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My IVF Cycle Failed – What Went Wrong? Question #8: Was the Timing, Dosage and Type of hCG “Trigger” Optimal?

Dr. Geoffrey Sher Recommends

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This is the 8th in a series of answers to common questions about failed IVF.

The precise timing to administer the hCG “trigger” that will launch a cycle of controlled ovarian stimulation (COS) for both IVF and non-IVF cycles is very important. If mis-timed by even one day, it can compromise egg/embryo quality and lead to IVF failure.

Those of us who have been in this field for some time will recall how (prior to the introduction of “prolonged coasting”), we would often administer hCG prematurely (i.e. prior to optimal follicle development) in an attempt to reduce the risk of life-endangering severe ovarian hyperstimulation syndrome (OHSS). This was done in a deliberate attempt to cut the cycle short, and more often than not we would end up with poor quality eggs/embryos and a failed IVF cycle. Many of us in years past also attempted to force the development of larger follicles in “poor responders” by delaying the hCG trigger shot, which also frequently netted poor quality eggs/embryos and failed IVF cycles.

Yes indeed…when it comes to the hCG trigger shot, timing is critical! However, knowing precisely when to give it requires both a high level of experience and a great deal of finesse! And, while there are certainly guidelines that are helpful in determining such timing (follicle size, blood estradiol level and number of days of ovarian stimulation), these are often inexact. The decision thus requires a clinical judgment call which is part of the essential “art” aspect of reproductive medicine, rather than the science. This article outlines some important roles of hCG both in terms of triggering ovulation and in the nurturing of early pregnancy.

Human chorionic gonadotropin (hCG) is a hormone produced by the cells that envelop the “root system” (trophoblast) of the early embryo. It reaches the mother’s circulatory system in a sufficient amount to be detectable in her blood within 5-7 days of implantation. Thereafter, hCG blood concentrations tend to double every 48 hours for several weeks, whereupon the levels rise more slowly throughout pregnancy. hCG reaches the urine in sufficient amounts to be detectable by most urine pregnancy tests about 10-12 days following implantation (about 14-16 days after ovulation).

The Role of hCG in Ovarian Stimulation and in the Ensuing Pregnancy

Maturing the egg in preparation for ovulation:

As a prelude to ovulation which usually occurs within 38-42 hours of the intramuscular administration of a dose of hCG (usually 10,000U) to women who have undergone controlled ovarian stimulation (COS), the egg begins a process known as meiosis (also known as reduction division or maturational division). Here, the egg, which to this point contains 46 chromosomes (23 pairs aligned in a spiral arrangement) sets out to halve its number of chromosomes from 46 to 23. The meiotic process is usually completed within 28-24 hours. Survival of the human species is totally dependent on the orderly occurrence of meiosis so that subsequent fertilization of the mature egg by a mature spermatozoon (which has also undergone meiosis to halve its number of 23 chromosomes) will result in the propagation of a chromosomally normal embryo (euploid embryo) with precisely 46 chromosomes (the normal human genomic make-up).

An egg that, following meiosis, ends up with an irregular quota of chromosomes is incapable of propagating an embryo with a regular number of 46 chromosomes. In this regard, it is important to recognize that it is the egg, rather than the sperm that plays the dominant role. An embryo that has more or less than 46 chromosomes is aneuploid (“incompetent”) and incapable of propagating a healthy pregnancy. It will not divide or implant properly, resulting in a failed pregnancy or miscarriage and in some cases, the birth of an aneuploid baby (e.g. Down syndrome).

Unfortunately, aneuploidyof human eggs/embryos is quite common. In fact, even in young women, only about two in five mature eggs will have a regular number of chromosomes (23), and the incidence of aneuploidy increases rapidly with advancing age. By the mid-forties, more than nine-in-ten are aneuploid, which serves to explain why the incidence of infertility, pregnancy loss/miscarriage, and Down syndrome all increase with advancing age of the egg provider. When only one or two of the 23 chromosome pairs of the embryo have an extra or missing copy, the condition is referred to as “simple aneuploidy,” whereas when three or more chromosome pairs are involved, we term it “complex aneuploidy” (see later)

Ensuring hormonal support for the early pregnancy:

During the immediate post-implantation period and during very early stages of pregnancy, hCG ensures survival of the ovarian corpus luteum which produces progesterone and estrogen to sustain the implanting pregnancy. This indispensable role of hCG continues up until about the 7^th-8^th week of pregnancy. In fact were the corpus luteum to die prior to this stage, the pregnancy would almost certainly die. However, after the 8^th week, placental development has reached the stage where ovarian hormone production is no longer indispensable to the survival of the pregnancy, and even removal of both ovaries would not likely lead to pregnancy loss.

