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      • Case Study: “Unexplained” Repeated Failed IVF in a Young Woman With Normal Ovarian Reserve: Case #4

      Dr. Geoffrey Sher Recommends

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      Today we continue our series of case studies on unexplained IVF failure with our fourth case of poor egg/embryo quality in young women. In this case study, we examine the effects of a combination of endometriosis and Immunologic Implantation Dysfunction.

      Background

      “Jamie” consulted with me when she was 34 years of age, after 3 years of failed treatment and a diagnosis of “unexplained infertility.”A laparoscopy had revealed her to have mild (Stage 1) endometriosis which was ablated at the time of surgery.The patient had undergone 3 IUI procedures, using clomiphene citrate in the first two procedures and letrazole in the last one.In all cases she developed between 5-8 follicles and triggered with 10,000 units of hCG.Ovulation occurred uniformly throughout, but she failed to conceive.

      She then moved on to In Vitro Fertilization, and over the course of 18 months, she underwent 3 failed IVF attempts.In each case she was stimulated with a modest, long pituitary down-regulation protocol involving the use of birth control pills, overlapped with an agonist (Lupron).Upon the onset of menstruation, she received between 250-400 units of gonadotropins (Gonal F/Menopur) daily for between 8 and 10 days.Her peak estradiol levels ranged between 2000-2600 pg/ml on the day of the hCG trigger (10,000 units of Novarel), at which point she had an excellent endometrium by ultrasound examination, (trilaminar and more than 9mm in thickness).Between 12 and 16 oocytes were recovered at egg retrieval, and following ICSI, she consistently produced between 2 and 5 blastocysts. Embryo transfers involving 2-3 blastocysts failed to achieve a pregnancy.At the time of our consultation she had 4 cryobanked (vitrified) blastocysts that not been transferred.

      Follow Up: We performed immunologic testing on this patient and found her to have activated Natural Killer cells (NKa) by the K562 target cell test, as well as antiphospholipid antibodies (APA).We made a diagnosis of autoimmune implantation dysfunction and scheduled the patient for a frozen embryo transfer (FET) with her residual cryobanked blastocysts.We prepared her with twice-weekly injections of Delestrogen (6 mg) combined with 0.75 mg dexamethasone daily, and 30 mg Lovenox daily starting at the onset of her cycle.

      Approximately 10 days prior to the anticipated FET she received an Intralipid (IL) infusion.At ET, we transferred 3 thawed blastocysts.Eight days later, her first beta hCG was 45, and 2 days afterward it had risen to 160.She thereupon received a second and final intralipid infusion. A subsequent ultrasound examination 3 weeks later revealed a healthy set of twins.She was weaned off the dexamethasone at 10 weeks gestation.The patient is presently about 24 weeks pregnant and progressing normally.

      Commentary:This patient’s infertility was really not “unexplainable” it was simply undiagnosed.Clearly there was not an underlying egg/embryo issue at all.The reason she failed to conceive on her own (in spite of spontaneous and regular ovulation) and following IUI was almost certainly due to the fact that all women with endometriosis (regardless of severity) have an underlying toxic peritoneal factor that compromises fertilization as the eggs pass from the ovary(ies) to the sperm waiting in the fallopian tube(s).This reduces fertilization potential and therefore compromises fecundity.This toxic peritoneal factor is present in 100% of women with this condition and explains why the chance of having a baby is reduced 4-6 fold in women with even the mildest of endometriosis.Since the visual endometriotic deposits represent just a small percentage of those that are in the process of developing, neither surgery to remove such lesions nor fertility drugs with or without IUI will likely significantly improve the baby rate per cycle (fecundity).

      Furthermore, there was the issue of an immunologic implantation dysfunction (IID) as evidenced by NK cell activation and antiphospholipid antibodies.IID occurs in about 30% of women who have endometriosis, and when it is associated with NK cell activation, the chance of a successful pregnancy is very low.When we administered intralipid, heparin (Lovenox) and steroids (dexamethasone), down-regulated the activated uterine NK cells, and counteracted the influence of antiphospholipid antibodies, the patient readily conceived following FET.

