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.

1,377 Comments

Fernanda

Good morning, Dr.! alright? I am from Brazil and I have been following your website. I did an IUI on 1/30 with 4 follicles and my hcg levels were: 12 / 02- 160 mui. 16 / 02-660 mui 22 / 02- 5157 01 / 3- 18000 and 07 / 3-50,000 with progesterone 58. I was worried because from Thursday to the sixth week I think my beta went up slowly and not every 48 hours as in other weeks. it’s worrying?

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Dr. Geoffrey Sher

You need an ultrasound which at this stage should be definitive, one way or the other.

Geoff Sher

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KAshley

Hi Doctor,
First off thank you so much for your post and the expertise!
Last Monday at 5 weeks 3 days my hcg was 14009, progesterone 29.3. Trans-vaginal US revealed gestational sac but nothing else. This Monday my hcg was 32297, progesterone 28.4. Trans-vaginal US revealed possibly a very faint flutter (could not consistently see so not sure if that is reliable) and yolk sac (sorry I should have gotten measurements).
I have a history of a pregnancy last year that had a strong very visible heartbeat at 6 weeks and resulted in missed miscarriage at 10w3d that had stopped developing right around 10 weeks. No levels were done at that pregnancy, tissue testing at D&C was actually lost by the lab so unsure what the complication was.
Unlike the last pregnancy I do not feel pregnant at all (no nausea, no tender breasts, no fatigue) and I am a little concerned that my doubling time is about 5.6ish days with a one point drop in progesterone. Thoughts?
Thank you so much!

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Dr. Geoffrey Sher

At this stage the hCG level will rise very much more slowly. The fact thatthere was a suspision of a HB, is a positive development. Finally pregnancy symptoms can be very subjective.

The bottom line is that you need a follow-up US in about 1 week….which should be definitive.

Good luck and G-d bless!

Geoff Sher

reply
Ally

**corrected transfer date **

Hello,

I transferred a 6AA and 6BA fully hathched and hatching via a modified natural FET on 3/23/20.
My Betas are

3/2/20 370
3/6/20 2205
3/9/20 6478
3/11/20 13,845

Does this mean I have a good chance of multiples?
Is this progression of Beta HCG typical ?

* Has a chemical in January. SO nervous I will be a first time mom at 38 if all goes well. Thanks in advance for responding .

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Dr. Geoffrey Sher

It could be a multiple, but I think it is more likely to be a singleton!

Good luck!

Geoff Sher

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Mary

Hi Dr. Sher,
I became pregnant after stimming/ timed intercourse. I am 4 weeks and 5 days pregnant. I had my first HCG test on Monday, and that was 207. Today I had my second and it was at 336. The nurse said it was lower than they would like, which, of course, made me panic. They’re having me come in again on Friday. Is this normal?

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Dr. Geoffrey Sher

Only time will tell. Let’s see whether the next beta done 2 days after the last one, doubles.

Good luck!

Geoff Sher

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Sophie

Hi Dr Sher,

Several days before my period was due, I was returning faint positives on urine tests. I then had a blood test done 2 days before my period was due and it was negative. I had a second blood test 3 days after my period was due and the HCG level was 99. A third test 2 days later was 133, so I prepared for the worst.

It’s now been 8 days since that test and I’ve not miscarried and I’m returning very dark lines on urine tests. Could this be a missed miscarriage?

Thank you for your time!

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Dr. Geoffrey Sher

Repeat the hCG test again and if +ve, do an US in a week!

Good luck!

Geoff Sher

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Stephy Zheng

Hello Dr. Sher,

I had a 5 day blast transferred on 2/27/20. Did my blood test on 3/8/20. It came back positive but the HCG level was only 80, estradiol was 215pg/ml, and progesterone was 21.8ng/ml. was the hcg considered low? Thank you

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Dr. Geoffrey Sher

It could still be fine. Repeat in 2 days to see if it doubles!

Geoff Sher

reply
S

Hi Doctor:
IVF, FET of two embryos transfer on 2/26/2020, first beta on 3/6 at 117 and second beta on 3/8 and it reduced to 109 and i have another one scheduled for 3/10-

Is it possible one embryo miscarried and the other is still good?

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Liz

Hi-
My HCG level on 3/4/2020, 11 dpo was 79. Today (3/10/2020) 17dpo my HCG level is 1,446. Is this too high?

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Abby

Hello,

I had two single embryo FETs that resulted in chemical pregnancies (2nd beta didn’t increase). I transfer 2 embryos on 2/14. 7dp5dt beta was 108, 10dp5dt beta was 343. Ultrasound was scheduled for today (6 weeks, 1 day) and the tech couldn’t find anything, not even a sac. I used pregnancy tests through Saturday (because I’m paranoid) and they were registering dark and strong. I have all of the pregnancy symptoms and my stomach has a firm small bump below my belly button like my uterus is growing and hardening.

Any thoughts are appreciated.

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Abby

They searched for an ectopic but did not find one. They’ve started tracking my HCG again and it is continuing to double. I have no symptoms of ectopic. My HCG Monday was 1204 and Wednesday was 2213. Repeating beta Friday.

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Dr. Geoffrey Sher

Hopefully all will turn out well! I would do an US again in 1 week from now and ofcourse…report any sudden pain or bleeding to your doctor.

