– Geoffrey Sher, MD
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Name: Aqsa G
I have suspected endometriosis and very low ovarian reserve. Should I do a laparoscopy for endometriosis, then PRP therapy to increase my ovarian reserve before I retry IVF?
Will this help? My last two attempts at IVF have only ever resulted in one embryo getting to blastocyst, and I’ve had two miscarriages. One at 18 weeks and one at 8 weeks.
Unless you need surgery because of intractable symptoms or you require surgical treatment of ovarian endometriomas, I would not advocate laparoscopy at all. Your miscarriages could well be due to endometriosis-induced , immunologic implantation dysfunction.
When women with endometriosis-related infertility seek treatment, they are often advised to try ovarian stimulation with or without intrauterine insemination (IUI) as a first option. However, it’s important to clarify the reality and set the record straight. In vitro fertilization (IVF) offers distinct advantages and a higher chance of success compared to IUI. Let’s explore why IVF should often be considered as the primary approach for women with endometriosis.
1. The Toxic Pelvic Factor:
Endometriosis causes the lining of the uterus to grow outside the uterus. As these deposits bleed over time, they release toxins into the pelvic secretions. These toxins coat the peritoneum, the membrane that covers the abdominal and pelvic organs. When eggs are released from the ovaries, they must pass through these toxic secretions to reach the sperm in the fallopian tubes. The toxins alter the egg’s envelopment, making it less receptive to fertilization. This explains why women with endometriosis are far less likely to conceive naturally, following ovulation induction or after surgical attempts to eliminate the condition. Consider the following: .
• Ovulation induction with or without intrauterine insemination (IUI) is commonly recommended for women with mild to moderately severe endometriosis. However, while fertility drugs can stimulate the growth of multiple follicles, ovulatory women (including those with mild to moderately severe endometriosis) usually ovulate only one egg a time. Therefore, the use of fertility drugs in such cases doesn’t significantly improve pregnancy potential.
• Surgery to remove endometriotic deposits or adhesions: Surgical removal of visible endometriotic lesions in mild to moderate endometriosis does not usually improve pregnancy potential significantly. This is because endometriosis is an ongoing process, with new lesions constantly developing. Even after the visible lesions are removed, invisible lesions continue to release toxins that can compromise natural fertilization. In contrast, IVF bypasses the toxic pelvic environment by retrieving eggs from the ovaries, fertilizing them outside the body, and transferring resulting embryos to the uterus. This makes IVF the preferred treatment for endometriosis-related infertility.
2. The Immunologic Factor:
Approximately one third of women with endometriosis also have an immunologic implantation dysfunction (IID) related to the activation of uterine natural killer cells (NKa). This requires selective immunotherapy with Intralipid infusions or heparinoids, which can be effectively implemented in combination with IVF.
3. Ovarian endometriomas :
Women, who have advanced endometriosis, often have endometriotic ovarian cysts, known as endometriomas. These cysts contain decomposed menstrual blood that looks like melted chocolate. Hence the name “chocolate cysts”. These space-occupying lesions inside the ovaries can activate ovarian connective tissue (stroma or theca) resulting in an overproduction of male hormones (especially testosterone). An excess of ovarian testosterone can severely compromise follicle and egg development in the affected ovary. Endometriomas of >1 cm in size should in my opinion be addressed because in my opinion, they can and do adversely affect the quality of eggs produced in the affected ovary. We confirmed this effect in a study where we evaluated egg quality in a number of women who had one or more endometriomas involving one ovary while the contralateral ovary was unaffected. We were able to show that those eggs aspirated from follicles in the endometrioma-affected ovary were of markedly reduced quality (and, the embryos and blastocysts they propagated were fewer in number and of markedly reduced quality as compared to those harvested from the un affected ovary.
• Conventional surgical treatment performed to remove endometriomas involvers laparoscopy or laparotomy with aspiration of the cyst content followed by complete removal and/or ablation/obliteration of the cyst wall. This should be done at least 6 weeks in advance of egg retrieval, in my opinion. Such treatment is associated with pain and a risk of surgical complications.
