I need to edit my previous post that my PIO dose was 50 mg once daily prior to FET then dropped to 12.5mg after P levels were checked day after FET
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Our Medical Directors are outstanding physicians that you will find to be very personable and compassionate, who take care to ensure that you have the most cutting-edge fertility treatments at your disposal. This is your outlet to ask your questions to the doctors.
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Dear Patients,
I created this forum to welcome any questions you have on the topic of infertility, IVF, conception, testing, evaluation, or any related topics. I do my best to answer all questions in less than 24 hours. I know your question is important and, in many cases, I will answer within just a few hours. Thank you for taking the time to trust me with your concern.– Geoffrey Sher, MD
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**correction ** progesterone levels after FET
Name: Lauren C
I need to edit my previous post that my PIO dose was 50 mg once daily prior to FET then dropped to 12.5mg after P levels were checked day after FET
Answer:
Same answer!
Geoff Sher
Progesterone levels after FET
Name: Lauren C
Hi Dr SHER, my clinic’s FET protocol has me on both progesterone vaginal capsules 200mg 3x/day plus 100mg PIO once daily in preparation for FET. They tested my levels day before transfer and was good; they tested day after and now is too high and want me to reduce PIO to 25mg until my beta in 2 weeks. Can this elevated P level have affected implantation? What effect can high levels of P have on implantation and should I be worried?
Answer:
I strongly doubt any adverse effect!
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
- “Recurrent Pregnancy Loss and Unexplained IVF Failure: The Immunologic Link
https://drive.google.com/file/d/1iYKz-EkAjMqwMa1ZcufIloRdxnAfDH8L/view
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Recurrent Miscarriage
Name: Mary P
After four losses (ages 23, 32, and 33) I was diagnosed with one copy of PAI-1 and one copy of MTHFR. I also have very high thyroid antibodies. Could all of this be causing the losses? We are moving on to a gestational carrier at this point after getting 10 embryos from our first round of IVF (waiting on PGT-A results now).
Answer:
I doubt that the heterozygous PAI-1 and one copy of MTHFR can explain the losses. the thyroid antibodies is however another matter …see below.
Geoff Sher
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Between 2% and 5% of women of the childbearing age have reduced thyroid hormone activity (hypothyroidism). Women with hypothyroidism often manifest with reproductive failure i.e. infertility, unexplained (often repeated) IVF failure, or recurrent pregnancy loss (RPL). The condition is 5-10 times more common in women than in men. In most cases hypothyroidism is caused by damage to the thyroid gland resulting from of thyroid autoimmunity (Hashimoto’s disease) caused by damage done to the thyroid gland by antithyroglobulin and antimicrosomal auto-antibodies.
The increased prevalence of hypothyroidism and thyroid autoimmunity (TAI) in women is likely the result of a combination of genetic factors, estrogen-related effects and chromosome X abnormalities. This having been said, there is significantly increased incidence of thyroid antibodies in non-pregnant women with a history of infertility and recurrent pregnancy loss and thyroid antibodies can be present asymptomatically in women without them manifesting with overt clinical or endocrinologic evidence of thyroid disease. In addition, these antibodies may persist in women who have suffered from hyper- or hypothyroidism even after normalization of their thyroid function by appropriate pharmacological treatment. The manifestations of reproductive dysfunction thus seem to be linked more to the presence of thyroid autoimmunity (TAI) than to clinical existence of hypothyroidism and treatment of the latter does not routinely result in a subsequent improvement in reproductive performance.
It follows, that if antithyroid autoantibodies are associated with reproductive dysfunction they may serve as useful markers for predicting poor outcome in patients undergoing assisted reproductive technologies.
Some years back, I reported on the fact that 47% of women who harbor thyroid autoantibodies, regardless of the absence or presence of clinical hypothyroidism, have activated uterine natural killer cells (NKa) cells and cytotoxic lymphocytes (CTL) and that such women often present with reproductive dysfunction. We demonstrated that appropriate immunotherapy with IVIG or intralipid (IL) and steroids, subsequently often results in a significant improvement in reproductive performance in such cases.
The fact that almost 50% of women who harbor antithyroid antibodies do not have activated CTL/NK cells suggests that it is NOT the antithyroid antibodies themselves that cause reproductive dysfunction. The activation of CTL and NK cells that occurs in half of the cases with TAI is probably an epiphenomenon with the associated reproductive dysfunction being due to CTL/NK cell activation that damages the early “root system” (trophoblast) of the implanting embryo. We have shown that treatment of those women who have thyroid antibodies + NKa/CTL using IL/steroids, improves subsequent reproductive performance while women with thyroid antibodies who do not harbor NKa/CTL do not require or benefit from such treatment.