Good luck!

Geoff Sher

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Megan Bigelow

Hi there! I am five weeks and 4 days pregnant. I have PCOS and went to check my progesterone levels after a previous miscarriage on Monday and it was beautiful at 23.9. I went again on Friday and it had dropped to 17.5. I know its still in range but I am concerned about it dropping. Is this normal?

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Dr. Geoffrey Sher

The progesterone can and does fluctuate. At this very early stage, 17.5ng/ml is still OK!

Geoff Sher

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Jean

Hello Doctor,

I had two 3 day embryos transferred on 2/18. My beta blood HCG test on 3/2 was 67. My blood HCG test two days later, on 3/4 was 174, and then my test two days later, on 3/6 was 171. Is this most certainly signs of a miscarriage?

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Dr. Geoffrey Sher

This is an abnormal rise, but iut could just be due to a start with >1 pregnancy and a spontaneous reduction which would account for the poor rise. An US done in about 10 days would clarify!

Geoff Sher

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Jean

Hi Doctor,

To follow up, on 3/9 the hcg number went up again – this time to 490, but then yesterday it went to 385. The doctor is having me stop all meds. Is this now definitely going to be a miscarriage?

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Maha

Hi dr. I have single embryo transfer (FET) on 2/21/20 11dp5dt hcg levels are 31.35
15dp5dt hcg levels are 124.5
16dp5dt hcg levels are 220.7
I started bleeding from 13dp5dt neither too heavy nor just spotting… Can I have some hope on this or it could end like ectopic pregnancy.. im quite worried about this

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Dr. Geoffrey Sher

Maha,

There is definitely hope! Vaginal bleeding occurs in about 25% of all pregnancies. When it happens, it almost invariably raises the concern of pregnancy loss (miscarriage). Undoubtedly, 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.

My hope is that this will happen in your case too!

Good luck and G-d bless!

Geoff Sher

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Anne

Good morning Dr. Sher.
I went for an ultrasound at 5 weeks 5 days (transabdominal) all they could see was a gestational sac. The day before my hcg was 12538 and two days later only 15912.
Does this mean something is wrong?
Thank you.

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Dr. Geoffrey Sher

An US at <6 weeks is often unreliable...especially when done abdominally.

I would repeat and do a vaginal ultrasound in 1 week when then fndings would be definitive.

Good luck and G-d bless!

Geoff Sher

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Maya

Hi Dr Sher,

I’m 32 years old. I had an IUI last cycle and had a bHCG level of 58 at 14 dpo. Today (16 dpo) I had another blood test and the HCG levels were 104. Are these good numbers or is it too low?

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Allie

I had IUI and on 14 dpo my beta level was 267 and on 16 dpo (today) it is 819.

1. Is this good?
2. Is this twins?

Allie

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Manisha

My hcg is 6.5 and I’m spotting. I got two faint positives three days ago. Is this chemical pregnancy?

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Dr. Geoffrey Sher

Possibly so…but you should repeat the test in 2 days to see whether it doubles (as it should).

Geoff Sher

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Allie

Thanks for responding! I learned that they are not going to do another HCG test so I won’t know anything until my next appointment at 7 weeks. I’ve had a miscarriage before at 8 weeks so I’m worried. Is there any reason to think that my HCG levels suggest I’m less likely to miscarry? As a reminder it was 267 on 14 dpo and 819 on 16 dpo.

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Dr. Geoffrey Sher

I agree with the decision not to do another hCG measurement. Your levels are good!

Geoff Sher

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Kayleigh McMahon

Hi, my HCG levels started at 65 last week and 2 days later went up to 150+ is that α good sign?

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Amber

My first HCG level was 25 on 2/27/20. I had another last night on 3/9/20 and it was 85. I should be 5.5 weeks. I have symptoms. Very positive tests. Do I stand a chance or is this a pretty cut and dry deal? (I’m an RN so I know that’s not a good number). But my OB keeps telling me to not be discouraged just yet. But I feel like I know where it’s headed. Doing a repeat tomorrow just to be sure. But be honest with me….

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Dr. Geoffrey Sher

Amber,

This low hCG and the slow rise does not bode well for a successful pregnancy!

So sorry!

Geoff Sher

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Tiff

Surrogate is almost 6 weeks pregnant. Beta hcg level a week ago was a little over 1000. Today it’s was over 11,000. Only one 5 day blastocyst was transferred. Any chance of twins or is this a normal singleton number?

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Dr. Geoffrey Sher

Could be normal or possibly it split to form a monozygous twin pregnancy!

Good luck!

Geoff Sher

Jaimee T

Hi there
I had my hcg’s drawn as follows
12dpo-7.7
15dpo-22.2
19dpo-32.2
22dpo-158
I’m very confused that they were double then stopped and are doubling again. Is this concerning?

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Dr. Geoffrey Sher

It is too early to tell. As long as the levels double every 2 days from here on out, you have a chance. Then do an ultrasound 1n 14 days for a definitive result!

Good luck and G-d bless!

Geoff Sher

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Haley

Got blood work done and my level
Was 500 (I was about 5 weeks) . 2 days later it went to 552. I have my ultra sound scheduled for Monday. Pregnancy tests are still very positive could it be my level just took longer to double and if I would have had another blood test a day or so later it would have gone up to 1,000?