• An alternative approach which I and my colleagues first reported on more than 2 decades ago, known as Ovarian Sclerotherapy is a highly effective, inexpensive and safe outpatient method for treating endometriomas in women planning to undergo IVF. The process involves needle aspiration of the “chocolate colored” liquid content of the endometriotic cyst, followed by the injection of 5% tetracycline hydrochloride into the cyst cavity. Such treatment will, more than 75% of the time result in disappearance of the lesion within 6-8 weeks. Ovarian sclerotherapy can be performed under local anesthesia or under conscious sedation. It is a safe and effective alternative to surgery for definitive treatment of recurrent ovarian endometriomas in a select group of patients planning to undergo IVF. It is in my opinion, unfortunate that Ovarian Sclerotherapy is not readily available in this country.
I am not suggesting that all women with infertility-related endometriosis should automatically resort to IVF. Quite to the contrary…. In spite of having reduced fertility potential, many women with mild to moderate endometriosis can and do go on to conceive on their own (without treatment). It is just that the chance of this happening is so is much lower than normal.
IVF is by far the most successful approach to dealing with endometriosis-related infertility , especially when it comes to women above the age of 35 years, those who have moderate or severe disease and for women who have DOR. Understanding how endometriosis affects IVF outcomes can help make informed decisions about treatment. By providing a more favorable environment for fertilization and implantation. IVF offers much higher success rates when compared to ovulation induction with or without IUI or surgical correction. Simply put……If you’re facing infertility due to endometriosis, it’s worth considering IVF as the first line of treatment to increase your chances of having a baby.
___________________________________________________________
PLEASE SHARE THIS WITH OTHERS AND HELP SPREAD THE WORD!!
Herewith are online links to 2 E-books recently co-authored with my partner at SFS-NY (Drew Tortoriello MD)……. for your reading pleasure:
1. From In Vitro Fertilization to Family: A Journey with Sher Fertility Solutions (SFS) ; http://sherfertilitysolutions.com/sher-fertility-solutions-ebook.pdf
2. Recurrent Pregnancy Loss and Unexplained IVF Failure: The Immunologic Link ;https://drive.google.com/file/d/1iYKz-EkAjMqwMa1ZcufIloRdxnAfDH8L/view
I invite you to visit my very recently launched “Podcast”, “HAVE A BABY” on RUMBLE; https://rumble.com/c/c-3304480
If you are interested in having an online consultation with me, please contact my assistant, Patti Converse at 702-533-2691 or email her at concierge@sherivf.com\
Name: jose s
Buenas tardes Dr
El resultado del examen PGT de mi esposa fue
Sample ID Sample Barcode Result Sex Chromosomes Impacted Interpretation
LB1 2023061467 Aneuploid XY +9 Abnormal
LB2 2023061467 Mosaic XY -Y [mos] Low Level Mosaic
Aconseja implantar el LB2 que es mosaico, que probabilidad de exito y bebe sano
gracias
Please re-post in English!
Geoff Sher
PLEASE SHARE THIS WITH OTHERS AND HELP SPREAD THE WORD!!
Herewith are online links to 2 E-books recently co-authored with my partner at SFS-NY (Drew Tortoriello MD)……. for your reading pleasure:
1. From In Vitro Fertilization to Family: A Journey with Sher Fertility Solutions (SFS) ; http://sherfertilitysolutions.com/sher-fertility-solutions-ebook.pdf
2. Recurrent Pregnancy Loss and Unexplained IVF Failure: The Immunologic Link ;https://drive.google.com/file/d/1iYKz-EkAjMqwMa1ZcufIloRdxnAfDH8L/view
I invite you to visit my very recently launched “Podcast”, “HAVE A BABY” on RUMBLE; https://rumble.com/c/c-3304480
If you are interested in having an online consultation with me, please contact my assistant, Patti Converse at 702-533-2691 or email her at concierge@sherivf.com\
Name: Anne C
Dear Dr. Sher,
Should Omnitrope continue to be taken on the day of the trigger and the next day, all the way till egg retrieval day, or stop two days before, when FSH stops? And what’s the optimal dosage?