      The lesson in this case is that all women with endometriosis have diminished fecundity because of the consistent presence of a toxic pelvic environment that cannot be resolved through surgery or medical manipulation.Only IVF, by transferring the embryo directly to the uterus, can bypass this problem.

      I do not mean to imply that all women with endometriosis will require IVF.In fact, for younger women who have associated ovulation dysfunction (which is not uncommon in women with endometriosis), fertility drugs can be tried.However, this will only deal with the ovulation dysfunction, but will not address the toxic peritoneal factor.Simply stated, women with mild to moderate endometriosis that conceive following the use of fertility drugs (with or without IUI), usually achieve this in spite of, rather than due to, such treatment.Ultimately, only IVF which consistently bypasses the toxic pelvic environment, will address this problem.

      Since 1/3 of women with endometriosis will have an IID which will prevent implantation, even IVF will fail unless this problem is dealt with through down-regulation of NK cell activity and treatment of often associated anti-phospholipid antibodies (as was done in this case).

      In summary, normally ovulating women with endometriosis-associated infertility who are under the age of 35 years, should consider timed intercourse (using home ovulation testing).If this fails to result in a pregnancy, IVF will in all likelihood be required.For women who do not ovulate normally, fertility drugs can be used to correct this problem, but when such treatment is implemented, it must be done with the full understanding that ovulation induction will not reverse the toxic peritoneal effect.Ultimately, IVF might still be needed.

      For women over the age of 35 and those with diminished ovarian reserve (cases where time is of the essence), IVF treatment should, in my opinion, be the first line of attack.

      Addendum: It is important to understand that IVF is an ART-Science blend and not all practitioners agree on the same strategies. Thus, in the final analysis, it is important, after discussion with your personal doctor, to follow his/her advice to the letter.

      Feel free to present your case history in the comments and I will do my best to offer my opinion.

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      24 Responses to “Case Study: “Unexplained” Repeated Failed IVF in a Young Woman With Normal Ovarian Reserve: Case #4”

      1. Ria says:
        July 12, 2012 at 11:20 pm

        Hi,
        I am 31 yrs old and TTc from past 4 yrs, 3 yrs with IVF.
        I have had 4 failed IVFs due to implantation failure. I had endometrioma which was removed 4 yrs back. Tubal blockage at Perifimbrial end.
        In 4th IVF I tried IVIG and heparin.
        Embryo quality was good in all cycles and 4-5 embies were transferred.
        Can tubal blockage cause toxic fluid which might be killing the embryos.
        I had unusual spotting while on last phase of ovarian stimulation.
        Can be it related to tubal discharge(hematosalpinx)?
        I once conceived naturally between the ivf cycles but miscarried at 2 months.

        Thanks for your help doctor.

        Reply
        • Geoffrey Sher says:
          July 13, 2012 at 2:40 pm

          Unless the tube(s) is/are distended with fluid (visible on ultrasound), it is not likely to be due to reflux of toxic fluid into the uterus.

          At 31, you should be able to conceive and have a baby with IVF. The fact that you were on IVIG once, is significant but not definitive. That cycle could have been one where the embryo(s) was/were chromosomally defective or the timing and dosage of IVIG might not have been right. It is also possible that, rather than an autoimmune implantation dysfunction, yours is alloimmune and if so the treatment needs to be modified.

          Please go to http://www.IVFauthority.com and when you get to the home page find the “search bar” in the right hand column. Type in the following subjects into the bar and it will take you to all the relevant articles I posted there.

           “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)
           “Agonist/Antagonist Conversion Protocol”
           “Immunologic Implantation Dysfunction” (posted on May, 10th and on May 16th respectively.
           “IVF success: Factors that influence outcome”
           “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
           “A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
           “Staggered IVF”

          I think I can help you sort this out, so consider calling 800-780-7437 or 702-699-7437 to set up a web-based video conference or a telephone consultation with me (which is free if you reside in the U.S.A or in Canada) so we might discuss your case in detail.

