IVF Pregnancy with a “Vanishing Twin”

Today, in first world environments where there is ready access to advanced medical technology, many women undergo ultrasound diagnosis of pregnancy as early as 5-6 weeks after their last menstrual period. As a result, multiple pregnancies are often recognized very early on. Serial ultrasound follow-up examinations performed in such cases have shown that often times one of the developing babies subsequently “mysteriously” vanishes while the remaining, surviving conceptus (baby) proceeds to a healthy birth. Since most multiple gestations comprise of twin pregnancies, the term “vanishing twin” has emerged as the term to describe this situation. While in most cases the vanishing of a twin is associated with an innocuous small bleed, this is not invariably the case.In fact, in many cases the disappearance of the conceptus goes undetected without there being any bleeding or other symptoms at all.

The incidence of spontaneous pregnancies resulting in twin births is about 1:80. But what many fail to appreciate is that about one in 10 spontaneous pregnancies start off as twins but as the pregnancy advances into the 1st trimester and beyond, one twin will “vanish” (absorb) while the other will continue as a healthy, unaffected singleton. The incidence of multiple pregnancies increases in women with absent or dysfunctional ovulation, who takes fertility drugs. In fact the incidence of multiple pregnancies in such women under 35 years of age who are treated, treated with Clomiphene and Femara is about 1:20. In similar women using injectible gonadotropin fertility medications the incidence is about 1:4-5, while women (regardless of their ovulatory status) who receive fertility drugs in preparation for IVF (where multiple embryos are usually transferred), the current incidence is about 1:3 to 1:4.

When with a multiple pregnancy, the occurrence of painless mild bleeding is followed by ultrasound evidence that one is “absorbing” or “vanishing” often evokes understandable alarm raising several concerns and questions:

Q : Am I destined to lose both concepti and miscarry?

A: The bleeding results from the absorption of one of the pregnancies and since the vast majority of twin pregnancies have separate and independent placentas; the loss of one will accordingly usually not affect the remaining twin. As long as the bleeding remains mild and she does not experience an increase in cramping and pain over a period of a few days, the pregnancy will probably not be lost. In fact, in the majority of such cases, this is precisely what happens!

Q: How long will I continue to bleed?

A:In most cases unless the remaining conceptus is also abnormal and thus destined to miscarry, the bleeding will remain slight, painless, and will usually stop within a week or so. However, this will depend on when the one twin succumbed. If it occurred late in the first trimester the bleeding could last longer (even for a few weeks) than when the pregnancy is lost earlier. It should be borne in mind however, that the loss of one conceptus (the “vanishing twin”) might not be accompanied by any bleeding at all In effect they might absorbs the one twin without symptoms and with no outward indication of the loss.

Q. How will the loss of one twin affect the surviving one?

Answ: In the majority of cases, the other conceptus usually progresses, unaffected, onto a healthy birth.

Q: Will there be any residual evidence of the “vanished twin” detected at birth?

A: Usually not! Sometimes a small area of scarring or “thickening” of part of the placenta will be seen. However, this will usually only occur in cases where the one conceptus succumbed late in the first trimester (10-12 weeks) or in the 2nd trimester. In rare cases where a baby is lost later in pregnancy. It might not absorb completely and be expelled with birth of the surviving baby (“fetus papyraceus”).

Q: Could the “vanishing” of one twin have been prevented — Did I do something wrong?

Answ: The vanishing twin is neither parents fault. In most cases the conceptus twin is lost because it is chromosomally or genetically abnormal. Since many “vanishing twins” are lost very early in pregnancy, before most women would have undergone a diagnostic ultrasound, most cases go undetected and the woman would have no knowledge that she had been carrying more than one conceptus. In fact as stated above, many more of us begin life as twins than was previously thought.

“Vanishing” concepti can also occur in high order multiple pregnancies (triplets or greater). In such cases the pregnancy could reduce from triplets to twins or even a singleton or even from a higher number downward. Since the incidence of multiple pregnancy as well as high order multiples are most common after IVF where several embryos are often deliberately transferred to the uterus, the incidence of a conceptus “vanishing” is greatest with IVF.

Regardless of the genesis of multiple gestations, individuals and families who experience the “vanishing” of a conceptus will often experience anxiety and even panic when bleeding starts and a sense of relief when it finally and  they learn that the remaining conceptus and the pregnancy have survived. However, in most cases there will inevitably be an accompanying sense of profound loss, sadness and even grief, especially in cases where prior ultrasound examination had spelled the “promise” of a multiple birth.