The immunologic role of hCG:

hCG Also plays a crucial role in promoting and modulating the immune acceptance of the fetal allograft (the implanting embryo). This function is most pronounced during early implantation but continues and protects placental growth and development throughout gestation.

Preparing the follicle for ovulation:

As is the case with the LH surge, hCG, among other things, signals the well-developed egg to alert the cumulus cells that bind it to the inner wall of the follicle to release enzymes that will cause these cells to segregate or disperse, allowing the egg to become very loosely attached to the lining of the follicle. Thereupon, through a combination of pressure changes in the fluid of the follicle and erosion of the follicle wall, the egg is extruded and released (ovulation has occurred).

What is not often well appreciated is that in order for the egg to interact properly with surrounding cumulus cells, it must have the required genetic ability. It so happens that severely (complex) aneuploid eggs often lack this ability, causing the cell dispersion mechanism to fail, and resulting in the egg being retained within the follicle. Such eggs will often fail to be retrieved during needle aspiration with IVF. In such cases, the patient is often led to believe that her follicle(s) was/were “empty”. Since no follicle can develop unless there is an egg to “direct” the process, this is a misleading conclusion. This is unfortunately sometimes still referred to as “empty follicle syndrome”. In such cases the unfortunate patient often reaches the erroneous conclusion that she had no eggs in the first place when the failure to harvest eggs might instead have been due to other factors that lead to complex egg aneuploidy, such as advanced age and/or a suboptimal protocol for ovarian stimulation.

The precise timing of administering the hCG trigger following COS is indeed critical. If the hCG injection is administered too early (prior to optimal follicle/egg development) or too late (when the egg is “over-developed) it is far more likely to result in disorderly meiosis and egg/embryo aneuploidy. Such an aneuploid egg, especially if it is complex aneuploid, might not come free at egg retrieval, it may not fertilize, or will result in an incompetent embryo.

What type of hCG should be used, and what about using an agonist “trigger” instead?:

Then there is the issue of the type of hCG administered (urinary derived [Profasi, Pregnyl, Novarel] or recombinant DNA-derived hCG [Ovidrel]), whether the dosage of hCG should be lowered in cases of threatening OHSS, and/or whether hCG should be supplanted by the administration of an agonist (Lupron) – which by triggering in the body’s own pituitary LH is thought to potentially lower the risk of OHSS.

First, there is no advantage in giving Ovidrel instead of urinary-derived hCG. Furthermore, in my opinion, at the recommended dosage, Ovidrel has a much lower biopotency (and is less effective) than 10,000U of urinary-derived hCG. It is also much more expensive. If Ovidrel is to be used to “trigger” ovulation, I believe that it should be prescribed at double the recommended dosage.

Second, in my opinion, administering urinary hCG at a reduced dosage from the usual 10,000U to lower the risk of OHSS in hyperstimulated women, will often result in an inadequate biological response, a low percentage of follicles that will yield eggs, and poorer quality eggs/embryos.

Third, initiating an LH surge with an agonist can be effective if used selectively since women who have had their pituitary reserves depleted by prior administration of an agonist during COS might not have enough left in reserve to surge after the agonist “trigger.” Besides, there is currently no consensus that doing so will lower the risk of OHSS.