          Geoff Sher

          Reply
      2. Ria says:
        July 15, 2012 at 5:03 am

        Thnx doc for ur invaluable response.

        IVIG was given during start of ovarian stimulation..
        Embryo transfer was done 1 month after the IVIG drip, As fresh cycle was converted to a FET due to unusual bleeding.

        BTW my TNF alpha test was normal. can there still be any immune problem?

        Thnx Doc.

        Reply
        • Geoffrey Sher says:
          July 18, 2012 at 12:35 pm

          The uterine cytokine test is helpful but not conclusive. You need a K562 target cell test for NK cell activity . This must be done in an Reproductive Immunology Refe4rrence Lab such as Reprosource (in Boston) or Reproductive Immunology Associates (in Van Nuys, CA). Call them and have your blood sent there for this test.

          Good luck!

          Geoff Sher

          Reply
      3. Lauren says:
        October 30, 2012 at 1:52 pm

        Hi Dr. Sher,
        I am 31 years old and have done 4 IUIs and 9 IVF transfers (3 of which were FETs) over the last 3 years. I have only gotten pregnant on 2 of these, both which were chemical pregnancies. The last 2 transfers I had were from donor embryos. I am going to be doing another cycle next month and hope to transfer 2 more donor embryos as blasts if they make it from the thaw to that stage. What are my chances of success after so many failed attempts? I have “unexplained” infertility and am on Lovenox to help my chances out since I have high beta 2 glycoprotein levels. I have been to 2 clinics, so I am doubtful that there is anything that they missed. What are your thoughts? Thanks in advance for any help you may have.

        Reply
        • Geoffrey Sher says:
          October 31, 2012 at 9:52 pm

          Hi lauren,

          I empathize but you need to appreciate that with repeated embryos transferred where these were derived from the eggs of a young woman and you repeatedly fail to conceive, this makes the most likely explanation an implantation problem. If that is the case, whether you use own eggs or donor eggs wont matter until this is addressed,. The implantation problem could be anatomical (lining thickness and/or surface lesions such as polyps in the uterine cavity) or an immunologic implantation dysfunction. My bet is on the latter. You have not provided enough information to help me understand as to why an egg donor was needed in your case.

          Please go to http://www.IVFauthority.com and when you get to the home page find the “search bar” in the right hand column. Type in the following subjects into the bar and it will take you to all the relevant articles I posted there.

           “Immunologic Implantation Dysfunction” (posted on May, 10th and on May 16th respectively.
           “Embryo Implantation………” (Part-1 and Part- 2—-Posted August 2012)
           “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
           “A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
           “IVF success: Factors that influence outcome”
           “Embryo Banking”
           “Egg Donation”

          Consider calling 800-780-7437 or 702-699-7437 to arrange a telephone or Skype consultation (free of charge to those who reside in the United States or Canada). While an audiovisual (Skype) interaction is much more personable and preferable than a discussion by telephone, either will suffice.

          Geoff Sher

          Reply
        • Geoffrey Sher says:
          October 31, 2012 at 10:00 pm

          I am now more persuaded than ever that your problem is likely hitherto undiagnosed implantation dysfunction. Please understand that doing immunologic testing does not mean that the right tests were done. You probably need a K-562 target cell test for natural killer cell activation, a full antiphospholipid antibody profile, an immunophenotype, antithyroglobulin and antimicrosomal antibodies plus, you and you husband need to be matched for DQ alpha and HLA similarities. In my opinion there are only 2-4 Reproductive Immunology Reference Laboratories in the United Stares that can perform these tests adequately. My preference would be to contact Reproductive Immunology Associates in Van Nuys, CA or \Reprosource in Boston, MA.

          I think I can help here so call 800-780-7437 or 702-281-7437 and set up a medical consultation with me by Skype or Telephone.