125 Comments

P

Hi Dr. Sher,

I am currently 5w3d pregnant. I’ve had great HCG doubling so far, most recently doubling yesterday morning (5w2d) at 36 hours with an 11,087 HCG. Throughout yesterday I was having heart palpitations that my doctor sent me to the ER for, and my HCG came back at 9537 (nearly a 15% lesser difference from earlier the same day). I understand labs can vary but this seems like a significant same day difference and in the opposite direction. Any hope for anything other than a loss?

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Dr. Geoffrey Sher

At this stage, the hCG levels can fluctuate. An US evaluation is much more indicative of viability!

Good luck!

Geoff Sher

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Jenny M

Hi Dr Sher,

I am pregnant via surrogate. (surrogate is age 25 and LMP was 17 march). The 3 day frozen embryo transfer (2 embryos) was on 1 april.

⁃ 15 april pregnancy test was positive and HCG was 652.65
⁃ 19 april HCG 1841.5 (1 gestational sac seen)
⁃ 22 april HCG 4150.2 doctor was not highly pleased with the number.
⁃ 27 april HCG has gone down to 3392.6 (1 yolk sac seen). 

⁃ Next scan is on 03 may. I am really worried something is wrong. Doc says she is surprised because the ultrasound looked great, and that it could be vanishing twin or abnormal pregnancy or a mistake in reading, but we have to wait till 3 May scan and HCG test.

Please advise and thanks in advance.

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Dr. Geoffrey Sher

I agree with your RE. Only time will tell. You will know in <1 week!

Good luck and G-d bless!

Geoff Sher

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Emmy H

Hello jenny
Hope all is well, please let us know how your pregnancy progressed!
Hope you did well with a healthy baby ❤️
Really anxious for your reply cause I’m kind of in the same situation and very worried

Thank you!

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LaurenK

Hello Dr. Sher,

This is my second round of Letrozole/trigger shot. I got a faint BFP 11dpo. First beta on 16dpo was 86. Second beta on 18dpo was 99. Is this to slow of an increase to be viable? They also mentioned it could be multiples where one did not make it. I will go back for another beta tomorrow but trying not to get my hopes up. What are my chances realistically and is there anything I can do in the meantime?

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Dr. Geoffrey Sher

You will need to repeat the hCG test in 2 days to see if it doubles!

Good luck!

Geoff Sher

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Amanda Dougherty

Hello this is suppose to be my 3rd miscarriage but im not bleeding im not cramping my cervix is closed. According to my HCg they are estimating im around 3-4 weeks.My doctor is saying because of my HCG levels are lowering im miscarrying but I have no symptoms
10/8/20- HCg 845
10/10/20- HCg 1496
10/12/20- HCg 895
10/14/20- HCg 506

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Dr. Geoffrey Sher

Sadly, it dos not look like this pregnancy is viable! I hope I am wrong….

When it comes to reproduction, humans are the poorest performers of all mammals. In fact we are so inefficient that up to 75% of fertilized eggs do not produce live births, and up to 30% of pregnancies end up being lost within 10 weeks of conception (in the first trimester). RPL is defined as two (2) or more failed pregnancies. Less than 5% of women will experience two (2) consecutive miscarriages, and only 1% experience three or more.
Pregnancy loss can be classified by the stage of pregnancy when the loss occurs:
• Early pregnancy loss (first trimester)
• Late pregnancy loss (after the first trimester)
• Occult “hidden” and not clinically recognized, (chemical) pregnancy loss (occurs prior to ultrasound confirmation of pregnancy)
• Early pregnancy losses usually occur sporadically (are not repetitive).