Thanks for the kind and expert guidance,
A.C.
No! It stops on the day of the “trigger”.
Good luck!
Geoff Sher
______________________________________________________________________________________
PLEASE SHARE THIS WITH OTHERS AND HELP SPREAD THE WORD!!
Herewith are online links to 2 E-books recently co-authored with my partner at SFS-NY (Drew Tortoriello MD)……. for your reading pleasure:
1. From In Vitro Fertilization to Family: A Journey with Sher Fertility Solutions (SFS) ; http://sherfertilitysolutions.com/sher-fertility-solutions-ebook.pdf
2. Recurrent Pregnancy Loss and Unexplained IVF Failure: The Immunologic Link ;https://drive.google.com/file/d/1iYKz-EkAjMqwMa1ZcufIloRdxnAfDH8L/view
I invite you to visit my very recently launched “Podcast”, “HAVE A BABY” on RUMBLE; https://rumble.com/c/c-3304480
If you are interested in having an online consultation with me, please contact my assistant, Patti Converse at 702-533-2691 or email her at concierge@sherivf.com\
Name: Monika O
I am currently 33 years old and have already had 3 ICSIs. However, the first one was 5 years ago. Last year I stimulated for 2 days with 375 Gonal f and 75 Menopur and then with 225 Gonal f and 75 Menopur. Ovulation was suppressed with Cetrotide and triggered with 2 injections of Decapeptyl. Of 15 follicles, 14 were mature and could be fertilised, we had 8 embryos.
During the IVF this year in another clinic, I continuously stimulated with 300 Gonal f and 150 Menopur. This time I received a Decapepyl depot injection 2 weeks before the start of stimulation for downregulation. It was triggered with 250 Ovitrelle. I had 15 follicles, but only 6 eggs, 4 of which fertilised and we have 2 embryos. This time we are having them genetically tested for the first time (PGT-A). The doctor told me that the result was good, but I was shocked by the high number of empty follicles. I wonder if something could be changed in the protocol next time. Our doctor thought it was good the way it went. But I’m afraid that we’ll end up with so many empty follicles again. My AMH is “only” 1.7 ng/ml, which is within the normal range.
“Empty Follicle Syndrome” is a misleading term because follicles always contain eggs. However, some eggs may have difficulties detaching and being retrieved. This is more likely to happen when multiple attempts are needed to retrieve an egg from a follicle, indicating the egg may have chromosomal abnormalities.
The hormonal environment created during controlled ovarian stimulation plays a significant role in egg development. In certain cases, follicles may not release their eggs during retrieval, leading to the misconception of “empty” follicles.
This situation is most commonly encountered in older women, those with diminished ovarian reserve (DOR), and women with polycystic ovarian syndrome (PCOS). To address this problem, personalized protocols for controlled ovarian stimulation and careful administration of the hCG trigger shot are important.
The hCG trigger shot is given after optimal ovarian stimulation to initiate the process of reducing the number of chromosomes in the egg. It also helps the egg detach from the follicle’s inner wall. This allows for easier retrieval during the egg retrieval procedure.
Women with increased LH activity, such as older women, those with DOR, and women with PCOS, are more susceptible to the negative effects of LH-induced ovarian testosterone. Excessive LH activity can compromise egg development and increase the chances of chromosomal abnormalities. Medications like clomiphene and Letrozole can stimulate LH release, and certain drugs containing LH or hCG can have negative consequences.
Individualizing the controlled ovarian stimulation protocol, determining the correct dosage and type of hCG trigger, and administering it at the right time are crucial. The recommended dosage of urinary-derived hCG products is 10,000 units, while for recombinant DNA-derived hCG, the optimal dosage is 500 micrograms. A lower dosage of hCG can increase the risk of chromosomal abnormalities in the eggs and negatively impact the outcome of IVF.