          Geoff Sher

          Reply
      4. Lauren says:
        October 30, 2012 at 4:22 pm

        I thought I should mention also that I have had several sonohystograms, a hysterosalpingogram both of which did not give the physicians any concern, and went to a hematologist who prescribed me the Lovenox, as I believe the only finding he could see was my elevated beta 2 glycoprotein levels. During my transfers, I had several protocols which used Follistim, Ganerelix, Lupron, Menopur, and I believe one other medicine. What additional testing would you recommend? I decided to use donor embryos after having several cycles where I did not have many embryos to retrieve (one cycle I did not have anything to transfer, another I had 3 4A embryos transferred, and then moved on with donor sperm, which did produce healthier looking embryos, but still only 3-4 which would go to 6 or 8 cell. The only two cycles which initially took were both blasts (one which was mine, and the other which was the donor embryo), none of the 8 or less cell transfers took. Would you suggest any additional testing? Do you think there could be something they missed? Do you have any thoughts as to why I would not be successful with donor embryos (the embryos actually had donor egg too, and the couple before me had instant success). Do you think you may be able to help me succeed?

        Reply
      5. Lauren says:
        November 3, 2012 at 11:32 am

        Dear Dr. Sher, I tried to set up a consultation, but since I have already started medications, they could not assist me. THey suggested I contact you once I have completed this cycle. So,I will contact you once the cycle is completed unless you want to speak before then. Thank you for your assistance and some shred of hope.
        Lauren

        Reply
        • Geoffrey Sher says:
          November 3, 2012 at 2:19 pm

          I suggest you set up the consultation now (tell them I so advised). If you conceive and do not need me thereafter, call up 800-780-7437 and cancel.

          Good luck!

          Geoff Sher

          Reply
      6. Lynn says:
        December 21, 2012 at 12:05 pm

        had 1 failed ivf and 1 failed FET so far. I’m 33 and my husband 38. My dr says I have no problem whatsoever. My husband suffers from OCD and hence take medications to help alleviate his anxiety: rivotril, Effexor and seroquel. Although he had previously done a sperm test that came back normal my dr seems to think that my embryos are not implanting because of these medications that might affect the sperm in some way. By the way with both our cycles we had PGD done for all our embryos so its not because of chromosomal abnormality that they are not implanting. Your help will be highly appreciated. I’m starting to loose hope.

        Reply
      7. Lynn says:
        December 21, 2012 at 12:08 pm

        I also want to add that I had an HSG test done plus a pelvic MRI and it all came back normal. My uterine lining is always perfect (above 9mm). But for some reasons my embryos won’t implant. Could it be the medications that my husband uses?

        Reply
        • Geoffrey Sher says:
          December 21, 2012 at 2:05 pm

          You need a full immunologic implantation assessment.This is not likely to be attributable to meds your husband is using. Please go to http://www.IVFauthority.com and when you get to the home page find the “search bar” in the right hand column. Type in the following subjects into the bar and it will take you to all the relevant articles I posted there.

           “Immunologic Implantation Dysfunction” (posted on May, 10th and on May 16th respectively.
           “Embryo Implantation………” (Part-1 and Part- 2—-Posted August 2012)
           “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)
           “A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)
           “IVF success: Factors that influence outcome”

          Geoff Sher

          Reply
      8. Andrea says:
        January 8, 2013 at 5:01 am

        Dr. Sher,
        I have stage 4 endometriosis. My husband and I are weeks away from starting our first attempt at IVF. I am to say the least a bit nervous and hope that because of the cost and stress. Since the IVF is near, I have been wondering if there are steps that I can take to increase my chances of success. I was on Clomid for the max amount of time, about 5-6 months, max dose 50 mg. I believe that from so much stimulation from the Clomid that it caused me to have endometriosis. My Doctor at Shady Grove insisted that this isnt true. On my own, I read many posts from other women who took Clomid who experienced similar symptoms. I have had two lap surgeries to remove the endometriosis and unfortunately both fallopian tubes. IVF is our only option. After reading many posts on your site I am interested in getting tested for immunologic factors including Antiphospholipid Antibodies (APA) and Natural Killer cell activation (NKa). The first step in my IVF cycle is bloodwork & ultrasound. I was wondering if I should also get an HSG to check to see how my ovaries and uterus look. I am trying to be proactive. Do you think that this is the right approach and would you suggest that I do anything else to increase my chances. Concerned because my endoetriosis is stage 4 and I have already experienced so much heartbreak from having tubes removed and pain associated with endo. I was also thinking of checking in my area to see if I should consider the Sclerotherapy as well. Thank you kindly for your assistance and very informative site.

