10 Responses to “IVF and Immunology: The Role of Immunologic Factors and Selective Immunotherapy”

1. Good Eggies says:

   December 21, 2009 at 3:40 pm

   I think that part of the issue here is that these immunological treatments for a failure conceive seem to be beginning to be touted as a panacea for any failure to get pregnant. "Your IVF doesn't work, it's immunological. Try these very expensive experimental treatments and let's hope you catch the Golden Egg."

   True, trial and error/empirical evidence seems to be the way to go regarding research but you have to have results that people can understand and evaluate and compare. The reality is that there is so little really know about how our bodies work and how the systems are truly intertwined. That needs to be admitted somewhere. Even if we know about certain immunological issues there are currently very few options for treatment and none that any research agrees on. This just means more info is needed and this is just the beginning.

   ART are sort of like using a blowtorch to light a cigarette at this point. If we still lack the ability to determine if egg and sperm have met in the fallopian tubes or to determine immediate implantation then we are not ready to declare that we know how to harness the other systems of the body and correct them in order to achieve a live birth.

   That said, it's exciting that someone is exploring these things in any manner because our bodies systems don't function independently and it's nice to see doctors and researchers trying to evaluate how things are interconnected. The CGH procedure sounds very promising to help with that 70%-80% of IVF failure that occurs from embryo abnormalities. I just hope it's not prohibitively expensive and that it catches on.

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2. Geoffrey Sher, MD says:

   December 21, 2009 at 4:16 pm

   I agree … no one should undergo immunologic therapy without a clear cut diagnosis that also typifies the problem. However, I respectfully disagree that evidence of efficacy is lacking in this therapeutic arena.

   I would submit that underpinning the reluctance on the part of many ART practitioners is is a fundamental lack of knowledge in the arna of Immunology! Remember, the field of immunology is far more complex than ART. Also there is an obvious but possibly understandable hesitancy on thepart of RE's to confront potential patients with additional costs associated with the diagnosis and treatment of immunologic implantation dysfunction. Bear in mind that this is a very competitive arena and many RE's are frightened of pricing themselves out of "business".

   Either way, it will be interesting to see how attitudes will change once this is finally put to rest on the basis of "Gold Standard" studies, currently underway.My guess is that some of the harshest critics will themselves then claim ownership.

   Geoff Sher

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3. Good Eggies says:

   December 22, 2009 at 10:48 am

   And I agree with you that the problem wrt those in the medical profession may be a fundamental lack of knowledge of immunology or maybe more importantly a lack of interest to look at all systems together. Perhaps because we don't have the technology to do that very well yet.

   And I agree about the pricing. Regular IVF just about kills the average person if they don't have insurance and then to add very expensive tests and very expensive, experimental procedures on top of that you're down to a small number of participants. The efficacy of the procedures (in laymans terms) needs to be made clear to woman desperate to become pregnant especially if there is a very small return.

   From personal experience, I was seeing an acupuncturist who works in conjunction with Western ART who, after my first IVF failed (at age 39), pushed the concept more likely than not my problem was immunological.

   My first thought was "How the h*** would he know definitively what the problem was beyond AGE?" The manner and tone in which he delivered these ideas really irked me because it was being brought out as a panacea of sorts for "the unknown" reasons why my 39 yr old eggs/embryo didn't implant. Now mind you this wasn't an RE but an acu who works very closely with REs. While this was not directly at a clinic these are some of the people pushing the ideas out there in a not so ethical manner. In theory it is in my best interest but to imply that nothing further can be done if I don't get immunological tests is wrong.

   I am at CRMI and I understand their beliefs to be thus…they aren't harshly criticizing the concept of immunological issues but they feel that they don't have enough information on both the problems or the solutions. And from my own observations, CRMI is a pretty conservative clinic. So put conservatism with lack of information and you have an entire group of doctors holding off on judgment until a further date. But this is just my interpretation of the situation there and I am not a participant in the medical community so I don't really know your professional interactions.

   This is a touchy, interesting subject and I'm interested to keep it in my sights.

   And by the by, your book on IVF was a great help to me as I began to delve into learning about my infertility. Thanks for that great resource.

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4. Geoffrey Sher, MD says:

   December 22, 2009 at 12:26 pm

   Thanks for your comments. I agree!

   Geoff Sher

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5. BKK Blonde says:

   April 18, 2010 at 12:46 am

   Hi Dr Sher-
   Since I am a IVF patient in Thailand and do not have access to the advanced screening labs in US to check for some of these ID issues, does it still make sense to do Prednisone or Dexamethasone as a preventative measure? Is starting 7 days bef ER sufficient?
   I am planning to propose your A/ACP protocol to my Dr for 3rd IVF cycle- thanks so much for providing all the valuable info on your website and blog!
   To give a bit of my background, I am 43 w all normal D3 levels, no known other structural issues and a good responder. My first 2 cycles were back-to-back low dose protocols (#1 Clomid 50mg D3-12 plus 150iu Gonal-F on D8 and 10 w 2 hi-grade embos transfered at D3 and #2 Clomid same as 1st but 150iu of Menogon D6-12 with 3 hi-grade embos trsfrd at D4 and 1-D6 blast frozen w no early LH surge on either as Clomid seemed to suppress as promised). I do not seem to get thinning from Clomid (had 8+ on #1 and 10+ on 2nd cycle) but I also supplement w acupuncture to improve blood flow. Does it make any sense to try the Viagra suppository method as well or is that only if endo is below a certain level? If it does make sense, could you tell me the protocol for making making these or could I call to get it?
   Lastly, we have been using a single dose of Ovidrel for trigger but you state in another blog that you prefer a double dose or 10,000iu of hCG, could you provide any more detail on what your rationale/experience has been with both?