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natasha

Hello I had 2 mc, both blighted ovum.. with a successful pregnancy in between.
Had the last mc on August 2019, at 10 weeks after finding out by ultrasound there was no baby, just an empty sac.
I had a positive pregnancy test on monday, went for my beta test on tuesday. came back 60.7 (I was 1 day late) did another beta test on Thursday and came back 53.6
I know, again, I will miscarry… but how long can it take for me to start bleeding.? I hate the waiting game.
My doctor says its too early, that i should re test on monday, that it might go up.. but i don’t want to get my hopes up…
What do you think?

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Dr. Geoffrey Sher

I am afraid it does not look promising!

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

reply
Jeanine

Hello I had previously written in about my hcg levels. I am now 7 weeks pregnant exactly. I had a 6 week ultrasound where everything measured 6 weeks and we saw the heartbeat. I had my second ultrasound today at 7 weeks the doctor said I am measuring 6 weeks 4 days and that is within normal range. Do you feel that is accurate? The heartbeat was measured at 104bpm. I see on American pregnancy association 90-110 at 6.5-7 weeks is a good heartbeat but he said he would like to see it closer to 120. What do you like to see the heartbeat at on a 7 week scan? Does this pregnancy sound non viable? Thank you

reply
Dr. Geoffrey Sher

I agree that the US findings are not alarming. However, in my opinion, a HB of 104 is a little slow. Hopefully when you do your US in a week from now, growth of the conceptus will be progressive and the HB closer to 120. Please keep me in the loop!

Good luck!

Geoff Sher

reply
natasha

Last question, why would I have all these problems if I already had 2 perfectly normal and healthy pregnancies before.
They just develop with time?
I already had antibodies tested all came back negative.

reply
Jeanine Smith

Hello so I had my 8 week scan the gestational sac shrunk and so did the embryo and the heartbeat had stopped this is my 2nd time now in a row that this has happened. I will be having a d and c next week. With genetic testing. How common is this to have more than one chromosomal abnormality? They said they will be doing genetic testing on me as well in addition to the tests I had back in 2016 when I got pregnant with my now 3 year old son. Why would I have a healthy baby then but I can’t now? Does it make sense to continue to try or is this something that will most likely keep happening?

reply
Dr. Geoffrey Sher

Hopefully it was sporadic and will not keep recurring. However, before trying again, please consider the following:

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

reply
Rakkileigh

Had a FET on 2/11/20. A little concerned about my numbers:

2/21: 236
2/24: 292
2/26: 413
2/28: 696

Going in on 3/1 for ultrasound.
I’ve read it should double every 48-72 hours…is that correct?
Thank you!

reply
Dr. Geoffrey Sher

Early in pregnancy the numbers should double every 2 days. Keep an eye on the rise in the days ahead and then do an ultrasound in about 10 days for a definitive answer.

Good luck!

Geoff Sher

reply
Ive

Respected Doctor,
My bhcg at 19dpo was 1801 and at 21dpo it was 3357. Is this ”not doubling in 48h” a concern?
I was in the US at 5 weeks + 1 day and only a gestational bag was seen.
Thank you very much
Ivana

reply
Dr. Geoffrey Sher

The hCG riser is adequate and it is too early to rely on US. Give it another 10 days!

Good luck!

Geoff Sher

reply
Nicole

Hi Dr. Sher. I am 43 and my day 14 hcg came in at 24. I know
I have to focus on this number doubling and not so much the low number but what are the chances that my numbers will double if I am starting so low at 24? Thank you!

reply
HEATHER GORSKI

Good morning! We just completed a 5 day FET with a transfer on 2-11-20, my levels came back on 2-24-20 at 1265. I am terrified it is multiples. I have done IVF 6 times and was only successful 1 time 5 years ago. I truly wanted it to work this round and was tired, I went against my better judgement and put in two embryos. My next draw is this morning and I am embarrassed to say that the sadness is overwhelming even thinking that there may be multiples. Do have cause to worry and how often are the HCG levels really an indication of multiples.

reply
Dr. Geoffrey Sher

Repeat the hCG in two days to see how it rises. If it >doubles, a twin pregnancy woulod be a possibility. However, in the final analysis you will not know, until an US is done in about 2 weeks time.

Good luck!

Geoff Sher

reply
Divya

HI Doc, i had 10,000 IU HCG trigger shot on 11 Feb 20 and had IUI on 12 Feb and 13 Feb. I tested today (25 Feb 20), my beta HCG level is – 98.6

Could it be my trigger shot HCG or am i pregnant.

Thanks

reply
Michelle

I’m probably about 5-6weeks and Monday my levels were around 3300 and two days later Around 4400. Is this bad?

reply
Dr. Geoffrey Sher

I would do an US in a week or so for a definitive answer.

Good luck!

Geoff Sher

Dr. Geoffrey Sher

I understand!

Just hang in there.

Geoff Sher

Rozy

Hi doc
I went for ultrasound at 7 weeks,baby was measuring 4.36 mm and was behind at 6 week 1 day heartbeat 129bpm…..next ultrasound next month….should i be concerned as the baby is measuring 5 days behind ,my specialist not concerned about that,and i also im not feeling any pregnancy symptoms but i stay super anxious

reply
Dr. Geoffrey Sher

I agree with your specialist!