        Reply
        • Geoffrey Sher says:
          January 8, 2013 at 7:57 am

          There are c2 considerations. The 1st is to exclude an ovarian endometrioma and to defer IVF until that has been eliminated. If you do not do this then the eggs that are harvested from the affected ovary are likely to be of poor quality. The second is to exclude autoimmune implantation dysfunction that occurs in 30% of endometriosis cases , regardless of severity. However with regard to this issue, I suspect that you will meet with resistance by your RE . When you are told (as I expect will happen) that he/she does not believe in immunologic factors impacting implantation, remember to demand a cleat explanation of the scientific theory that the doctor does not agree with and for reasons why. In most cases you will find such explanation to be lacking because many RE’s do not understand the principles of immunologic implantation(see the articles on Endometriosis and the ones on immunologic implantation dysfunction, elsewhere on http://www.IVFauthority.com).

          Good luck!

          Geoff Sher

          Reply
      9. farhy says:
        February 26, 2013 at 1:51 pm

        HI Dr Sher

        Is it a case of immunologic implantation dysfunction if IVF failed although the NK cell K562 test was normal and intralipid was administered? Is there a need to do further testing of APA in this case to diagnose deeper issues or could the failed IVF be something else?

        Thanks,

        Reply
        • Geoffrey Sher says:
          February 26, 2013 at 2:04 pm

          If interpretation of NKa (correctly performed) was accurately found to be normal, then you can by and large rule out an autoimmune implantation dysfunction.

          Geoff Sher

          Reply
      10. megan duffy says:
        March 1, 2013 at 11:49 am

        Dr. Sher,

        I have endometreosis and to date have two failed IVF cycles and two failed FETs. My immunologic testing (performed at Reprosource) revealed activated NKc and extremely high cytokine levels. I was treated with lovenox, intralips, and a high dose of prednisone in conjunction with my second IVF cycle. My cytokine and NKc barely responded, and the IVF cycle was unsuccessful. Thoughts?

        Megan

        Reply
        • Geoffrey Sher says:
          March 1, 2013 at 1:48 pm

          Remember, simply correcting the endometrial receptivity alone, does not impact embryo quality.

          Please go to the home page of this blog, (www.IVFauthority.com). When you get there look for a “search bar” in the upper right hand column. Then type in the following subjects into the bar, click and this will take you to all the relevant articles I posted there.

          1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)

          2. “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”

          3. “Agonist/Antagonist Conversion Protocol”

          4. “Immunologic Implantation Dysfunction” (posted on May, 10th and on May 16th respectively.

          5. “Embryo Implantation………” (Part-1 and Part- 2—-Posted August 2012)

          6. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)

          7.“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)

          8. “IVF success: Factors that influence outcome”

          9. Endometriosis”

          Consider calling 800-780-7437 or 702-699-7437 to arrange a telephone or Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail.

          Geoff Sher

          Reply
      11. Dana Case says:
        March 7, 2013 at 8:20 pm

        Hi,
        In the past 1 1/2 yrs. I have had 4 IVF cycles and 1 FET. None of which have worked. I had 1 chemical pregnancy. I have a problem of which I don’t get my period and my uterus gets thick and I have had 2 biopsies cause of this. My 1st biopsy came back with simple & comlex hyperplasya without atypia. The second one came back normal. I had 2 surgies to clean out my uterus(I have PCOS too). Of all my IVF’S the last one I had 5 day blast that made it freeze. They told my I have egg quality issues. My last IVF cycle I had 5-8 grade cells that they said looked great and 1-4 cell that they said was pretty good too. My insurance covered 4 IVF cycles(otherwise I coud not afford to do this). After my last IVF failed then my doctor did a US HSG, which came back that I need my second surgery to remove polys. By this time I only had my 2 frozen left. Why wouldn’t they have checked this prior to my last IVF? I had a regular HSG about 2-3 years ago. I’m so desperate and upset. What should be my next step. PLEASE HELP! I probably should have mentioned that I am 36yrs old and been TTC for many years.