Tags: empty follicles, hcg trigger, IVF Authority, ovarian hyperstimulation syndrome, prolonged coasting

30 Responses to “My IVF Cycle Failed – What Went Wrong? Question #8: Was the Timing, Dosage and Type of hCG “Trigger” Optimal?”

sondacop says:

July 1, 2011 at 6:27 am

I have been through 14 cycles of ivf (the 4th was successful and I have a 2.5 yo daughter). I have been through 2 cycles of EFS. The last cycle I had 9 follicles and only 4 eggs retrieved (all became good embryo) none of the 4 took. In almost every cycle I am also plagued with a functional cyst. Other than that I am "unexplained" with everything coming out normal including a fsh of 8 (I am 41).

Do the 2 problems (efs and cyst)stem from the same source, the LH surge? Is there a protocol that can deal with this?

Thank you for your informative site and answers.

Reply
Geoffrey Sher, MD says:

July 1, 2011 at 10:17 am

I would love to give you a direct answer, but obviously without much more information I cannot! WE need to talk and thereafter I would be in a much better position to advise you!

Call 800-780-7437 (or if you are from out of country, call 702-617-7437) to set up a free consultation by phone!

Geoff Sher

Reply
jenicini says:

July 7, 2011 at 8:59 pm

Is it worth it to try a double HCG shot for the "empty follicles" or are the eggs in those follicles simply aneuploid and not worth trying to get?

Reply
Geoffrey Sher, MD says:

July 10, 2011 at 8:40 pm

Hi Jenicini,

Sorry but I am afraid that will not help!

Geoff Sher

Reply
Jamie says:

July 14, 2011 at 3:15 pm

I recently had my first IUI using Follistim/Ovidrel. I am concerned about the timing of the IUI, and/or am wondering if it is possible that the Ovidrel trigger sometimes not stimulate ovulation in the timeframe you suggested. I was taking Follistim for five days and had an ultrasound on the 8th day of my cycle. It showed 3 follicles approximately 11mm in size and then some smaller follicles. My RE increased my Follistim dose (from 50mg to 75mg) for three more days. I then took the Ovidrel at 10:00am on the 11th day of my cycle with the IUI at 11:30am the following day. Forgive me in advance as I know these are not valid measures of ovulation, but I have been monitoring my BBT and cervical mucus, and I continued to have fertile cervical mucus for three days after the trigger, and my temperature has still not risen (and it does so consistently each cycle). Is it possible the trigger didn't work?

Reply
Geoffrey Sher, MD says:

July 14, 2011 at 5:16 pm

Indeed! For the reasons cited in this article, Ovidrel can in m y opinion cause "triggering problems". Why don't you go for an ultrasound stat and ask your RE to look for signs that ovulation occurred.Also do a plasma progesterone level. It is possible that you have luteinized unruptured follicle syndrome (read up on this condition elsewhere on this site.

Good luck!

Geoff Sher
702-699-7437

Reply
carmen says:

July 27, 2011 at 3:28 am

I recently had my first IUI with no stimulation (with Ovidrel to trigger). Trigger was 0h30 CD11 with insemination at 11h30 on CD 12, at 35 hours from the trigger shot.

I have been tracking my LH surge through OPKs and although I had a dark line (almost positive) on CD12 morning after the shot…it seems darkest this morning on CD13. Also my BBT was not significantly higher this morning.

Is it possible that the shot didn't trigger ovulation within 36 hours? Could I be ovulating later than expected?

Reply
Gretchen says:

April 4, 2013 at 10:56 am

Can one ovulate earlier than 36 hours after HcG trigger? Are there a subset of women who ovulate sooner than expected, and could I be one of them?

Let me explain. I have now been through two failed mini-IVF cycles. (clomid, femara and follistim 75u, stim for 6 days roughly) I was told to do minimal stimulation was the right course of action for me because I am 38, and have DOR – and that I wouldn’t produce lots of eggs, so I would get a better result trying for 4-6 high quality eggs that 12-15 and having most of them be immature. I have follicles – and with even these low levels I am producing 4-6 good sized follicles and a number of smaller ones. However twice now, I have ended up with nothing to transfer back.

The first time, despite having lots of follicles prior to the trigger, they were only able to get 1 egg, and then after some digging got three more small ones. Only the one was mature, and although all of them eventually fertilized, none made it to blastocyst. Afterward they told me that it was likely due to poor quality eggs that weren’t quite mature enough, and next time they would stimulate me a little longer.