Good luck!

Geoff Sher

TomL

Are these numbers looking good?
2/04/20 – Transfer (5 day)
2/17/20 – 91
2/19/20 – 217
2/23/20 – 841

reply
Rebecca

I did a 3 day transfer on feb 2 The 18 my beta was 323 feb 24 it is 1573. Just wondering if that’s good

reply
Ashley Romero

I am 24 yrs old,
My beta 8dp5dt was 183
10dp5dt was 410
We did a singleton frozen embryo transfer.

My question is do I have good numbers? Multiple?

reply
Elise

Hi Dr,

I had a blood test done yesterday and my HCG level came back at 152 (13dpo). Is this a promising number??

reply
Dr. Geoffrey Sher

Yes it is promising but you need to repeat the test in 2 days to see if the level doubles. If so, it would be an encouraging sign!

Geoff Sher

Micaela Swegle

Hi Dr.
my HCG at 14dpiui was 54 and at 16 days it was only 74 should I be considering that this is a non viable pregnancy?

– Micaela

reply
Dr. Geoffrey Sher

Sadly that is not a very promising rise. I suggest you repeat the hCG test 2 days later to see if it at least doubles (hopefully to >140).

Good luck!

Geoff Sher

reply
Marie

Hi Dr. Sher
I had an IUI on 2/11/20 with mild cramping on day 6 after IUI, and on 2/18/20 they checked my blood, but I’m not sure what these numbers mean. I am on estradiol patches and vaginal progesterone 3 times a day. I will have another test on 2/25/20 to see if I’m pregnant.

Estradiol 616 (was 425 on IUI day)
Progesterone 38.5

reply
Maha

Hi dr. I have single embryo transfer (FET) on 2/21/20 11dp5dt hcg levels are 31.35
15dp5dt hcg levels are 124.5
16dp5dt hcg levels are 220.7
I started bleeding from 13dp5dt neither too heavy nor just spotting… Can I have some hope on this or it could end like ectopic pregnancy.. im quite worried about this

reply
Dr. Geoffrey Sher

Yes! These are good numbers and painless light bleeding in early pregnancy is often benign.

Good luck!

Geoff Sher

reply
Katie

This is Katie here again who posted today 2/20/20. Just wanted to add that I did use Clomid days 5-9 of my last cycle before the positive test so that insurance would cover IVF.

reply
Katie

Hi Dr. Sher,

Thank you for this incredible resource that you and your website are. I’m 43 and this is my first pregnancy though I believe for the past 10 months I was getting pregnant every month with a failure to implant. I would get early pregnancy symptoms then have a heavy, painful period which I usually do not get. No RE or IVF doctor I consulted with believed that I may have been having early loses. Did research, charted my BBTs and figured out that I most likely had low or borderline progesterone. The last IVF MD consulted with did prescribe Prometrium 200 mg BID to be taken intravaginally. I finally got a positive pregnant last month (January) and initial levels looked promising but now not so much. Would appreciate your opinion on the hCG values: 18 DPO 725, 22 DPO 1945, 24 DPO 2845, 32 DPO 3238, 37 DPO 1601. No bleeding or major cramping. U/s on Friday. I’m just bracing myself. Thank you so much.

reply
Dr. Geoffrey Sher

katie,

Go and have an US examination to evaluate for a pregnancy. Sadly, I am not optimistic about the prospects for a viable pregnancy here.

So Sorry!

Geoff Sher

reply
Dr. Geoffrey Sher

Not really because when hCG levels rise above 6,000, the doubling rate slows down.

Geoff Sher

reply
Rozy

Thanks doc i m super worried cause im not having even a single pregnancy symptom

Dr. Geoffrey Sher

Rozy,

Please also bear in mind that pregnancy symptoms are subjective. I have seen many thriving pregnancies where there were virtually no pregnancy symptoms.

Geoff Sher

Rozy

Hi doc
Due to this corona thing my 10 week scan is cancelled as of now. I dont have even a single pregnancy symptom….so my question is can progesterone pills and shot can mask a miscarriage…i had a miscarriage last time too. Im worried coz im not having any symptom of pregnancy and neither im cramping or bleeding ….and now the scan is delayed …..wondering if progesterone is just masking the bleeding ?

Dr. Geoffrey Sher

No Rozy,

In my opinion progesterone will not indefinitely mask a miscarriage.

Try to hang in there….

Geoff Sher

Deepu

I had my beta done yesterday at 7dp5dt. It was 34. I had 3 blastocysts fresh transfer. Is it a good number? Am just so worried.

reply
Dr. Geoffrey Sher

It is a few days early to comment fully but it looks promising to me!

Geoff Sher

reply
Vanessa fulcher

I know that after 6000 hcg slows down but 1st was 10856 2 days later 11705. Wasn’t a full 48 hours but I think it should have rose higher. I’m 6 weeks today.

reply
Dr. Geoffrey Sher

If the US is normal, I would not be overly perturbed.

Good luck!

Geoff Sher

reply
Vanessa Fulcher

Thank you for answering the ultrasound is only showing a yolk sac no fetal pole should I be worried

Dr. Geoffrey Sher

5 weeks 4 days is too early. Repeat in 10 days.