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.
- 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) Why did my IVF Fail
- Recurrent Pregnancy Loss (RPL): Why do I keep losing my Pregnancies
- Genetically Testing Embryos for IVF
- Staggered IVF
- Staggered IVF with PGS- Selection of “Competent” Embryos Greatly Enhances the Utility & Efficiency of IVF.
- Embryo Banking/Stockpiling: Slows the “Biological Clock” and offers a Selective Alternative to IVF-Egg Donation
- Preimplantation Genetic Testing (PGS) in IVF: It should be Used Selectively and NOT be Routine.
- IVF: Selecting the Best Quality Embryos to Transfer
- Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
- PGS in IVF: Are Some Chromosomally abnormal Embryos Capable of Resulting in Normal Babies and Being Wrongly Discarded?
- 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!
- 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 several Pre-scheduled “Batches” per Year
- A personalized, stepwise approach to IVF
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ADDENDUM: PLEASE READ!!
INTRODUCING SHER FERTILITY SOLUTIONS (SFS)
Founded in April 2019, Sher Fertility Solutions (SFS) offers online (Skype/FaceTime) consultations to patients from > 40 different countries. All consultations are followed by a detailed written report presenting my personal recommendations for treatment of what often constitute complex Reproductive Issues.
If you wish to schedule an online consultation with me, please contact my assistant (Patti Converse) by phone (800-780-7437/702-533-2691), email (concierge@SherIVF.com) or, enroll online on then home-page of my website (www.SherIVF.com).
PLEASE SPREAD THE WORD ABOUT SFS!
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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
- “Recurrent Pregnancy Loss and Unexplained IVF Failure: The Immunologic Link
https://drive.google.com/file/d/1iYKz-EkAjMqwMa1ZcufIloRdxnAfDH8L/view
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Success after successful transfer
Name: Megan W
Hi! We just had our baby girl (4BB). Are the odds better doing a transfer for a second child since the first one worked? We had MFI and are 28! We transferred two embryos the first time (4AA & 4BB) we had success and one stuck. Would you recommend we transfer two again? We have a 4AB and a 4BB remaining, plus 3 untested embryos. How do you feel about mixing batches, tested and untested from different clinics?
Answer:
I think your chance of success is good. I personally am willing to transfer up to 2 embryos at a time unless there is a specific obstetrics contraindication against twins.
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
- “Recurrent Pregnancy Loss and Unexplained IVF Failure: The Immunologic Link
https://drive.google.com/file/d/1iYKz-EkAjMqwMa1ZcufIloRdxnAfDH8L/view
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Safety of Letrozole – Limit?
Name: Kristin C
Hi Dr.Sher,
Is there a limit to the number of letrozole cycles that one can do due to safety. I have done 12 cycles of letrozole. 8 of these have included using a trigger shot, Ovidrel. I know there are concerns with Clomid with regards to ovarian cancer and am wondering if the same applies to Letrozole as it is also used to induce ovulation, similar to Clomid? What are your thoughts? Have I put myself at considerable risk? I also have PCOS.
Answer:
In my opinion it is safe! However, that does not mean it is a judicious approach. Perhaps we should talk. I invite you to call my assistant Patti Converse at 702-533-2691 and set up an online consultation with me.
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
- “Recurrent Pregnancy Loss and Unexplained IVF Failure: The Immunologic Link
https://drive.google.com/file/d/1iYKz-EkAjMqwMa1ZcufIloRdxnAfDH8L/view
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Hcg level
Name: Briyah B
Hello,
My Hcg level on 25 January was 811 and now my Hcg level on 20 February is 14,328. I haven’t had my first prenatal visit yet, but according to my app I’m supposed to be around 10 weeks pregnant. I’m wondering if I’m possibly not as far along as I think or are my Hcg levels just low for 10 weeks. Please advise.
Answer:
My bet is that this is normal!
Geoff Sher
Measuring and interpreting Blood hCG to Assess Pregnancy Viability Following ART Treatments.
Geoffrey Sher MD
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:
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- 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.
__________________________________________________________________________________________________________
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
- “Recurrent Pregnancy Loss and Unexplained IVF Failure: The Immunologic Link
https://drive.google.com/file/d/1iYKz-EkAjMqwMa1ZcufIloRdxnAfDH8L/view
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