This time around I was basically on the same protocol, but we did go one extra day. At trigger I had three large follicles on my left 25, 23, 21 – and an 18 and 19 on my right pus a couple smaller ones ones the right. The next day (about 15 hrs later) blood levels looked good they said – LH had increased 22 (from 7),progesterone was 2.4, HcG was 63 – and said we were on target for retrieval. That night I had pains, but didn’t think much of it. At my scan the next day, the nurse saw only one large follicle on the left, and three on the right 17, 16 and 14. She was ready to send me to egg retrieval when I told her there must be something wrong – all my big follicles were on the left. she checked again and then went to talk to the doctor. They determined that it looked like I ovulated – but wanted to do the retrieval anyway to see if they could get those follicles on the right. I told them I didn’t think it seemed worth it, but they insisted and I was so distraught and emotional I finally agreed. At the retrieval we discovered the large one on the left was just a cyst, probably leftover from the release of the other eggs. They got three eggs from the right, but they were all immature, and 2 days later still have not fertilized. I’m not holding my breath.

So to get back to my original question – it appears that I ovulated — but not because of lack of suppression which is what happens to most people – instead I ovulated sooner than expected after the trigger. And now, I am wondering if maybe that’s what happened the first time too. I hadn’t been writing down all my follicle sizes etc.. the first time around, but I knew there were plenty- so I was so confused to end up with so few eggs. I kept wondering what could have happened to them!!! Is it reasonable to think that I might respond more quickly than average to the hcg trigger and ovulate in 24 hours rather than 40? If so, how do we go about timing it in the future? Is there a better way to optimize it for me so they can still have time to mature, but we can capture them before they are released?

Reply
- Geoffrey Sher says:
  
  April 4, 2013 at 11:38 am
  
  What you are experiencing is the consequence of “premature Luteinization” (premature LH surge. This is commonly seen in women with DOR who are on protocols of stimulation that result in excess LH-induced testosterone. You need a long pituitary don-regulation protocol using the agonist/antagonist conversion protocol (A/ACP) approach.See below.
  
  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. “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. “Premature Luteinization”
  
  5. “Empty follicle syndrome”
  
  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”
  
  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
  
  Geoff Sher
  
  Reply
  - Gretchen says:
    
    April 4, 2013 at 11:50 am
    
    But my LH remained low until I triggered. Since HcG mimics LH, why would it matter if my LH began to rise after the trigger? Shouldn’t it still take 36 hours?
    
    Reply
Gina says:

April 17, 2013 at 5:25 pm

I have been through four IVF cycles with only one success. The successful cycle was when I had the fewest number of follicles prior to retrieval. That cycle we retrieved four eggs and all four embryos fertilized and implanted. We had to do selective reduction to one. I have used the 250 mcg trigger of Ovidrel for all of my cycles and I was wondering if you think that doubling the dose of Ovidrel would be beneficial. My doctor said that it should have no effect, but I have read online that 250 mcg is an insufficient dose for IVF.

Reply
- Geoffrey Sher says:
  
  April 17, 2013 at 10:14 pm
  
  I would respectfully vehemently disagree. 250mcg of Ovidrel in my opinion is equivalent go about 5,000U of regular uhCG (i.e., about half the ideal dosage).
  
  Geoff Sher
  
  Reply
Sneha says:

April 26, 2013 at 1:49 am

Dear Doctor, my progesterone levels are 3ng/ml, today is the day of my HCG trigger. Given the slightly higher number, should I just freeze all the embryos or should I go ahead? My previous fresh cycle resulted in ectopic pregnancy, and then of 6 frozen day2 embryos, only 1 resulted in pregnancy- which was biochemical

Reply
- Geoffrey Sher says:
  
  April 26, 2013 at 10:32 am
  
  It is not whether you freeze embryos. If a problem is associated with an elevated P4, it relates top egg and subsequently embryo quality, not uterine receptivity.
  