Geoff Sher

Susan

My first hcg (8 dp5dFET) was 165, then 320 10d and then only 520 12dpFET. Should I be concerned that the last hcg only rose 62%?

reply
Dr. Geoffrey Sher

In my opinion, you should repeat the hCG at 2 day intervals over the next 4-6 days and then reassess!

Geoff Sher

reply
Susan

Thank you for your fast reply on Feb 18th. This is Susan. I had another hcg done today-

10dpt 709
This is only a 36% increase so I’m quite worried. My doc has me booked for an U/S at 6 weeks.
Is this looking really bad?

reply
Susan

Hi Dr. Sher

I received another hcg reading-

14dpt 1431

It took 4 days to double and I’m not feeling pregnancy symptoms anymore.

Should I be concerned?

Dr. Geoffrey Sher

The level is rising slowly and it is of concern. Only time will tell!

Good luck!

Geoff Sher

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

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.

Good luck!

Geoff Sher

reply
Ben Ramirez

Our surrogate had her 8 week ultrasound today. Embryo and gestational sac are appropriate for
Singleton pregnancy. Heart rate was 171 and we could see heart beating. Say yolk sac is reading about a week behind. What does this mean? Today’s HCG was 26640. Surrogate has no spotting, bleeding or cramping. Just nauseated and tired. Thoughts?

reply
Dr. Geoffrey Sher

Ben! I do not think this means anything sinister. It will likely correct itself!

Good luck!

Geoff Sher

reply
Ben Ramirez

Our surrogate had her 8 week ultrasound. HCG was 26644. Fetal heart rate is 171, which we could see. Gestational sac present as well as fetal pole. Report says yolk sac is measuring a week behind. What does this mean? Thoughts?

reply
Jessi

Hello Dr. Sher,

I had a singleton frozen embryo transfer of a blastocyst on 01/31/2020. My beta hcg is below

10dp5dt beta hcg: 206
12dp5dt beta hcg: 394

I have another beta hcg schduled for 19dp5dt on 2/19/2020.
Are the numbers good? I’m getting worried that it didn’t double within 48 hours.

reply
Fabienne

Hello Dr. Sher, I’m 41 yr old ,feb17 I transfer 3 frozen embryos. The first 3 days I had little cramping, crazy headache and fatigue. Friday morning went in to do blood work my Estradiol was 111 and progesterone 23 . Saturday night had severe back pain cramps. Not really having symptoms like others females are having should I be worried examples, bleeding, breast soreness, craving etc.Go back on Friday for beta

reply
Dr. Geoffrey Sher

I am afraid, all you can do is wait until your betas are tested.

Good luck! Please keep me in the loop!

Geoff Sher

reply
LaTanya Felder

Hi there
I had 2 fresh blasts transferred on day 5. My first beta at 14 days past transfer was 1928. My second beta today at 18 days past transfer is 7472

What are the odds I’m having more than 2 babies?

reply
Caroline Hagedorn

Hi, I did a fresh Ivf transfer. My results:

7dp5dt: 51
9dp5dy: 88
11dp: 134.5

Have another one scheduled. Very nervous.

reply
Dr. Geoffrey Sher

The rise is a little slow, but it could pick up. Only time will tell!

Good luck!

Geoff Sher

reply
Victoria

I tested positive at 6 days post ovulation—which I’ve read is rare. A blood test 7 days post ovulation confirmed HCG with beta levels at 5,985. From what I’m reading this can’t be ectopic. What else could it be for a healthy 35 year old woman with a first time pregnancy?

reply
Dr. Geoffrey Sher

I find it hard to accept that you truly were actually only 6 days post ovulation with that hCG level. I say this because the embryo only begins to implant about 1 week post ovulation. There must be a mistake here. I suspect that you are 5-6 weeks pregnant. I recommend an ultrasound be done stat to see what is going on.

Please keep me in the loop!

Geoff Sher

reply
Liz

Hi Dr. Sher,

I had a blood test done at 5weeks 1 day PO and my HCG level was only 524. I’ve had a second blood test done and am awaiting results. I’m pretty certain that my dates are correct and am just wonderingif, in your opinion, a healthy pregnancy is possible with such a low HCG rate at 5 weeks?

reply
Dr. Geoffrey Sher

The level is borderline but yes! It is still possible. However, the hCG level should double in the next 2 days.

Good luck!

Geoff Sher

Courtney

Positive OPK 1/26/20 in the AM and went in for IUI 1/27/20. Faint positive home pregnancy test today 2/11/20 and hcg was only 31. I had very light spotting since last Friday but stopped this morning. Any thoughts?

reply
Dr. Geoffrey Sher

I would repeat the hCG test 2 days later . Hopefully it will double.

Good luck!

Geoff Sher

reply
Joanne

I had an ectopic pregnancy in May 2019 after taking Clomid, and kept my damaged tube after being treated with methotrexate. I began the IVF process in October 2019 after being told the chance of a second ectopic via IVF falls to 1-2%, and had 1 pgt-a tested embryo transferred on January 21, 2020. The following are my betas:
2/4/2020 (14dp5dt) – 139
2/6/2020 – 119
2/8/2020 – 188
2/10/2020 – 345.1

I’ve been told that this is a non-viable pregnancy and highly likely to be ectopic due to initially low and fluctuating levels. My levels are too low to have a scan done so my clinic is continuing to collect more data with blood draws every 2 days.