In more than 70% of cases the loss is due to embryo aneuploidy (where there are more or less than the normal quota of 46 chromosomes). Conversely, repeated losses (RPL), with isolated exceptions where the cause is structural (e.g., unbalanced translocations), are seldom attributable to numerical chromosomal abnormalities (aneuploidy). In fact, the vast majority of cases of RPL are attributable to non-chromosomal causes such as anatomical uterine abnormalities or Immunologic Implantation Dysfunction (IID).
Since most sporadic early pregnancy losses are induced by chromosomal factors and thus are non-repetitive, having had a single miscarriage the likelihood of a second one occurring is no greater than average. However, once having had two losses the chance of a third one occurring is double (35-40%) and after having had three losses the chance of a fourth miscarriage increases to about 60%. The reason for this is that the more miscarriages a woman has, the greater is the likelihood of this being due to a non-chromosomal (repetitive) cause such as IID. It follows that if numerical chromosomal analysis (karyotyping) of embryonic/fetal products derived from a miscarriage tests karyotypically normal, then by a process of elimination, there would be a strong likelihood of a miscarriage repeating in subsequent pregnancies and one would not have to wait for the disaster to recur before taking action. This is precisely why we strongly advocate that all miscarriage specimens be karyotyped.
There is however one caveat to be taken into consideration. That is that the laboratory performing the karyotyping might unwittingly be testing the mother’s cells rather than that of the conceptus. That is why it is not possible to confidently exclude aneuploidy in cases where karyotyping of products suggests a “chromosomally normal” (euploid) female.
Late pregnancy losses (occurring after completion of the 1st trimester/12th week) occur far less frequently (1%) than early pregnancy losses. They are most commonly due to anatomical abnormalities of the uterus and/or cervix. Weakness of the neck of the cervix rendering it able to act as an effective valve that retains the pregnancy (i.e., cervical incompetence) is in fact one of the commonest causes of late pregnancy loss. So also are developmental (congenital) abnormalities of the uterus (e.g., a uterine septum) and uterine fibroid tumors. In some cases intrauterine growth retardation, premature separation of the placenta (placental abruption), premature rupture of the membranes and premature labor can also causes of late pregnancy loss.
Much progress has been made in understanding the mechanisms involved in RPL. There are two broad categories:
1. Problems involving the uterine environment in which a normal embryo is prohibited from properly implanting and developing. Possible causes include:
• Inadequate thickening of the uterine lining
• Irregularity in the contour of the uterine cavity (polyps, fibroid tumors in the uterine wall, intra-uterine scarring and adenomyosis)
• Hormonal imbalances (progesterone deficiency or luteal phase defects). This most commonly results in occult RPL.
• Deficient blood flow to the uterine lining (thin uterine lining).
• Immunologic implantation dysfunction (IID). A major cause of RPL. Plays a role in 75% of cases where chromosomally normal preimplantation embryos fail to implant.
• Interference of blood supply to the developing conceptus can occur due to a hereditary clotting disorder known as Thrombophilia.

2. Genetic and/or structural chromosomal abnormality of the embryo.Genetic abnormalities are rare causes of RPL. Structural chromosomal abnormalities are slightly more common but are also occur infrequently (1%). These are referred to as unbalanced translocation and they result from part of one chromosome detaching and then fusing with another chromosome. Additionally, a number of studies suggest the existence of paternal (sperm derived) effect on human embryo quality and pregnancy outcome that are not reflected as a chromosomal abnormality. Damaged sperm DNA can have a negative impact on fetal development and present clinically as occult or early clinical miscarriage. The Sperm Chromatin Structure Assay (SCSA) which measures the same endpoints are newer and possibly improved methods for evaluating.