  Geoff Sher
  
  Reply
Tilda says:

May 1, 2013 at 6:21 am

I have undergone 4 unsuccessful IVF cycles. 1(4 eggs,2 fertilized, 1 transfer), 2(4 eggs all immature), 3(9 eggs only 1 mature,fertilized & transfer), 4(6 eggs, none mature). My dr’s are now trying a different trigger of 3 ovidril pens plus lucrin (1st and 3rd cycle was pregnol, 2 & 4 was ovidril, with 4th using 3 pens). Plus delaying trigger till after day 12 (trigger times varied day 11 to 13). Do u think this will be enough to get mature eggs? Also I have the option again of using Growth Hormone – will this benefit as i used it cycle 3 & 4 but hard to tell as only 1 mature egg?

Reply
- Geoffrey Sher says:
  
  May 1, 2013 at 6:46 am
  
  This has to do with ovarian reserve and the protocol used for ovarian stimulation. I cannot comment about what would be ideal for you without knowing much more, I am afraid.
  
  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. “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”
  
  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
  
  Geoff Sher
  
  Reply
Chitra says:

May 1, 2013 at 9:05 pm

Hi my sister went through two IUI, which failed. Now she went with IVF, and the implantation was on 17 april 2013, and yesterday (1-5-2013) she was asked to do a HCG test, the result from the blood drawn at 8am, HCG levels came 11.19, and the doctor asked her to take another test some place else, and the result taken from the blood sample drawn at 1.30pm was 11.20.
However the doctor explained that it should have been atleast 100+, and asked her to take another test on 4-5-2013. What do you suggest is going on, any medications to improve. or anything at all which can be done. Please suggest.
Thanks a lot

Reply
- Geoffrey Sher says:
  
  May 2, 2013 at 6:19 am
  
  Ideally she should already be on hormonal supplementation therapy. The blood beta hCG levels should double over a period of approximately 48H. If it doubles, then you should discuss with the treating RE on how to proceed.
  
  Geoff Sher
  
  Reply
chitra says:

May 2, 2013 at 1:39 am

Hi.. my sister had done last year two IUI, they failed. This march, she went for IVF treatment, and the implantation was done on April 17th, and the doctors said, there are 2 excellent embryos, and one good, all the three were implanted. And she was under medication and yesterday (1-5-2013), she took HCG test, the blood sample drawn at 8am, showed 11.19 mIU/ml, and doctor explained, the level should have been atleast around 100, so asked her to take test in another center, the blood sample drawn at 1pm, the HCG level was 11.20 mIU/ml. Is there anything that can be done at all. She is asked to take another test on saturday, just in case.
Can any medication be done this time or any procedure at all. Please suggest

Thanks a lot…

Reply
Chitra says:

May 3, 2013 at 6:00 am

My sister wrote on my behalf (previous) mail. I am currenly on –
Susten 300
Folic acid
progynova
Nutracell
and Duphaston.

My BHCG was 11.20 on 1st May and i need to go for another blood test tomorrow. what should the ideal HCG level be tomorrow so that i can hope for the best.
My embyros were excellent on the day of transfer. I did not freeze any hoping that this would work for me.
I am really disappointed.
Please suggest something so that i can follow.

Regards,
chitra.

Reply
- Geoffrey Sher says:
  
  May 3, 2013 at 6:20 am
  
  Hi Chitra,
  
  Thanks for taking the time to post here.
  
  Your beta should double by tomorrow. Let’s wait and see first how that turns out!
  
  Good luck!
  
  Geoff Sher
  
  Reply
Chitra says:

May 5, 2013 at 11:24 am

Hi Geoffrey,

Bad luck, my HCG showed 2 and i got to know that my IVF failed, i was given Lupi HMG HP 75 shots for close to 15 days to enhance good quality eggs and during the egg retrieval, i had too much of pain and the doc said that it was difficult to remove the eggs. During the ET, the doc said that the egg quality was excellent, after the IVF failed, i inquired what went wrong, she informed that the egg quality matters and she said some chromosomes and anomaly, i was not in a mindset to listen to all that. NOw she is suggesting i go for donor eggs, and also suggested that i give a endometrium biopsy to rule our endometrium TB, now this is a new thing for me. I do not want to waste my money because i have no money, i have spent a lot and in mood to get disappointed again. This is my 3rd failure (2 IUIs and 1 IVF). I am obese, i do not get my periods regularly and have PCOD. During the doppler scan, the doc said everything is fine, but due to overweight, the ovaries are not in the right position.
Now you suggest me doc, with all these will i be able to conceive again. I have no hope and have lost intrest in everything. Should i try another IVF with donor eggs, What are the chances of conception? Monetarily, i am not strong and now i am not strong mentally as well, appreciate your time and valuable suggestion.