        Reply
        • Geoffrey Sher says:
          March 7, 2013 at 10:12 pm

          I sense your desperation and would be happy to review your records thoroughly and advise. To do that you would need to call 702-699-7437 and set up a Skype consultation with me.

          Good luck!

          Geoff Sher

          Reply
      12. Rashmi Agarwala says:
        April 19, 2013 at 9:36 am

        I have been married since 6 years . Initially I went 6 iui all unsuccessful . Then we went to another doctor who suggested laparoscopy. I had adhesions septum uterus and my tbpcr was positive the I underwent anti tb treatment for 7 months and had three unsuccessful iui after which I underwent Ivf it was successful and had fetal heartbeat on 6 week of pregnancy I had mild bleeding and on 8 week ultrasound the heartbeat was not there . I had d /e procedure and again went 2 more ivf 1 frozen and another fresh both failed then I came to usa . All my test and my husband test is normal my biopsy for tbpcr is also negative. So we went ahead with stimulation retrieved 9 eggs three fertilized but on the day of retrieval my uterus showed water accumulation so we underwent next artificial cycle I was on estrogen patch vaginal cream and oral tablet for almost 26 days and my lining was 6.8 before progesterone start but again this failed so please guide me how to proceed further I have one frozen embryo

        Reply
        • Geoffrey Sher says:
          April 19, 2013 at 10:58 am

          It sounds as if the intrauterine infection might have severely damaged your potential to develop a good uterine lining. This is the likely reason for the miscarriage as well as the thin lining in your last cycle. Sometimes the lining can be enhanced with estrogen therapy and vaginal viagra.

          I would be happy to discuss this with you. Consider calling 800-780-7437 or 702-699-7437 to arrange a Skype consultation (free of charge to those who reside in the United States or Canada) with me so we can discuss your case in detail

          Please go to the home page of this blog, http://www.IVFauthority.com . When you get there, look for a “search bar” in the upper right hand corner. Type the following subjects into the bar, click on it and it will take you to all the relevant articles posted there.

          1. “Pelvic Tuberculosis and IVF”

          2. “Asherman’s syndrome”

          3. “Endometrial thickness and Viagra therapy”

          4. “Embryo Implantation………” (Part-1 and Part- 2—-Posted August 2012)

          5. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)

          7.“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)

          8. “Gestational Surrogacy”