   As I will likely only have the funds to do one more retrieval with cycle commencing soon, I want to make every reasonable effort to make it successful- any advice you can provide on these topics would be greatly appreciated!

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6. Geoffrey Sher, MD says:

   September 27, 2010 at 12:47 pm

   I would need to discuss this with you. Please consider calling 800-780-7437 and set up a free medical telephone consultation with me.

   Geoff Sher

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7. Geoffrey Sher says:

   September 6, 2012 at 8:55 am

   Please discuss with your RE. However, do not be concerned about the prednisilone affecting egg/embryo quality adversely….it should not. Also, unless you are diabetic, diabetic, do not worry about the effect on your blood sugar. This will not have an adverse effect. Steroids such as prednisilone are used by most IVF programs must be continued to the 10th week and then tailed off over 7-1- days.

   good luck!

   Geoff Sher

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8. Geoffrey Sher says:

   September 6, 2012 at 8:56 am

   Responded above!

   Good luck!

   Geoff Sher

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9. Nicole says:

   December 19, 2012 at 4:08 am

   Hi Dr Sher I was very much hoping you could help with my infertility nightmare!

   Myself – 30 yrs old, AMH: 3 / FSH 9 / ttc 7 years / diagnosed this year with severe endometriosis mostly around my ovaries.

   My partner – 39 yrs old – no issues

   After trying unsuccessfully naturally for 4 years (tried using ov kits but no signs of ov) I consulted my gp & was referred to our local hospital for ‘basic fertility tests’. No issues apparently found & I was diagnosed with ‘unexplained infertility’!
   I was then given 3 months of clomid & a follow up appointment for 6 months later! Clomid did nothing for me (no ovulation detected on ov kits). My periods were horrendous whilst on this & shortened to 24 days following it. They went back to 28-29 days after a few months.
   I was then referred to another hospital for IVF. Again only the basic tests were carried out (blood, semen etc). This was when I was found to have an AMH of 3.

   IVF 1 – 0.5 burselin / 4 vials of menopur / gonasi hcg trigger shot / 2x 400mg cyclogest.

   Stimmed for 12 days in total – produced 10 eggs of which 5 fertilised. Transferred 1 hatching blast on day 5. Other 4 embryos did not make it to freeze.

   Day 3 started to spot pink blood & by day 5 had period. I did have a very strong ‘immune reaction’ the day after transfer (flu like symptoms which lasted 12 hrs).

   My consultation advised he thought the egg quality was to blame causing the early bleed after implantation.

   I insisted on further tests & 3 months later had a Hyscosy & LAP. I was then diagnosed with severe endo. I was also given a cervical dilation due to a difficult transfer. I apparently have a small & narrow cervix & forward tilting uterus.

   IVF 2 – 0.5 buserelin / 6 vials of menopur / gonasi hcg shot / 3x4200mg of cyclogest (after my insisting on increasing the dosage). 1x 75mg asprin daily.

   Stimmed for 13 days & was very slow to respond this time. 6 eggs collected of which 3 fertilised. 2 blasts transferred on day 5 (1 more advanced than the other). The other embryo did not make it to blast.

   Day 6 after transfer brown spotting on & off throughout the day & by day 7 had developed into period. Felt slightly unwell with flu type sysmptoms the day after transfer but not as intense as the first ivf).

   Both IVF’s resulted in negatives.

   My questions are:

   1, what is your opinion on the early bleeds? Do you think it’s embryo quality (I don’t know there officially grading by the lab). Or is it an immune issue possibly linked to the endo? Or both?
   My aim next is to have level 1 & 2 immune testing.

   2, do you think the progesterone support is enough? May I possibly also need estrogen support? My hosp don’t believe in this! I am also considering asking for progesterone injections instead.

   My aim is to try with DE next time due to my poor response on IVF 2 & my low AMH level. Do you agree?

   My main concern is the amount of time I have been infertile plus the 2 failures. I have never achieved a pregnancy yet. Do I have hope in your opinion?

   Thank you so much for taking the time to read this.

   Nicole.

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   • Geoffrey Sher says:

     December 19, 2012 at 9:11 am

     Hi Nicole,

     In my opinion, at 30Y and blastocysts transferred,it is inconceivable to me that you would have an intractable egg issue requiring an egg donation approach. I think your spotting tracks back to the protocol of stimulation which I would want to delve in to. Then there is the very important consideration of your possibly having an immunologic implantation dysfunction linked to activated uterine natural killer cells. This sounds a likely scenario given your history of endometriosis which is associated with NK cell activation and implantation dysfunction in 30% of cases.

     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)
      “Ovarian Stimulation in IVF: Why is it important to down-regulate LH?”
      “Agonist/Antagonist Conversion Protocol”
      “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”
      “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). While an audiovisual (Skype) interaction is much more personable and preferable than a discussion by telephone, either will suffice.

     Geoff Sher

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