Of course this is a theoretical possibility only, but logically it is a potential scenario.

Geoff Sher

Maja

Hello,
I am currently 6w3d pregnant. I had a m/c two years ago and am really worried about this pregnancy as well: my bhcg levels at 5w were 966, then at 5w4d just 1.151. I had an US on the same day and there were a GS (0.52 cm) and a YS (0.25 cm) clearly visible. I have another US tomorrow. My doctor told me everything does llok pretty normal and that a heartbeat should be visible tomorrow but if not I shouldn’t worry, it can happen a few days later. The bhcg levels still worry me. I did not go for another blood test because my doctor advised me not to – she said it would only confuse me. But I am extremely nervous about the US tomorrow.
What do you think about these bhcg levels? Is there hope that everything will be ok tomorrow? I do still have all the symptoms as before – tender breasts, bloating, fatigue and food cravings (no nausea so far).
Thank you so much for your help and I do apologize for my English – I am not a native speaker.

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Dr. Geoffrey Sher

You are correct, this is slowish rise in the beta and yes…it could go either way. The ideal time to do an US is closer to 7 weeks.

Good luck!

Geoff Sher

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Maja

I just had the US and there was a heart beat of 107 and the measured age is 6w not 6w4d. the size is 0.36 cm. The doctor said everything looks fine although the heart beat is a bit slow. Do you think it’s too slow?
Thank you so much!

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Dr. Geoffrey Sher

It s on the slow side Maja. Repeat the US in 1 week and reassess.

I wish you well!

Geoff Sher

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Rosie

Hi Dr. Sher,

My hcg at 5 weeks 3 days was 4309 and 6 weeks 3 days increased to 12,201….my RE is cautious due to the slow rise….what do you think?

I have a US scheduled for 3 days time.
Thanks,
Roisin

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Dr. Geoffrey Sher

I think it is fine and expect an ultrasound will confirm this.

Geoff Sher

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Natalie

Hello Dr.Sher,

I’m about 5 weeks and I had my first hcg taken 72hrs ago measuring at 550. I had another one done at the 48hr mark which came back 883 – a 60% rise. One Doctor said I’m between the normal range but just on the low end. Another Doctor said I’m not rising fast enough. Could you shed some light on the accuracy of hcg levels and a viable pregnancy. Thank you.

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Dr. Geoffrey Sher

This is a slow rise and it could go either way with regard to this pregnancy. Wait 1week and then do an ultrasound examination to determine.

Geoff Sher

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Brittney Ferguson

My last period was somewhere between March 17- 23ish. I noted myself bleeding on April 19 around 12am thought it was my period and put in a tampon. When I woke up it was completely dry. On April 19 I took a pregnancy test with my first morning urine and got a very fast faint positive. I went to the Dr later and the urine test I took there was negative. I insisted they gave me a blood test which the did my levels were 5.1 Today April 20 I’ve started bleeding. Is this my period?
I just don’t know what’s going on. I have another blood draw today.

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Dr. Geoffrey Sher

It looks like the cycle failed. Please consider calling or emailing Julie Dahan, my patient concierge. She will guide you on how to set up an in-person or Skype consultation with me so we can discuss your case. 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

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

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Erin

I had an iui and a positive blood test on 3/25. I’ve had 4 hcg draws. 150, after 2 days 385, after 6 days 2520, after 2 days only 3075. They said it could go either way, but they don’t have me coming back until 4/12. Is there really any hope?

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Dr. Geoffrey Sher

Yes there certainly is some hope but only time will tell.You need an US to see if there is an intrauterine gestation. and it could be done now.

Geoff Sher

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Erin

I forgot to mention this. There was a gestational and yolk sac on the day of the 3075 draw.

reply
Kayla

Is 7000 hcg levels normal for 5 and half weeks pregnant.i woke up this morning with light pink spotting.january 5th I had a miscarriage and I missed my period on the 9th of february.was tested February 17th and levels were 7000.should I be concerned with the pink spotting?please and thank you

reply
Dr. Geoffrey Sher

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 15y 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
e. Ureaplasma Urealyticum (UU) Infection of cervical mucous and the endometrial lining of the uterus, can sometimes present as unexplained early pregnancy loss or unexplained failure following intrauterine insemination or IVF. The infection can also occur in the man, (prostatitis) and thus can go back and forth between partners, with sexual intercourse. This is the reason why both partners must be tested and if positive, should be treated contemporaneously.
Certain causes of infertility are repetitive and thus cannot readily be reversed. Examples include advanced age of the woman; severe male infertility; immunologic infertility associated with alloimmune implantation dysfunction (especially if it is a “complete DQ alpha genetic match between partners plus uterine natural killer cell activation (NKa).
I strongly recommend that you visit http://www.DrGeoffreySherIVF.com. Then go to my Blog and access the “search bar”. Type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.