IMMUNOLOGIC IMPLANTATION DYSFUNCTION
Autoimmune IID: Here an immunologic reaction is produced by the individual to his/her body’s own cellular components. The most common antibodies that form in such situations are APA and antithyroid antibodies (ATA).
But it is only when specialized immune cells in the uterine lining, known as cytotoxic lymphocytes (CTL) and natural killer (NK) cells, become activated and start to release an excessive/disproportionate amount of TH-1 cytokines that attack the root system of the embryo, that implantation potential is jeopardized. Diagnosis of such activation requires highly specialized blood test for cytokine activity that can only be performed by a handful of reproductive immunology reference laboratories in the United States.
Alloimmune IID, i.e., where antibodies are formed against antigens derived from another member of the same species, is believed to be a relatively common immunologic cause of recurrent pregnancy loss.
Autoimmune IID is often genetically transmitted. Thus it should not be surprising to learn that it is more likely to exist in women who have a family (or personal) history of primary autoimmune diseases such as lupus erythematosus (LE), scleroderma or autoimmune hypothyroidism (Hashimoto’s disease), autoimmune hyperthyroidism (Grave’s disease), rheumatoid arthritis, etc. Reactionary (secondary) autoimmunity can occur in conjunction with any medical condition associated with widespread tissue damage. One such gynecologic condition is endometriosis. Since autoimmune IID is usually associated with activated NK and T-cells from the outset, it usually results in such very early destruction of the embryo’s root system that the patient does not even recognize that she is pregnant. Accordingly the condition usually presents as “unexplained infertility” or “unexplained IVF failure” rather than as a miscarriage.
Alloimmune IID, on the other hand, usually starts off presenting as unexplained miscarriages (often manifesting as RPL). Over time as NK/T cell activation builds and eventually becomes permanently established the patient often goes from RPL to “infertility” due to failed implantation. RPL is more commonly the consequence of alloimmune rather than autoimmune implantation dysfunction.
However, regardless, of whether miscarriage is due to autoimmune or alloimmune implantation dysfunction the final blow to the pregnancy is the result of activated NK cells and CTL in the uterine lining that damage the developing embryo’s “root system” (trophoblast) so that it can no longer sustain the growing conceptus. This having been said, it is important to note that autoimmune IID is readily amenable to reversal through timely, appropriately administered, selective immunotherapy, and alloimmune IID is not. It is much more difficult to treat successfully, even with the use of immunotherapy. In fact, in some cases the only solution will be to revert to selective immunotherapy plus using donor sperm (provided there is no “match” between the donor’s DQa profile and that of the female recipient) or alternatively to resort to gestational surrogacy.
DIAGNOSING THE CAUSE OF RPL
In the past, women who miscarried were not evaluated thoroughly until they had lost several pregnancies in a row. This was because sporadic miscarriages are most commonly the result of embryo numerical chromosomal irregularities (aneuploidy) and thus not treatable. However, a consecutive series of miscarriages points to a repetitive cause that is non-chromosomal and is potentially remediable. Since RPL is most commonly due to a uterine pathology or immunologic causes that are potentially treatable, it follows that early chromosomal evaluation of products of conception could point to a potentially treatable situation. Thus I strongly recommend that such testing be done in most cases of miscarriage. Doing so will avoid a great deal of unnecessary heartache for many patients.
Establishing the correct diagnosis is the first step toward determining effective treatment for couples with RPL. It results from a problem within the pregnancy itself or within the uterine environment where the pregnancy implants and grows. Diagnostic tests useful in identifying individuals at greater risk for a problem within the pregnancy itself include:

Karyotyping (chromosome analysis) both prospective parents
• Assessment of the karyotype of products of conception derived from previous miscarriage specimens
• Ultrasound examination of the uterine cavity after sterile water is injected or sonohysterogram, fluid ultrasound, etc.)
• Hysterosalpingogram (dye X-ray test)
• Hysteroscopic evaluation of the uterine cavity
• Full hormonal evaluation (estrogen, progesterone, adrenal steroid hormones, thyroid hormones, FSH/LH, etc.)
• Immunologic testing to include:
a) Antiphospholipid antibody (APA) panel
b) Antinuclear antibody (ANA) panel
c) Antithyroid antibody panel (i.e., antithyroglobulin and antimicrosomal antibodies)
d) Reproductive immunophenotype
e) Natural killer cell activity (NKa) assay (i.e., K562 target cell test)
f) Alloimmune testing of both the male and female partners