In your opinion, could this be something else other than another ectopic?

reply
Dr. Geoffrey Sher

It is not a normal progression and I agree it could be an ectopic! Your physician needs to watch itclosely!

Good luck!

Geoff Sher

reply
Victoria

My first beta at 10dpo was 27 then at 17dpo 380 so a good rise and appropriate. My next beta at 24dpo only 1600. Not a good increase. I’m now not at all hopeful this pregnancy will be viable and highly concerned it is ectopic filling a mmc in Novemer 2019 and an early loss in June 2019. I’m now in limbo waiting for my next blood test in 2 days but it seems certain to me it is non viable.

reply
Dr. Geoffrey Sher

I think you need an ultrasound done in a few days from now. That should provide a definitive answer.

Good luck!

Geoff Sher

reply
Victoria

Thank you. The scan showed it was definitely not ectopic which is s massive relief. At 5 weeks 5 days we saw the gestational sac and yolk measuring right on time. I’m not sure what my hcg levels are now but I’m not overly confident this will progress to be a normal pregnancy. I’m just so relieved it’s nothing worse. I will have another scan in two weeks if I have not miscarried by then.

reply
Victoria

My hcg increased 53% so again not great. I should mention we have 1 child with t21, 1 miscarriage with t15 . The slow rising hcg makes me think this pregnancy may also be affected by another trisomy.

Dr. Geoffrey Sher

Not possible to so predict. I would suggest chorionic villus sampling (CVS) or amnio if your pregnancy progresses.

Geoff Sher

Victoria Coleman

Thank you for your advice. This pregnancy also ended in missed miscarriage with medical management at home and has been sent for testing. This is our 3rd miscarriage in 10 months so If the POC has a normal number of chromosomes I will ask for further testing on myself. Despite having no other symptoms following an emergency c section and an D&C I wonder if it is possible I have developed Asherman’s syndrome.

Dr. Geoffrey Sher

It is possible but there are many other possible explanations.

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.

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

Jeanine

Hello is a beta of 80 a normal beta for 14 days post iui? I had a medication induced miscarriage in November after an iui. I was 9.5 weeks along my starting beta at 14 days post iui for that cycle was 99 and appropriately did rise. The pregnancy never developed past 6 weeks we saw a fetal pole and a slow heart beat and then it faded over the next couple weeks. The gestational sac from the beginning was small. I was told it was most likely chromosomal. And wouldn’t affect future pregnancies. So my current concern is that my hcg is only 80 at 14 days post iui with this current pregnancy I go in tomorrow for another beta. Is a beta of 80 to start with a bad sign? I am worried this whole thing is happening again. I should note that in 2017 I had a healthy baby that was conceived with iui.

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Dr. Geoffrey Sher

I think that an hCG of 80 at 14 days post IUI is adequate. However, its rate of rise from here on out is even more relevant. At this stage it should double every 2 days.

Good luck!

Geoff Sher

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Jeanine

Thank you for your response, I had my blood drawn again 72 hours after this initial beta of 80. That result came back at 231 the nurse said this was fine not an exact double but definitely within normal range. She said they mostly care that it’s at least a 60% rise. Do you feel that this is accurate and my numbers look good for three days after my first beta? I will be having another draw tomorrow.

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Belinda

Hi there,

My hcg rise was initially doubling every 1.3 days, then second 1.5 days, now at 5 weeks every 48.5 hours and its 3082. I’m worried I will have a third miscarriage. What do you think?

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Dr. Geoffrey Sher

hard to be sure but it looks good to me. Have a confirmatory ultrasound done soon.

Geoff Sher

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Belinda

Thank you.

My hcg increase rate seems to improve each pregnancy but I’m still worried it’s slowing again. Progesterone is high at 116 so fingers crossed. I’ll keep you posted. Thanks again.

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Belinda

**update**
HCG has only risen by about 800 in 48hours. Looks like another miscarriage unfortunately.

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Dr. Geoffrey Sher

Hang in there! Perhaps we should talk.

G-d bless

Geoff Sher
702-533-2691

Belinda

Thanks Geoffrey.

I’d love to chat but unfortunately I’m all the way over here in Australia.

I’d welcome any tips or suggestions though.
Cheers,
Belinda

Dr. Geoffrey Sher

There is no reason why we could not consult online.

Geoff sher

Belinda

I should add I’m 39. I’ve had three healthy babies (last one 12 years ago) I guess I just expected it to be easy 🙁

Belinda

***Update***
Now I’m even more confused.
I had a follow up hcg of 13784 last week 10 days after my last hcg which was at 3975 at that stage. It has sped up (not sure if it’s enough)
Now today I had my 7 week scan with a good size baby (8.8mm) and a good heart beat (122bpm). Do you think this could be viable or do you think I should still brace for the worst?

Dr. Geoffrey Sher

The US findings are somewhat encouraging! Do a repeat US in a week!

Good luck!

Geoff Sher

Alisha Billman

Hi. I’ve had a few US’s that have shown HB’s and I should be about ten weeks along now, but around 5 weeks I had slow rising HCG levels (about 52%). I was told not to worry about the HCG levels now that I’ve seen a heartbeat, but I can’t help but wonder if that is an inaction there will be something wrong with this pregnancy? Could it mean something will be wrong with the baby?