• The IVF Journey: The importance of “Planning the Trip” Before Taking the Ride”
• Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
• IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation (COS)
• The Fundamental Requirements for Achieving Optimal IVF Success
• Use of GnRH Antagonists (Ganirelix/Cetrotide/Orgalutron) in IVF-Ovarian Stimulation Protocols.
• Ovarian Stimulation in Women Who have Diminished Ovarian Reserve (DOR): Introducing the Agonist/Antagonist Conversion protocol
• Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
• Human Growth Hormone Administration in IVF: Does it Enhances Egg/Embryo Quality and Outcome?
• The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
• Blastocyst Embryo Transfers should be the Standard of Care in IVF
• IVF: How Many Attempts should be considered before Stopping?
• “Unexplained” Infertility: Often a matter of the Diagnosis Being Overlooked!
• IVF Failure and Implantation Dysfunction:
• The Role of Immunologic Implantation Dysfunction (IID) & Infertility (IID): PART 1-Background
• Immunologic Implantation Dysfunction (IID) & Infertility (IID): PART 2- Making a Diagnosis
• Immunologic Dysfunction (IID) & Infertility (IID): PART 3-Treatment
• Thyroid autoantibodies and Immunologic Implantation Dysfunction (IID)
• Immunologic Implantation Dysfunction: Importance of Meticulous Evaluation and Strategic Management 🙁 Case Report)
• Intralipid and IVIG therapy: Understanding the Basis for its use in the Treatment of Immunologic Implantation Dysfunction (IID)
• Intralipid (IL) Administration in IVF: It’s Composition; how it Works; Administration; Side-effects; Reactions and Precautions
• Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
• Endometrial Thickness, Uterine Pathology and Immunologic Factors
• Vaginally Administered Viagra is Often a Highly Effective Treatment to Help Thicken a Thin Uterine Lining
• Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
• A personalized, stepwise approach to IVF
• How Many Embryos should be transferred: A Critical Decision in IVF?
______________________________________________________
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.

Patients are encouraged to share the information I provide, with their treating Physicians and/or to avail themselves of my personal hands-on services, provided through batched IVF cycles that I conduct every 3 months at Los Angeles IVF (LAIVF) Clinic, Century City, Los Angeles, CA.

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

Niki

Hello!

I had a FET on Feb. 26 – 2 great looking embryos
On March 7 (10dp5dt) my first HCG Beta number was 109,
On March 10 (12dp5dt) my second HCG Beta number was 169- So it did not double.
I go in tomorrow for a 3rd blood draw- March 11
Still on Progestrone, and estrogen, baby aspirin but no pregnancy symptoms.
Online beta hcg calculators confuse me more(can you help here too?)
, but the IVF due date calculator has me at 4 weeks and 4 days.
Do you think we still have Hope?

Thank you so much for all that you do!

reply
Dr. Geoffrey Sher

Yes indeed there is hope. However, you will know much more after the next beta hCG test.

Geoff Sher

reply
Sarah

First I’d like to say thank you for providing this service. We hcg tested 9 days after transfer. My levels rose slowly and then suddenly shot up 90%. The numbers were 147,201,298 and finally 574. We go in for our 6w5d u/s in a few days. Could the slow rate of initial increase be a sign of chemical pregnancy or ectopic? Have you seen viable pregnancies with similar numbers?

reply
Dr. Geoffrey Sher

I suspect all will be well but honestly, while I wish I could say for sure…..I cannot. You will have to endure the anguish and wait it out until the ultrasound.

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:
o 3 weeks LMP: 5 – 50 mIU/ml
o 4 weeks LMP: 5 – 426 mIU/ml
o 5 weeks LMP: 18 – 7,340 mIU/ml
o 6 weeks LMP: 1,080 – 56,500 mIU/ml
o 7 – 8 weeks LMP: 7, 650 – 229,000 mIU/ml
o 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:
o A recovering implantation, destined to develop into a clinical gestation
o A failing implantation (a chemical pregnancy)
o A multiple pregnancy which is spontaneously reducing (i.e., one or more of the concepti is being lost) or,
o 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.

Hope this helps!

Good luck!

Geoff Sher

reply
Audra

Transvaginal US
Showed 12mm empty sac 6w no yolk , no pole
I’m 41 he’s 49. Hcg was 17791. Should they be able to see something at that level? Any input sincerely appreciated! No bleeding , lots of cramping which I understand as normal . No symptoms what so ever.

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Ann

Hi Dr Sher,

My first HCG came back at around the 7000 mark for 5 and a half weeks, 2 days later it had only progressed to 9000. An ultrasound was performed at 6 weeks 2 days and heartbeat found (but low at 90 beats per minute). Waiting next blood results. Does the initial rise suggest this is not viable? Thank you.

reply
Dr. Geoffrey Sher

No! I dont think you can go that far in your deductions. The beta hCG slows down in its rise after about the 5th-6th week. The next US will however probably be definitive,.

Good luck and G-d bless!