TREATMENT OF RPL
Treatment for Anatomic Abnormalities of the Uterus: This involves restoration through removal of local lesions such as fibroids, scar tissue, and endometrial polyps or timely insertion of a cervical cerclage (a stitch placed around the neck of the weakened cervix) or the excision of a uterine septum when indicated.
Treatment of Thin Uterine Lining: A thin uterine lining has been shown to correlate with compromised pregnancy outcome. Often this will be associated with reduced blood flow to the endometrium. Such decreased blood flow to the uterus can be improved through treatment with sildenafil and possibly aspirin.
Sildenafil (Viagra) Therapy. Viagra has been used successfully to increase uterine blood flow. However, to be effective it must be administered starting as soon as the period stops up until the day of ovulation and it must be administered vaginally (not orally). Viagra in the form of vaginal suppositories given in the dosage of 25 mg four times a day has been shown to increase uterine blood flow as well as thickness of the uterine lining. To date, we have seen significant improvement of the thickness of the uterine lining in about 70% of women treated. Successful pregnancy resulted in 42% of women who responded to the Viagra. It should be remembered that most of these women had previously experienced repeated IVF failures.
Use of Aspirin: This is an anti-prostaglandin that improves blood flow to the endometrium. It is administered at a dosage of 81 mg orally, daily from the beginning of the cycle until ovulation.
Treating Immunologic Implantation Dysfunction with Selective Immunotherapy: Modalities such as IL/IVIg, heparinoids (Lovenox/Clexane), and corticosteroids (dexamethasone, prednisone, prednisolone) can be used in select cases depending on autoimmune or alloimmune dysfunction.
The Use of IVF in the Treatment of RPL
In the following circumstances, IVF is the preferred option:
1. When in addition to a history of RPL, another standard indication for IVF (e.g., tubal factor, endometriosis, and male factor infertility) is superimposed.
2. In cases where selective immunotherapy is needed to treat an immunologic implantation dysfunction.
The reason for IVF being a preferred approach in such cases is that in order to be effective, the immunotherapy needs to be initiated well before spontaneous or induced ovulation. Given the fact that the anticipated birthrate per cycle of COS with or without IUI is at best about 15%, it follows that short of IVF, to have even a reasonable chance of a live birth, most women with immunologic causes of RPL would need to undergo immunotherapy repeatedly, over consecutive cycles. Conversely, with IVF, the chance of a successful outcome in a single cycle of treatment is several times greater and, because of the attenuated and concentrated time period required for treatment, IVF is far safer and thus represents a more practicable alternative
Since embryo aneuploidy is a common cause of miscarriage, the use of preimplantation genetic diagnosis (PGD), with tests such as CGH, can provide a valuable diagnostic and therapeutic advantage in cases of RPL. PGD requires IVF to provide access to embryos for testing.
There are a few cases of intractable alloimmune dysfunction due to absolute DQ alpha matching where Gestational Surrogacy or use of donor sperm could represent the only viable recourse, other than abandoning treatment altogether and/or resorting to adoption. Other non-immunologic factors such as an intractably thin uterine lining or severe uterine pathology might also warrant that last resort consideration be given to gestational surrogacy.
The good news is that if a couple with RPL is open to all of the diagnostic and treatment options referred to above, a live birthrate of 70%–80% is ultimately achievable.
I strongly recommend that you visit http://www.SherIVF.com. Then go to my Blog and access the “search bar”. Type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.
• The IVF Journey: The importance of “Planning the Trip” Before Taking the Ride”
• Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
• IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
• The Fundamental Requirements For Achieving Optimal IVF Success
• Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the “Conventional” Antagonist Approach
• Ovarian Stimulation in Women Who have Diminished Ovarian Reserve (DOR): Introducing the Agonist/Antagonist Conversion protocol
• Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
• Human Growth Hormone Administration in IVF: Does it Enhances Egg/Embryo Quality and Outcome?
• The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
• Blastocyst Embryo Transfers Should be the Standard of Care in IVF
• IVF: How Many Attempts should be considered before Stopping?
• “Unexplained” Infertility: Often a matter of the Diagnosis Being Overlooked!
• IVF Failure and Implantation Dysfunction:
• The Role of Immunologic Implantation Dysfunction (IID) & Infertility (IID):PART 1-Background
• Immunologic Implantation Dysfunction (IID) & Infertility (IID):PART 2- Making a Diagnosis
• Immunologic Dysfunction (IID) & Infertility (IID):PART 3-Treatment
• Thyroid autoantibodies and Immunologic Implantation Dysfunction (IID)
• Immunologic Implantation Dysfunction: Importance of Meticulous Evaluation and Strategic Management:(Case Report
• Intralipid and IVIG therapy: Understanding the Basis for its use in the Treatment of Immunologic Implantation Dysfunction (IID)
• Intralipid (IL) Administration in IVF: It’s Composition; How it Works; Administration; Side-effects; Reactions and Precautions
• Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
• Endometrial Thickness, Uterine Pathology and Immunologic Factors
• Vaginally Administered Viagra is Often a Highly Effective Treatment to Help Thicken a Thin Uterine Lining
• Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
• A personalized, stepwise approach to IVF
• How Many Embryos should be transferred: A Critical Decision in IVF.
• The Role of Nutritional Supplements in Preparing for IVF

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ADDENDUM: PLEASE READ!!
INTRODUCING SHER FERTILITY SOLUTIONS (SFS)
Founded in April 2019, Sher Fertility Solutions (SFS) offers online (Skype/FaceTime) consultations to patients from > 40 different countries. All consultations are followed by a detailed written report presenting my personal recommendations for treatment of what often constitute complex Reproductive Issues.

If you wish to schedule an online consultation with me, please contact my assistant (Patti Converse) by phone (800-780-7437/702-533-2691), email (concierge@SherIVF.com) or, enroll online on then home-page of my website (www.SherIVF.com).

PLEASE SPREAD THE WORD ABOUT SFS!