Dr. Geoffrey Sher

Only time will tell! You need to repeat the US’s weekly at this stage to determine.

Good luck!

Geoff Sher

Belinda

***Update****
Hi Geoffrey,
I had my follow up ultrasound today at 9 weeks 1 day and baby is measuring on track but heart rate was 197bpm. The specialist was very positive but I’m still in doubt. That heart rate now seems very high!

This has been the most confusing stressful early pregnancy ever. What are your thoughts? My specialist thinks I only have roughly 10% chance of miscarriage now.

Belinda

Dr. Geoffrey Sher

As of now, I would agree with your RE.

Good luck!

Geoff Sher

Belinda

***update***
Hi Geoffrey,

I thought I’d give you an update since you were nice enough to give me advice over that last few weeks. I had a scan last Monday (11weeks) for some minor spotting. There was still a very active little baby with a heart rate of 170bpm but it’s looking like I have a single vessel cord, omphalocele and a slightly thickened nuchal cord. Two days later I received my NIPT and have been flagged as high risk for mosaic trisomy 9. I have my CVS and another scan on Monday but I’m almost certain these results are correct. I thought I’d share for your research or notes or whatever. If there is ever a stall in HCg that it’s very suspect for a problem. I’ll keep you posted as this particular trisomy is unbelievably rare. Have you heard of it? Is it likely that my previous miscarriages were caused by this? My husband and I had three healthy children together (last one 12 years ago) so I don’t know why we’re having so much trouble now. I’m 39 and my husband is 41. Thanks Geoffrey

Dr. Geoffrey Sher

Trisomy 9 is a very rare developmental defect. Perhaps you would be advised to give it another 2 weeks + and then reconfirm through another US and amniocentesis before intervening to terminate the pregnancy.

So sad for you!

Geoff Sher

Michelle

Egg Retrieval on 1/12/2020

2 Embryo Transfer at 5 days on 1/17/2020 (2 blastocyst 1-HAA-Good, 2-HAB-Good)

1/27/2020 @10 dp5dt- HCG 128

1/29/2020 @ 12 dp5dt-HCG 261

1/31/2020 @14 dp5dt-HCG 481

2/4/2020@18 dp5dt-HCG 777

2/6/2020 @ 20dp5dt-HCG 660

I am really concerned about the decrease in HCG level from 777 to 660. My provider advised it could be a loss of one of the embryos and not both. Is this common? Or should I consider myself out this cycle?

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Dr. Geoffrey Sher

I agreee with your concern. Repeat the test in 2 days time. It needs to be >12oo. Then sdo an US examination a week later to get a definitive answer.

Good luck!

Geoff Sher

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Michelle

Egg Retrieval on 1/12/2020
2 Embryo Transfer at 5 days on 1/17/2020 (2 blastocyst 1-HAA-Good, 2-HAB-Good)
1/27/2020 @10 dp5dt- HCG 128
1/29/2020 @ 12 dp5dt-HCG 261
1/31/2020 @14 dp5dt-HCG 481
2/4/2020@18 dp5dt-HCG 777
2/6/2020 @ 20dp5dt-HCG 660

I am really concerned about the decrease in HCG level from 777 to 660. My provider advised it could be a loss of one of the embryos and not both. Is this common? Or should I consider myself out this cycle?

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Dr. Geoffrey Sher

I am a little concerned about the tail off in hCG. Repeat in 2-4 days to see where it is headed.

Good luck!

Geoff Sher

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Katie W

What do you make of these #’s?

14DPO – 48.10
18DPO – 206.90 (45.61 hr DT)
20DPO – 354.60 (61.76 hr DT)

My RE doesn’t seem concerned as they just look for a 66% increase over 2 days, and even the slower one was a 71% increase. I’m just really nervous as I was hoping for a higher 20DPO number, and the numbers seem low in general. With my daughter, my levels were over 1,200 by now. I just don’t know what to think…

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Dr. Geoffrey Sher

Ib agree with your doctor but only time will tell. Do an US in 1 week to determine the viability of the pregnancy!

Good luck!

Geoff Sher

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Katie W

Just following up here… I really appreciate you taking the time to respond. So, the HCG increase slowed significantly, and then started declining and I got my period. Needless to say that it was not viable. Looking forward to trying again. Thanks again. ~Katie W.

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Denay Davies

missed my period. took 3 urine tests, jan 31, feb 3 and feb 4, all positive, had blood done feb 4, levels are at 5699. is this good?

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Sandra

Hi Doctor!
Is it possible to have a strong positive pregnancy test 7 days after intercourse and HCG 78 from a blood test?

Or is it from an earlier time one week before?

Many thanks

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Dr. Geoffrey Sher

Only if ovulation was triggered with hCG or if this is truly an implanting pregnancy.

Geoff Sher

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Sandra

Hi again Dr!
I’m 6 months pregnant now. But trying to find out which date made me pregnant. 2 possibilities 🙁
This was all natural and no doctor has been able to help me get my peace in mind yet.

Period started the 18th (usually last 5 days)
Had intercourse 29th, 30th, 31th and. 1th. With my partner coming inside.
But then had another time Monday the 9th…..(pulling out method)
On Saturday the 14th I took a pregnancy test and it was positive very clear and strong positive.
And the following Monday 17th I did the blood test saying 78 Hgc level.