Reply
- Geoffrey Sher says:
  
  May 5, 2013 at 5:00 pm
  
  Chitra,
  
  Perhaps we should talk rather than try and address many complex issues via this forum. In the meanwhile, 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. “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. “Polycystic Ovarian Syndrome (PCOS)”
  
  10. “Use of the Birth Control Pill in IVF”
  
  Consider calling 800-780-7437 or 702-699-7437 to arrange for 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
  
  Geoff Sher
  
  Reply
Chitra says:

May 5, 2013 at 10:46 pm

Hi Geoff,

I will log into those pages and will check the information. Meeanwhile, please let me know what would be the best time to contact you over the phone – time zone. I am from India, is there any particular number i need to dial in?

Reply
- Geoffrey Sher says:
  
  May 6, 2013 at 9:03 am
  
  702-699-7437 (on the West coast of the U.S.A)…between 9.00AM and 5.00PM.
  
  Geoff Sher
  
  Reply
Alan says:

May 10, 2013 at 10:22 am

Dr. Sher,

Our second IVF cycle just failed. We had a perfect looking 5-day blast transferred. Today hcg level came out to be 3. We also have 3 frozen embryos. This time, we were on 1mll PIO. Wife didn’t have any spotting, but at same time she didn’t have any signs of being pregnant. Not sure what happened.

Reply
- Geoffrey Sher says:
  
  May 10, 2013 at 3:00 pm
  
  I cannot comment with consulting on the specifics.
  
  Sorry!
  
  Geoff Sher
  
  Reply
Lisa says:

May 21, 2013 at 8:02 am

Dear Dr. Sher:

Seeking a second opinion re my fertility Tx. Had second IUI 5/17/13 (1st with Clomid). Ovidrel shot on 5/16/13AM. Got positive OPK on 5/19/13 AM, had intercourse that night. Still another positive OPK 5/20/13 PM and 5/21/13 AM. Noted cervical mucous 5/20/13 and 5/21/13. Concerned that did not ovulate in time for IUI and it was not well timed. Are there any other factors that could cause this? Also am interested in a free phone consult if you are providing those.

Thanks,
Lisa

Reply
- Geoffrey Sher says:
  
  May 21, 2013 at 8:52 am
  
  In my opinion you had intercourse late. Once the hCG is given, you need to have intercourse within 36-40 hours or so or it will be too late.
  
  Geoff Sher
  
  Reply
  - Lisa says:
    
    May 21, 2013 at 9:34 am
    
    Do you provide free consults via phone?
    
    Reply

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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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IVF: Coping With the Emotional Roller Coaster Ride

Procreation – and with it the ability to achieve immortality by living on through one’s children – is one of the most insatiable human needs. This strong natural urge exerts tremendous pressure on couples unable to have a baby. And ... more

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DQ alpha/HLA Sharing: Does It Always Lead To Reproductive Failure?

It is not unusual for couples who share DQ alpha/HLA similarities to first give birth to a healthy baby only to subsequently develop infertility, recurrent IVF failure or recurrent pregnancy loss. Such couples find it hard to comprehend how after hav... more

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Dr. Geoffrey Sher Recommends

CGH Embryo vs. Blastocyst vs. Cleaved Embryo

IVF Success Rate Reporting – Are We There Yet?

Please join me on Wed, February 6 at 8:30pm Eastern for a live webinar where I’ll discuss this topic in detail and take your questions. For more information or to register, click HERE ————- I have, for many years, tak... more

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IVF Success Rate Statistics: The Time Has Come to Revise the Present Reporting System

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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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?

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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

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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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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

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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?

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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?

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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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