          Geoff Sher

          Reply

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      IVF programs currently report their outcome statistics in a number of categories: a)      Number of IVF cycles initiated in a given year b)      Number of single and multiple pregnancies that occurred c)      Number of cycles that res... more
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      Mother Gives Birth Using Daughter’s Eggs: Was It “Ill Conceived”?
      I wish to share a very interesting case with you; one that I’m pretty sure will meet with the approval of some and evoke criticism by others. Before I even tell you about it, let me say that I and my team thought long and hard before going ahead wi... more
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      IVF Authority - Dr. Sher's Blog
      Gender Selection in IVF: What Is Its Place?
      Couples have for centuries sought to influence the gender of their offspring. More than seven centuries ago the ancient Chinese developed a birth calendar said to be able to predict gender on the basis of when conception occurred. Later, the ancient ... more
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      Acupuncture and IVF: Does it Improve Success?
      Acupuncture involves the insertion of thin needles into the skin along so-called meridians (energy channels). It has been used in China for centuries to regulate and treat many health disorders including ailments involving the female reproductive sys... more
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      Understanding Immunologic Implantation Dysfunction Part 2: A Rational Basis for Selective Intralipid & IVIg Immunotherapy in IVF
      ALLOIMMUNE VS. AUTOIMMUNE DYSFUNCTION Alloimmune Implantation Dysfunction Every human being has two DQ-alpha genes. One is contributed by the father and the other by the mother. In a small percentage of patients undergoing IVF, paternal-maternal DQ-a... more
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      Understanding Immunologic Implantation Dysfunction Part 1: Setting the Stage for Selective Immunotherapy with Intralipid and IVIg
      It is an unfortunate reality that many IVF programs attach little importance to factors that affect embryo implantation in general, and immunologic implantation dysfunction (IID) in specific (see below). Perhaps the lack of attention given to evaluat... more
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      DQ-alpha Matching in IVF: The Controversy, How It Affects Outcome, & How to Treat!
      IVF patients, especially those who find themselves inexplicably repeatedly failing treatment after treatment are no longer willing to blindly accept platitudes from those who would ignore the role of immunologic causes of IVF failure while unable to ... more
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      Unexplained Infertility: True Diagnosis or Cop Out?
      For about 10% of all infertile couples, the cause of the infertility cannot be readily determined using conventional diagnostic methods. Such cases are often referred to as “unexplained infertility.” The truth, however, is that in most su... more
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      Egg Banking of Genetically (CGH)-Tested Eggs Could Change The Face Of IVF-Ovum Donation
      For more than a quarter century, medical scientists have attempted to defy the biological clock by freezing a woman’s eggs to preserve her fertility. Most of these efforts have failed. Consider the fact that since the birth of the world’s 1st “... more
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      Case Study: Hydrosalpinx (Blocked/Fluid Filled Fallopian Tubes) and IVF Failure
      RL, a 31-year-old woman, presented with a 7 year history of inability to conceive, in spite of 2 prior fresh and 1 frozen IVF attempts, where a total of six good quality blastocysts had been transferred to her uterus.  Her husband PL, had normal spe... more
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      Recurrent Unexplained IVF Failure with “Good Quality” Embryos
      The following is a case study of a recent patient that came to me for treatment.  CJ, a 34 year old, and her husband RJ (age 35) presented to me with a six-year history of infertility. Based on semen analysis, RJ, who had initiated two pregnancies i... more
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      Karmann and Ryan’s Journey – My Approach to Their Treatment
       Please refer to last week’s blog post, where Karmann tells in her own words her struggles with recurrent miscarriage – nine miscarriages to be exact – and her long journey  of heartbreak, disappointment, and finally – hope.... more
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      Wennerlinds
      Karmann and Ryan – Nine Miscarriages, Then Hope!
      In observation of National Infertility Awareness Week (NIAW), I wanted to share the touching story of a couple that I first met last year – after they had already experienced 8 years of heartbreak and frustration.  Their story is representativ... more
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      IVF in a Same-Sex Male Couple: A Case Study
      Background: About two years ago, I received a call from a gentleman that I will call “John”. John was a movie producer who stated that he and his partner “Brian” had been in a monogamous same-sex relationship for 7 years and each wanted to si... more
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      Recurrent Molar Pregnancy Treated By “IVF Genetic Chess”
      Background: Maria (fictitious name), a childless 34-year-old Hispanic lady, presented with a history of having had five (5) successive spontaneous pregnancy losses at 7 weeks gestation, all due to hydatidiform moles. Four (4) of these losses were ... more
