At this stage, an ultrasound should be able to diagnose a viable pregnancy,

Good luck!

Geoff Sher
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ADDITIONAL INFORMATION:

I am attaching online links to two E-books which I 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) “

https://sherfertilitysolutions.com/sher-fertility-solutions-ebook.pdf

1. “Recurrent Pregnancy Loss and Unexplained IVF Failure: The Immunologic Link

https://drive.google.com/file/d/1iYKz-EkAjMqwMa1ZcufIloRdxnAfDH8L/view

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Dear Oksana,

Thank you for reaching out. I fully understand your situation as it relates to breast cancer and I empathize with you. However, in my opinion your age being 51y, virtually precludes successful IVF with your own eggs. In fact the chance of successful IVF, would be less than 1% . Therefore any  discussion as it relates to your breast cancer, is moot…

I wish I had better news to impart, but alas this is the reality.

By the way, whenever you hear of a woman in her 50’s, having had an IVF baby using own eggs, the overwhelming likelihood is that she used donated eggs or embryos.

So sorry!

G-d bless!

Geoff Sher

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ADDITIONAL INFORMATION:

I am attaching online links to two E-books which I 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) “

https://sherfertilitysolutions.com/sher-fertility-solutions-ebook.pdf

1. “Recurrent Pregnancy Loss and Unexplained IVF Failure: The Immunologic Link

https://drive.google.com/file/d/1iYKz-EkAjMqwMa1ZcufIloRdxnAfDH8L/view

………………………………………………………………..

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.

_____________________________________________________________

ADDITIONAL INFORMATION:

I am attaching online links to two E-books which I 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) “

https://sherfertilitysolutions.com/sher-fertility-solutions-ebook.pdf

1. “Recurrent Pregnancy Loss and Unexplained IVF Failure: The Immunologic Link

https://drive.google.com/file/d/1iYKz-EkAjMqwMa1ZcufIloRdxnAfDH8L/view

………………………………………………………………..

I do not believe tyhat an E2 of 3000pg/ml at peak, is potentially harmful. This having been said, the protocol used for ovarian stimulation is important, but without much more information in this regard, I cannot comment authoritatively.

Av separate issue is the effect of endometriosis on IVF outcome (see below).

Geoff Sher

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When women with infertility due to endometriosis seek treatment, they are all too often advised to first try ovarian stimulation (ovulation Induction) with intrauterine insemination (IUI) ………as if to say that this would be just as likely to result in a baby as would in vitro fertilization (IVF). Nothing could be further from reality It is time to set the record straight. And hence this communication!

Bear in mind that the cost of treatment comprises both financial and emotional components and that it is the cost of having a baby rather than cost of a procedure. Then consider the fact that regardless of her age or the severity of the condition, women with infertility due to endometriosis are several fold more likely to have a baby per treatment cycle of IVF than with IUI. It follows that there is a distinct advantage in doing IVF first, rather than as a last resort.

So then, why is it that ovulation induction with or without IUI is routinely offered proposed preferentially to women with mild to moderately severe endometriosis? Could it in part be due to the fact that most practicing doctors do not provide IVF services but are indeed remunerated for ovarian stimulation and IUI services and are thus economically incentivized to offer IUI as a first line approach? Or is because of the often erroneous belief that the use of fertility drugs will in all cases induce the release (ovulation) of multiple eggs at a time and thereby increase the chance of a pregnancy. The truth however is that while normally ovulating women (the majority of women who have mild to moderately severe endometriosis) respond to ovarian stimulation with fertility drugs by forming multiple follicles, they rarely ovulate > 1 (or at most 2) egg at a time. This is because such women usually only develop a single dominant follicle which upon ovulating leaves the others intact. This is the reason why normally ovulating women who undergo ovulation induction usually will not experience improved pregnancy potential, nor will they have a marked increase in multiple pregnancies. Conversely, non-ovulating women (as well as those with dysfunctional ovulation) who undergo ovulation induction, almost always develop multiple large follicles that tend to ovulate in unison. This increases the potential to conceive along with an increased risk multiple pregnancies.