Geoff Sher

reply
Jag

Hi Dr

My wife and I recently transferred a frozen embryo and we are having a hard time figuring out what is going on. We transferred a frozen day 6 blast on feb 3. We got tested on the 12 and the hcg level was only 15. It went up to 23 on the 15th and we were told to stop all meds. My wife took an at home test on the 17 and noticed the line got brighter. We asked for another blood test and on the 19th hcg was 172. We were told to start all medication again and go test again on the 22nd. Tested again on the 22nd and it was 440. It then went up to 690 on the 24th and and its 980 on the 26th. Is there an explanation for this? We fear this can be ectopic and the whole thing has been a less than ideal situation. We accepted it probably isn’t viable at this point but we aren’t sure how long this can drag on.

reply
Dr. Geoffrey Sher

Yes, it could be an ectopic but it could also be an intrauterine pregnancy. An US done in 10-14 days will be definitive.

Good luck!

Geoff Sher

reply
Jag

Thanks for your response. Given that it was a day 6 blast and the numbers being low and not doubling, we kind of ruled out this being a normal pregnancy. It’s reassuring to know we may still have a chance.

reply
Jag

We had our ultra sound today and it’s not ectopic so that’s a good thing. They did see a small sac however we were told it’s too small ( measuring in at only 6 weeks). We were told to stop the meds and just wait for the miscarriage. I guess it wasn’t meant to be.

Dr. Geoffrey Sher

So sorry Jag,

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

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

Geoff Sher

Kat

Hi Dr Sher,

I had an IUI 13 days ago.
I received a positive hcg result at 11dpo of 25, and then another result of either 32 or 34 (my memory is hazy as I’m upset) today at 13dpo.
I had a trigger shot of ovidrel 250, two days before ovulation.
Is there any hope that this pregnancy will progress, given the slow hcg rise?
Thanks

Kat

reply
Dr. Geoffrey Sher

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:
o 3 weeks LMP: 5 – 50 mIU/ml
o 4 weeks LMP: 5 – 426 mIU/ml
o 5 weeks LMP: 18 – 7,340 mIU/ml
o 6 weeks LMP: 1,080 – 56,500 mIU/ml
o 7 – 8 weeks LMP: 7, 650 – 229,000 mIU/ml
o 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:
o A recovering implantation, destined to develop into a clinical gestation
o A failing implantation (a chemical pregnancy)
o A multiple pregnancy which is spontaneously reducing (i.e., one or more of the concepti is being lost) or,
o 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.

I hope this helps.

Geoff Sher

reply
Maya

Dear Dr.
First of all sorry for my pour English since it’s not my native language.
I did IVF and embryo transfer was on 1/28/2016. My first beta was on 2/8/2016 59.9; 2nd 2/10/2016 103.1; 2/12/2016 159.9 and 2/15/2016 275.8
What is your opinion since values are small and not doubling as it should?
Thank you.

reply
Dr. Geoffrey Sher

This is a very slow rise. It could be a failing intrauterine implantation or a tubal (ectopic) pregnancy. I suggest you discuss this with your RE and be sure that he/she follows up with you.

Geoff Sher

reply
Duha

Hi Dr Sher,

I finally got a positive on Sep 10th 15 days after ovulation, after 3 years since my last pregnancy which ended in a missed miscarriage. My hcg on that day was 97. Sep 14th – 512. Sep 17th – 1620. Sep 21st – 6531. Today, Sep 25th – 21001. I have my ultrasound on Oct 1st, but I just want to make sure if this pregnancy looks like a viable one so far, also is there any possibility of twins with my hcg levels?

Duha

reply
Dr. Geoffrey Sher

I do not think it is a multiple, but certainly the possibility does exist.

Good luck!’

Geoff Sher

reply
Kristi

Went to ER for bleeding and ultrasound revealed a subchorionic hemorrhage and that I was 5 weeks pregnant and too early to detect heartbeat. However, lab work indicated hcg levels were 1600 but 5 days ago they were 2500. They said to come back in 48 hours to test levels again but I was told it was a miscarriage – should I count on that or hold onto hope?

Dr. Geoffrey Sher

This is potentially bad news. Repeat the hCG in 2 days and the US in 1 week!

Good luck!

Geoff Sher

Mandie

LMP September 19th 2020
Slow rising HCG
October 14th 2020 HCG 17
October 21st 2020 HCG 334
October 23rd 2020 HCG 400 (had ultrasound nothing seen in uterus)
October 25th 2020 HCG 656
October 27th 2020 HCG 740
Please give you impression of what is going on. Thanks

reply
Dr. Geoffrey Sher

This is an erratic and slow increase in hCG. You need to be observed by doing an US at 6-7 weeks and be on the lookout for an ectopic at the same time.

Good luck and G-d bless!

Geoff Sher

reply
Mandie

Thanks for your input. I will be having an ultrasound in that time frame. I have no pain, no bleeding, and no fever. I continue to go for blood draws every two days. The most recent Hcg levels were taken October 29th 2020 and were 852.

reply

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