Friday, December 14, 2007

Good post from Dr. Sher

Here is what Dr. Sher himself posted on his forums (one of the founders and a good RE from SIRM -Sher institute)

…………………………………….It is unfortunately not often appreciated that IVF should never be undertaken without a prior, thorough and comprehensive clinical and psychological evaluation. IVF is an emotional, financial and physical roller coaster which is only worth contemplating when you have reasonable expectations about the outcome. It is simply not good enough to jump right in to the process without undergoing an in-depth assessment of all the variables that can impact outcome. Always remember…., IVF is a classic example of the "chain being as strong as it’s weakest link". So “plan the trip, before taking the ride” or be prepared for a poor outcome.

Simply because a woman conceives once does not mean that she is just as likely (or even able) to be successful again. Let me pose two (2) theoretical examples to clarify what I mean:

Example #1: A woman with endometriosis has one baby with fertility drugs than cannot get pregnant a second time after repeated attempts with the same treatment: All women with endometriosis (regardless of severity) inevitably have to contend with the existence of “peritoneal toxins” in the pelvic secretions on the surface of and surrounding their ovaries, tubes and uteri .When upon ovulation, eggs pass from the ovary to the tube(s), they come in contact with this “toxic peritoneal factor” which renders the envelopment of the egg(the zona pellucida) less pregnable to sperm. As a consequence, such eggs subsequently 4 to 6 times less likely to be successfully fertilized upon arriving in the Fallopian tube(s).. This explains why a 35year old woman who has endometriosis will have about a 3% chance of conceiving per month of trying as compared with about 15% in for fertile woman of the same age. The “toxic peritoneal factor impacts on eggs that are ovulated (whether spontaneously or following the use of fertility drugs) and serves to explain why the chance of pregnancy is much reduced in normally ovulating women with endometriosis, regardless of whether fertility drugs and/or intrauterine insemination is used , or whether endometriotic deposits are removed surgically. An ovulating woman who fits the bill as outlined above in example #1, does have a chance (albeit markedly reduced) but this chance is markedly compromised and can only be improved by side tracking the toxins in the pelvis through IVF. .AND if such a woman were to conceive following spontaneous or induced, her chances of repeating her good fortune again, by the same approach would revert to being much reduced. It would be wrong for her or her physician to assert otherwise. But alas, all to often the prior pregnancy leads to a sense of false confidence that the same good fortune will again occur, just as easily as the first time. Often times this results in women trying cycle after cycle , often for years , only to be rewarded by “failure” and despondency. Eventually time runs out as, her egg quality declines with age and her ovarian reserve becomes depleted as she gets nearer to the pre-menopause.

Example #2: A 36 year old woman with endometriosis does IVF, has a baby but cannot conceive a few years later after trying IVF again and again and again…. The reason might be that 30% of women with endometriosis develop uterine natural killer cell activation (NKa) . This might not have occurred to the extent of precluding a viable pregnancy by her first IVF attempt, but now is in full force…resulting in a profound immunologic implantation problem. Going to IVF was appropriate but failure to keep an eye open for an emerging immunologic implantation problem…was in my opinion constitutes an error of omission. She might well have had another IVF baby had she undergone NKa down-regulation with IVIG 7-14 days prior to embryo transfer and perhaps had one follow up IVIF infusion upon the diagnosis of pregnancy!

So, simply because one confounding issue (e.g natural killer cell activation [NKa] is detected does not mean that other issues are not coexisting or in the process of developing.

my favorite part is his conclusion

This is one of my biggest gripes about how IVF is often conducted because failure to perform a THOROUGH and comprehensive evaluation in all women undergoing IVF represents a serious error of omission and one that fundamentally compromises the chance of a success birth following IVF. After all, this is NOT about doing IVF, it is about having a baby and the cost of the latter not the former is what counts. Simply stated, if treatment for IVF is approached correctly and all variables that affect seed (embryo) quality and Soil (uterine receptivity) are evaluated and addressed thoroughly upfront, then the cost per baby (emotional, physical and financial goes DOWN).

If you now cannot afford to be properly and thoroughly reassessed and treated, do not do another IVF. Save your money for the child you already have been blessed with!


M said...

What great commentary from Dr.Sher! Bravo!

Even though I like my doctor, I feel there are more tests that can and should be done. It frustrates me that we need to wait for repeated failures to investigate further.

I am glad Dr.Hill is starting to give you some answers. Did your last RE put you on antibiotics before transfer? I had tetracycline for 4 days-- but I think that was just to prevent infection after egg retrieval. I guess you would have to have been on an antibiotic for over a week though to help the endometritis.

M said...

Everything that Dr. Sher said should give you great hope for your next IVF to work. Your last RE never ran the right tests AND he never gave you the right treatments.

You are finally on the right track!

Amy said...

Actually endometritis can be caused from procedures like IUI's and IVF ER and ET. I was never given anything to help an infection. Doxycycline is a member of the tetracycline ntibiotics group and is commonly used to treat a variety of infections. Doxycycline is a semi-synthetic tetracycline. It's VERY good that your Re puts you on that med to prevent infection!!!! I'm very very upset that my RE never did that. Needless to say I might be writing a letter to them at some point.

M said...

Wow. That puts a new spin on it. I don't blame you for being mad. I am mad for you! He really was terrible. More and more evidence supports it all the time. He didn't do ANY of the basic things.

Thank goodness you have moved on now!

M said...

Not to add fuel to the fire, but look at Jennifer's post from December 6. The protocol for her upcoming FET is antibiotics and steroids for 1 week before and after transfer.

After my ER I was on medrol and tetracycline for 4 days. I hope your RE at least put you on medrol--or another steroid. Did he?

I can imagine your frustration. You must have felt you were in good hands to go to such a reputable clinic like Boston IVF, then to come to find out your RE didn't even do the basic stuff is absolutely confusing and devastating.

Again, thank goodness you will have a decent chance now.

Jennifer said...

I like Dr. Sher - he's always really good about providing thorough answers to questions in his forum. I posted there after my last IVF failure - when I really needed some answers, and Dr. Sher was really great to give me some good responses.

Do you think you'll go with Dr. Hill locally or start your next cycle with Sher or CCRM?

I'm so glad you're starting to get the answers and attention you need!!!

Amy said...

Nope no steroids or anything. I'm going to ask the girls on FF and see how many of them had this as their protocol.

Anonymous said...

I don't think Dr. Sher or his clinic have the technology to have successful IVF pregnancies. We at least had eggs fertilized at Cornell but after Dr. Sher looked at all the past treatments from Cornell he stated that he would put my wife on a more aggressive treatment to produce more eggs. However, she produced half the eggs she did at Cornell and had no fertilization of any of the two eggs. In hindsight we should have frozen our first cycle from Cornell and combined that with the second cycle and this would have been 3 fertilized eggs. Cornell is much more equipped than Sher institute and now 2 months after the cycle I'm informed we need to wait an additional 8-12 weeks to get a refund for what he had to pay in advance. Not a very good experience. Please shop around and don't be sold by a doctor's personality and knowledge like we were.

Anonymous said...

Hi dr.... My hcg read 0.6 today. This is my third ivf ( icsi) failure. The quality of my embryos were very good. My endometruim was 9 mm. However today the doctor says maybe i hv a problem in my womb. My question is why do doctors mk us go thru all this. When he knew my last two ivfs failed without a reason why didnt he do his clarification of the womb before the treatment. Dr sher can you please throw some light as to what went wrong. I am only 35.