Understanding the role of LH activity, the effects of medications on hormone release, and the importance of personalized protocols are vital. By optimizing these factors, the risk of failed egg retrieval and “empty follicle syndrome” can be minimized, improving the chances of successful IVF outcomes.
____________________________________________________
PLEASE SHARE THIS WITH OTHERS AND HELP SPREAD THE WORD!!
Herewith are online links to 2 E-books recently co-authored with my partner at SFS-NY (Drew Tortoriello MD)……. for your reading pleasure:
1. From In Vitro Fertilization to Family: A Journey with Sher Fertility Solutions (SFS) ; http://sherfertilitysolutions.com/sher-fertility-solutions-ebook.pdf
2. Recurrent Pregnancy Loss and Unexplained IVF Failure: The Immunologic Link ;https://drive.google.com/file/d/1iYKz-EkAjMqwMa1ZcufIloRdxnAfDH8L/view
I invite you to visit my very recently launched “Podcast”, “HAVE A BABY” on RUMBLE; https://rumble.com/c/c-3304480
If you are interested in having an online consultation with me, please contact my assistant, Patti Converse at 702-533-2691 or email her at concierge@sherivf.com\
Name: Irit L
Dear Dr. Sher,
Thank you for your answer.
I did take ivig before pregnancy was diagnosed. Took 30g ivig on ovulation and on positive hgc test but it faild to relax my immune system.
I refuse to take steroids as i was provided with 20mg prednison for 8 months. I had adison crises and ovarian shutdown with extremly elevated fsh. Took me a year to heal my ovaries and get pregnant again after i did a big research how to heal my ovaries and it luckily worked.
I want to try treatments that wont affect egg quality at all like ivig, lit, intralipids and plasmapheresis. I hope that i’ll manage to bank embryos for surrogacy but i am 44 so i need to see if ivf works for me.
I have a few questions:
1. I Did 3 lit treatments 1.5 years ago. Lads were negative.
After the last pregnancy loss I did the 4th lit. Finally lad became weak positive 40%. Do you think that positive lads gives me a better chance to carry a pregnancy?
2. Do you think tacro can be a good option after failing with ivig? Does it have horrible side effects like steroids?
Thanks a lot for your advises and terrific website. It helped me a lot.
Irit
This is my original message:
Just had my 6th miscarriage, natural conception with ivig and lit.
I am disgnosed with partial dq-alpha gene match (0301) and elevated nk cells.
We have a 4.5 years old son concieved naturaly and easily.
My miscarriages are very early.
We had 3 LITs a year and a half ago however LAD is still negative.
I took 30g IVIG on ovulution and on positive hgc test.
Aldo added ovidral on positive hgc test.
Immune pannel taken a day after the second ivig showed elevated tnf-alpha, elevated nk cell activity and 29.4% nk cell count.
We lost the pregnancy, the sac was empty and matched 4 weeks size.
I Did 3 lit treatments 1.5 years ago. Lads were negative.
After the last pregnancy loss I did the 4th lit. Finally lad became weak positive 40%. Do you think that positive lads gives me a better chance to carry a pregnancy?
A: I do not believe this to be so
2. Do you think tacro can be a good option after failing with ivig? Does it have horrible side effects like steroids?
A: Sorry, I have no experience with this treatment.
Name: Arielle M
I’ve had ECF ever since a d&c and forcep removal of rpoc in Jan 2022. I’ve taken prophylactic abx, hysteroscopy with loa and normal lap, 2.5 months lupron and letrozole for adeno. Failed medicated FET.
1) should I do a modified natural right away or do more lupron first?
2) I assume fluid is from adenomyosis (mri confirmed) but I’ve been trying to push my rei to do Emma and Alice to make sure no bacterial cause of fluid and inflammation but he doesn’t do. How can I find a doctor who will do it near me or is fertilysis of menstrual blood as good?
You can reply with med terms as I am a physician thanks!
There is too much here to discuss with a short response. We should talk. If you are interested in having an online consultation with me, please contact my assistant, Patti Converse at 702-533-2691 or email her at <a href="mailto:concierge@sherivf.com.
GS
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