So let me take a stab at explaining why IVF is more successful than IUI or surgical correction in the treatment of endometriosis-related infertility:

1. The toxic pelvic factor: Endometriosis is a condition where the lining of the uterus (the endometrium) grows outside the uterus. While this process begins early in the reproductive life of a woman, with notable exceptions, it only becomes manifest in the 2ndhalf of her reproductive life. After some time, these deposits bleed and when the blood absorbs it leaves a visible pigment that can be identified upon surgical exposure of the pelvis. Such endometriotic deposits invariably produce and release toxins” into the pelvic secretions that coat the surface of the membrane (the peritoneum) that envelops all abdominal and pelvic organs, including the uterus, tubes and ovaries. These toxins are referred to as “the peritoneal factor”. Following ovulation, the egg(s) must pass from the ovary (ies), through these toxic secretions to reach the sperm lying in wait in the outer part the fallopian tube (s) tube(s) where, the sperm lie in waiting. In the process of going from the ovary(ies) to the Fallopian tube(s) these eggs become exposed to the “peritoneal toxins” which alter s the envelopment of the egg (i.e. zona pellucida) making it much less receptive to being fertilized by sperm. As a consequence, if they are chromosomally normal such eggs are rendered much less likely to be successfully fertilized. Since almost all women with endometriosis have this problem, it is not difficult to understand why they are far less likely to conceive following ovulation (whether natural or induced through ovulation induction). This “toxic peritoneal factor impacts on eggs that are ovulated whether spontaneously (as in natural cycles) or following the use of fertility drugs and serves to explain why the chance of pregnancy is so significantly reduced in normally ovulating women with endometriosis.
2. The Immunologic Factor: About one third of women who have endometriosis will also have an immunologic implantation dysfunction (IID) linked to activation of uterine natural killer cells (NKa).  This will require selective immunotherapy with Intralipid infusions, and/or heparinoids (e.g. Clexane/Lovenox) that is much more effectively implemented in combination with IVF.
3. Surgical treatment of mild to moderate endometriosis does not usually improve pregnancy potential:. The reason is that endometriosis can be considered to be a “work in progress”. New lesions are constantly developing. So it is that for every endometriotic seen there are usually many non-pigmented deposits that are in the process of evolving but are not yet visible to the naked eye and such evolving (non-visible) lesions can also release the same “toxins that compromise fertilization. Accordingly, even after surgical removal of all visible lesions the invisible ones continue to release “toxins” and retain the ability to compromise natural fertilization. It also explains why surgery to remove endometriotic deposits in women with mild to moderate endometriosis usually will fail to significantly improve pregnancy generating potential. In contrast, IVF, by removing eggs from the ovaries prior to ovulation, fertilizing these outside of the body and then transferring the resulting embryo(s) to the uterus, bypasses the toxic pelvic environment and is therefore is the treatment of choice in cases of endometriosis-related infertility.
4. 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 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. Thus there are two reasons for treating endometriomas. The first is to alleviate symptoms and the second is to optimize egg and embryo quality. Conventional treatment of endometriomas involves surgical drainage of the cyst contents with subsequent removal of the cyst wall (usually by laparoscopy), increasing the risk of surgical complications. We recently reported on a new, effective and safe outpatient approach to treating endometriomas in women planning to undergo IVF. We termed the treatment ovarian Sclerotherapy.  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

 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.

IN SUMMARY: For young ovulating women (< 35 years of age ) with endometriosis, who have normal reproductive anatomy and have fertile male partners, expectant treatment is often preferable to IUI or IVF. However, for older women, women who (regardless of their age) have any additional factor (e.g. pelvic adhesions, ovarian endometriomas, male infertility, IID or diminished ovarian reserve-DOR) IVF should be the primary treatment of choice.