I really hope I got pregnant from my partner and not the one time on the 9th…
What are the chances doctor?

This is really making me not beeing able to relax during my pregnancy.
Best regards

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Dr. Geoffrey Sher

It sounds to me as if it happened with your partner around he 1st!

Good luck!

Geoff Sher

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Sarah

Hi Doctor,

We recently got our first BFP after two previously failed cycles. My first beta HCG came back at 85. I am getting my second Beta done on Monday. Do you think this is indicative of a potential early
miscarriage? My doctor said they like to see levels at 150 10dp5dt. I have continued to take HPTs and the line seems to be getting darker … is this a good sign? I’m feeling very anxious.

Dr. Geoffrey Sher

I , in contrast am optimistic. As long as the levels double every 2 days in the early stage of pregnancy. !

Good luck!

Geoff Sher

E

Hi!
I wanted to ask about my case. I’ve been having trouble getting pregnant since I haven’t been ovulating. I did progesterone blood tests and it seems that they are very low at day 23. I took letrozole this month and I am on day 40 of my cycle. The doctor did a blood test for me and said that the HCG came back positive but very low so I shouldn’t get my hopes up. I have a lot of cramps when I walk and some other different symptoms but not staining. I am out of town this week and I won’t be able to come back in for another blood test until next week. I would love to hear what you think. Am I pregnant do I have a chance ?

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Dr. Geoffrey Sher

You need to do a blood quantitative hCG test and if +ve repeat itin 2 days to see if it doubles. However, this does not sound very encouraging, I am afraid.

Good luck!

Geoff Sher

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KaihlaMarie

Last cycle 12/16/19, My hcg level was 43 1/24/20 with bleeding. 1/27/20 hcg is 58 still bleeding. 1/30/20 hcg 68 very little bleeding. 2/1/20 hcg 78 no longer bleeding. Ultrasound shows no sac which was expected due to low levels. I have cysts on both ovaries. Hubby is in military and we have been trying, I dont know what to expect and my ob just keeps saying to wait and see what body does but we know where its headed. I dont! Any clues for an answer?

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Dr. Geoffrey Sher

Sadly, this does not sound very optimistic. Rather, it suggests a failing implantation.

Sorry!

Geoff Sher

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KaihlaMarie

Why do numbers still go up, and how long do they usually continue. I dont want to wait til I see a baby on an US before I lose it. If its gonna happen I wish it would happen sooner rather then later.

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Dr. Geoffrey Sher

Unfortunately it is not in your control.

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.

______________________________________________________
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

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Alexis

Hi Dr. Sher – I had my first FET done on Tuesday 2/11/2020. My beta is scheduled for 2/24/2020 per my team’s instructions. I took a clear blue home pregnancy test and it was negative. How accurate is this? I’m worried. It’s going on two weeks so I though it would be positive. Thank you

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Dr. Geoffrey Sher

If your 1st beta is due on the 24t, then this is much to early!

Good luck!

Geoff Sher

Heather

Hello I had my first beta test today 16 this is 8 days after transfer of 2 frozen embryos. They said that it is a positive pregnancy test and will repeat on Monday to see if it doubles . Is this a good first number?

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Jewel

Hi Dr. Sher,

I had IUI on 2/1/20 and received my first positive IHP test on 2/12. My blood test on 2/14/20 confirmed. My levels have been checked as follows:

2/14- 73 hcg
2/16- 132 hcg
2/18- 196 hcg (difficulty drawing my blood, vein collapsed)
2/20- 306 hcg

My dr wants me to go back on 2/24 to do another blood test. I’m not doubling every 48hrs but every 72hrs. Should I be concerned with the viability of my pregnancy? I’ve had no cramping or bleeding.

Dr. Geoffrey Sher

Yes Jewel!

This is concerning!

Only time will tell!

Good Luck

Geoff Sher

Melissa Rafe

Hi Dr Sher.
I am 39 yrs old. I have had one successful IVF pregnancy 10 yrs ago, fresh transfer, day 5, and one failed frozen transfer of “competent” day 5 blastocyst in Sept 2019. On 2/6/20 I had frozen transfer of one competent 5 day blast. First beta
taken on 2/14 was 10.4
Second beta on 2/16 35.5
My husband and I are being warned by our nurse that while increasing, these numbers may not be indicative of a viable pregnancy. I have a lab order for a third beta to be taken 2/20. We can hardly stand the wait. What do you think of these numbers?

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Dr. Geoffrey Sher

As long as the beta’ keep doubling every 2 days at this stage of pregnancy, you have reason to be hopeful. In about 2 weeks from now, an US should be definitive.

God luck!

Geoff Sher

gEOFF sHER

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Lindsay

Hi there I’m super nervous. ultrasound measures 6 weeks with hcg 47,000 and heartbeat 102, however doctor is concerned baby isn’t growing
… I had 40hcg level Dec 6th. But I ovulated super later abnormal cycle, unsure how many weeks I should be. Super nervous of viability, previous miscarriage.

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Dr. Geoffrey Sher

The HB is on the slow side but hCG is in acceptable range. Unfortunately there is nothing much you can do about this. Only time will tell. Another US in a week mor two will provide a clearer indication.

Good luck!

Geoff Sher

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