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      Case Study: Donor Egg IVF in a Post Menopausal Woman
      Mary (fictitious name), a 54 year menopausal woman, presented at SIRM-Las Vegas for IVF using an egg donor. She had been menopausal for 7-plus years and had NOT been on any hormone replacement therapy. Mary gave a history of having undergone IVF with... more
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      Case Study: Endometriosis Presenting as “Unexplained Infertility”
      I consulted with a 36 year old lady (whom I will refer to as “Sandra”) and her partner, about 18 months ago. She and her husband of 5 years had been having regular unprotected intercourse throughout this time and had been unable to conceive. Sand... more
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      Case Study: Pelvic Tuberculosis, Hypothyroidism, and Immune Implantation Dysfunction
      About 18 months ago I saw an Asian Indian couple who presented with a very interesting history. The female partner (whom I will refer to as DB) had regular menstrual cycles and normal ovarian reserve, was ovulating regularly and had a fertile male pa... more
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      Dear Dr. Sher: A Healthy Baby Followed by Multiple Miscarriages
      This is the second in a series of posts taken from questions that have been submitted to me via email, website, or discussion boards.  This question is from a patient who had a healthy baby from her first pregnancy, but then went through a period of... more
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      Karmann and Ryan’s Journey – My Approach to Their Treatment
       Please refer to last week’s blog post, where Karmann tells in her own words her struggles with recurrent miscarriage – nine miscarriages to be exact – and her long journey  of heartbreak, disappointment, and finally – hope.... more
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      Why Did My IVF Fail? Part 2 – Uterine Receptivity and Transfer Technique
      This is the second part of a two-part post on IVF failure. In my January 22nd post, I discussed what I often refer to as the “seed” variable in the “seed/soil” relationship – the embryo. This week’s post will address the “soil” variab... more
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      My IVF Cycle Failed – What Went Wrong? Question #19: Why Do I Keep Having Chemical Pregnancies and Miscarrying?
      This is the 19th in a series of answers to common questions about failed IVF. Early pregnancy loss – whether due to miscarriage or chemical pregnancy – is due to two major factors. In more than 70-80% of cases the cause is attributable to... more
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      My IVF Cycle Failed – What Went Wrong? Question #18: My Fertility Clinic Reports a High Success Rate – How Could I Have 2 Failed Cycles In A Row?
      This is no. 18 in a series of answers to common questions about failed IVF. While it is true that IVF failure can be due to preventable factors, it is as important to understand that optimal medical care does not always equate with an optimal outcome... more
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      My IVF Cycle Failed – What Went Wrong? Question #17: Why Didn’t I Get Pregnant When I Used a Young Egg Donor and Had Good Quality Embryos?
      This is #17 in a series of answers to common questions about failed IVF. For women whose advancing age and/or ovarian resistance make having a baby with their own eggs unfeasible or unlikely, IVF using donated eggs from a young donor (under 35 years)... more
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      My IVF Cycle Failed – What Went Wrong? Question #16: Why did my hCG levels stop rising properly?
      This is the 16th in a series of answers to common questions about failed IVF. Immediately following implantation, the root system (trophoblast) of the embryo begins to release the pregnancyhormone, human chorionic gonadotropin (hCG) into the surround... more
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      My IVF Cycle Failed – What Went Wrong? Question #15: Might My Mental State Have Played a Role?
      This is the 15th in a series of responses to common questions about failed IVF There is little doubt that stress and emotional lability plays a role in the normal physiological/hormonal regulation of the menstrual cycle.After all, Eskimos often stopp... more
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      My IVF Cycle Failed – What Went Wrong? Question #14: Could it Have Been Due to Inadequate Hormonal Support After the Egg Retrieval & Embryo Transfer?
      This is the 14th in a series of answers to common questions about failed IVF. In vitro fertilization establishes an abnormal hormonal environment in the uterus.In some cases (especially older women and those with a diminished ovarian reserve), high o... more
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      My IVF Cycle Failed – What Went Wrong? Question #13: Did the Number of Embryos I Had Transferred Play a Role?
      This is the 13th in a series of answers to common questions about failed IVF. Virtually everyone recognizes that pregnancy with multiples (especially triplets or greater) is associated with a high incidence of premature delivery that has serious cons... more
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      My IVF Cycle Failed – What Went Wrong? Question #12: Might the Timing of Embryo Transfer – Day 2-3 (Cleaved) vs. Day 5-6 (Blastocyst) Play a Role?
      This is the 12th in a series of answers to common questions about failed IVF. (Note: I’ll be hosting a live video chat on Aug. 2 on the topic of Failed IVF where I’ll discuss the issues addressed in this series of posts and take your ques... more
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