I strongly recommend that you visit 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.
• Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF:
• 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!
• Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas
• Should IVF Treatment Cycles be provided uninterrupted or be Conducted in 7-12 Pre-scheduled “Batches” per Year
• A personalized, stepwise approach to IVF
• How Many Embryos should be transferred: A Critical Decision in IVF?
• Endometriosis and Immunologic Implantation Dysfunction (IID) and IVF
• Endometriosis and Infertility: Why IVF Rather than IUI or Surgery Should be the Treatment of Choice.
• Endometriosis and Infertility: The Influence of Age and Severity on Treatment Options
• Early -Endometriosis-related Infertility: Ovulation Induction (with or without Intrauterine Insemination) and Reproductive Surgery Versus IVF
• Treating Ovarian Endometriomas with Sclerotherapy.
• Effect of Advanced Endometriosis with Endometriotic cysts (Endometriomas) on IVF Outcome & Treatment Options.
• Deciding Between Intrauterine Insemination (IUI) and In Vitro Fertilization (IVF).
• Intrauterine Insemination (IUI): Who Needs it & who Does Not: Pro’s &
• Induction of Ovulation with Clomiphene Citrate: Mode of Action, Indications, Benefits, Limitations and Contraindications for its use
• Clomiphene Induction of Ovulation: Its Use and Misuse!

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ADDENDUM: PLEASE READ!!

INTRODUCING SHER FERTILITY SOLUTIONS (SFS)

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

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

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ADDITIONAL INFORMATION:

I am attaching online links to two E-books which I 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) “

https://sherfertilitysolutions.com/sher-fertility-solutions-ebook.pdf

1. “Recurrent Pregnancy Loss and Unexplained IVF Failure: The Immunologic Link

https://drive.google.com/file/d/1iYKz-EkAjMqwMa1ZcufIloRdxnAfDH8L/view

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Very likely this will be a viable pregnancy (probably—80%+).

Good luck!

Geoffrey Sher

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Each and every patient/couple, in undergoing IVF makes huge emotional, physical and (in most cases) also financial investment. The fact that receiving the result of the blood human chorionic gonadotropin (hCG) pregnancy test represents the first decisive hurdle that must be confronted makes this a very big deal The few days after the embryo transfer, waiting for this first outcome report is usually anxiety ridden and highly stressful.  It is thus imperative that the IVF physician and his/her staff deal delicately with the transfer of this critical information. Dropping the ball at this time would be unconscionable. The physician and staff must make themselves accessible to the patient/couple and effect the conveyance of results promptly, professionally and with sensitivity.

At least 2 beta hCG blood tests are done (2-4 days apart). The reporting of pregnancy test results is invariably best deferred until after the 2^nd blood test results are in. This is because an initial equivocal (or even negative) result can correct itself and also, a strongly positive result can become negative by the second test. Sometimes (albeit rarely) a normal embryo will be slow to implant and the hCG level can be <5IU/ml. It can even be undetectable at first. Thus, regardless of the initial blood hCG level, this test should be repeated two days later in order to see if there has been an appreciable rise in hCG since the first test. A significant rise (about a doubling of the initial value) usually suggests that an embryo is implanting and is a prognostic indication of a possible pregnancy. Thus by waiting to report the results until the 2^nd test result is in, will in most cases avoid conveying false hope and/or disappointment.

It is important to bear in mind that beta hCG blood levels do not double every 2 days throughout pregnancy. In fact once the levels start to rise above 4,000U they tend to increase more slowly.

Since (with the notable exceptions of IVF using an egg donor and the transfer of genetically (CGH) tested “competent” embryos, the likelihood of a successful IVF outcome will (in younger women) at best be 50-55% (at best), it is important to counsel patients in advance of the need to have rational expectations. It is equally important to inform patients exactly how, when and by whom they will receive the news and thereupon, in the event of a “negative outcome” when and by whom they will be counseled.

As soon as an embryo begins to implant and its root system (trophoblast) comes into contact with endometrial tissue, the embryo starts to release the pregnancy hormone, hCG in to the woman’s blood stream. About 12 days after egg retrieval, 9 days after a day 3 embryo transfer and 7 days after a blastocyst transfer the woman should have a quantitative beta hCG blood pregnancy test performed. By that time almost all hCG injected to prepare the developing eggs for egg retrieval, there should be minimal hCG left in the woman’s blood stream. Thus the detection of >5 IU of hCG per ml of blood tested is an indication that the embryo tried to implant.

Since with Third party-IVF (i.e. Ovum donation, gestational surrogacy, embryo adoption or frozen embryo transfers-FET) no hCG “trigger is administered, the detection of any amount of hCG in the blood is regarded as significant.

What is Considered Slow Rising hCG Levels?

Often times an initial rise in hCG (between the 1^st and 2^nd test) will be slow (failure to double every 48 hours). When this happens, a 3^rd and sometimes even a 4^th hCG test should be done at 2 day intervals. A failure to double on the 3^rd and/or 4^th test is a poor prognostic sign. It usually indicates a failed or “dysfunctional implantation but in some cases a progressively slow rising hCG level might point to a tubal (ectopic pregnancy. Diagnosis requires additional serial blood hCG testing, ultrasound examinations and clinical follow-up to detect any symptoms or signs of an ectopic pregnancy.

In some cases the 1^st beta hCG level starts high (well over 20IU/ml) and then drops with the 2^nd test, only to start doubling once again thereafter. This sometimes suggests that there were initially more than one embryos implanting and that one of these subsequently succumbed and one survived to continue a healthy implantation.

It is customary for the IVF clinic staff to call the patient/couple and the referring physician with the results of the hCG pregnancy test. Often times, the IVF physician or nurse‑coordinator will work through the referring physician to arrange for the all pregnancy tests. . If the patient/ couple wishes to make their own arrangements, the program should give them detailed instructions about the necessary tests.

If the two blood pregnancy tests indicate that one or more embryos are implanting, some programs advocate daily injections of progesterone or the use of vaginal hormone suppositories for several weeks to support the implanting embryo(s). Others, including our own, give hCG injections three times a week for several weeks until the pregnancy can be defined by ultrasound. Some IVF programs do not prescribe any hormones at all after the transfer.

Patients with hCG levels that show the appropriate doubling 2 day doubling following FET or third‑party parenting through IVF surrogacy or ovum donation will receive estradiol and progesterone injections, often in conjunction with vaginal hormone suppositories, for 10 weeks following the diagnosis of implantation by blood pregnancy testing.

Although a positive Beta hCG blood pregnancy test indicates the possibility of a conception, pregnancy cannot be confirmed until it can be defined by ultrasound. Until then it is referred to as a “chemical pregnancy). Only once ultrasound examination can confirm the existence of a gestational sac, clinical examination can establish the presence of a viable pregnancy or following abortion, products of conception can be recognized, is it referred to as a clinical intrauterine pregnancy. A strongly positive beta hCG blood level in association with an inability beyond 5 weeks gestation to detect a gestational sac inside the uterus by ultrasound examination is suggestive of an ectopic (tubal) pregnancy The chance of miscarriage progressively decreases from the point of diagnosing a viable clinical pregnancy (a conceptus that has a regular heart beat of between 110 and 180 beats per minute). From this point onwards the risk of miscarriage is usually <15% in women under 39 years of age and less than 35% in women in their early forties.

Dealing with an IVF success is easy…. Everyone feels elated and vindicated. It is dealing with  unsuccessful cases that offer the real challenge. In this regard, nothing is more important than establishing rational expectations from the get go. In some cases (fortunately rarely), the patient/couple will crack under the emotional pressure and will need referral for counseling and in some cases psychiatric therapy.

I always counsel my patients that optimal care does not necessarily equate with an optimal outcome. There are too many variables that are outside of our control…especially the “divine” one. Having been involved in this field for about 30 years, it is my fervent belief that when it comes to IVF, the adage…”man proposes while G-d disposes is always applicable!

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ADDITIONAL INFORMATION:

I am attaching online links to two E-books which I 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) “

https://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

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I would not test the “inconclusive” blastocyst. In my opinion, 2ndary testing is too traumatic on trhe embryo. I would also not do another ER. You had a good result and all things being equal (e.g., the absence of an implantation dysfunction) you should be able to ave at least one baby out of the batch by FET (s)…over time, of course.

Geoff Sher

__________________________________________________________________

ADDITIONAL INFORMATION:

I am attaching online links to two E-books which I 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) “

https://sherfertilitysolutions.com/sher-fertility-solutions-ebook.pdf

1. “Recurrent Pregnancy Loss and Unexplained IVF Failure: The Immunologic Link

https://drive.google.com/file/d/1iYKz-EkAjMqwMa1ZcufIloRdxnAfDH8L/view

………………………………………………………………..