Geoff Sher

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Jillian

Hi Doctor, at 4 weeks my hcg was 153, 3 days later it was 222. My doctor thought it was alitte slow so retested 3 days later and it was only 251. They thought it was a ectopic so retested 2 days later at 5 weeks 1 day and it doubled and was 553. They want me to come back in 2 days. Could this be a vanishing twin or viable pregnancy? Or does it sound like a ectopic pregnancy? I’m confused why it went so low then doubled. Thanks

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Dr. Geoffrey Sher

This does not bode well for a viable intrauterine pregnancy. It could be an ectopic and you shouyld be watched closely by your treating doctor. More than likely it will be an early miscarriage,

Geoff Sher

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Carmen Frontera

I had an FET on the 9/24th, one 5 day embryo, 2 weeks later HCG as below:

10/6: 322
10/8: 429
10/10: 566

Do you think it’s an un-vailable pregnancy/failed implantation? Should I end the pregnency?

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Carmen Frontera

Symptoms: left side cramping since the beggining (on and off)
Dark brown spotting for 4 days
Low Back pain that lasted less than 1hr
Lab results: Progesterone 25
Estrogen 192

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Dr. Geoffrey Sher

Although not likely, I would still have your doctor be on the look-out for an ectopic (tubal) pregnancy.

Good luck!

Geoff Sher

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Dr. Geoffrey Sher

Although not likely, I would still have your doctor be on the look-out for an ectopic (tubal) pregnancy.

Good luck!

Geoff Sher

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Dr. Geoffrey Sher

I do not think this is a viable pregnancy.I would discuss stopping meds with your personal REW.

Geoff Sher

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Caitlyn Wynn

I transferred 2perfect 4AA embryos in a fresh transfer 9/9 . I had beta done Yesterday at noon at 4686 and 3567 12hrs later at a different lab do to some bleeding (which I’ve had since 6 days past 5 day embryo transfer) is there anyway this can be losing just one . 3 days before yesterday’s noon draw it was 2140. They did an ultrasound a little over 4w3d but they were surprised to even see a full sac. Yesterday I was 5w3d. Could this be lab to lab error or definite miscarriage of all?

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Dr. Geoffrey Sher

It could be a lab error, but it might also be a faltering ofthe pregnancy!

Do another US i 1 week!

Geoff Sher

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vin k

Hi doctor my HCG level on 14 dpo was 340 on 17 dpo was 2222 and on 21 dpo it is 3492 dr checked and there is yolk sac my next HCG test on 19 sept 20 .what do you feel anything is wrong as my HCG level was not doubled in last test

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Dr. Geoffrey Sher

I would suggest doing another US in 7-10 days for a more definitive answer.

Geoff Sher

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Jacqueline

I’m curious if you feel this pregnancy was ended too early. Was it possibly viable? Please help me clear my mind.

HCG history:
8/13: 126 (brown discharge and lower abdominal cramps (not one sided) and lower back cramps. 4 weeks gestational )
8/14: 223.2
8/16: 426.5
8/17: 770.2
8/20: 1400
8/24: 1245
8/27: 1150
8/28: 1176
8/28: 1219 (right before being given methotrexate. Day 1)
8/31: 1399 (day 4 after methotrexate 86mg)
9/2: passed a very obvious gestational sac
9/3: (day 7): 340.5

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Ashley White

Hi! I found out I was pregnant 8 days after ovulation (according to temps). I went in a couple of days before my cycle was due and had a beta of 18..two days later it had more than doubled. It doubled as it should have until about a week and half later where it started to decline. It went from 370 to 220 to 192 so they said I was miscarrying and told me to come back in a week to make sure levels were still declining. I went back and my levels have doubled every two days since reaching 192. They did an ultrasound to check tubes and found nothing in them, but found a gestational sac in my uterus that was measuring 5 weeks 4 days when I should have been 6 weeks. I have had absolutely no bleeding or cramping. What could cause the hcg to drop then start rising again? Am I grasping at straws here? My doctor is baffled and doesn’t know what is going on so I go back next week for another scan and blood draw. Thank you for your time!

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Dr. Geoffrey Sher

It is hard to say. I would sit it out and repeat the US in 10-14 days for a definitive answer.

Good luck!

Geoff Sher

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Ashley

Hello, Doctor!

Last week I experienced very light bleeding and some abdominal cramping at approximately 5w3d. My OB sent me to get my HCG levels checked. The first draw was at 3404 and my second two days later was at 344. She had me go in for a third draw today and my levels are now at 377. I haven’t heard back from her yet and have been trying to figure out all day why my levels could be rising, though obviously very slowly. Do you have any opinions? Thank you in advance.

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recia harris

Hi doctor at 6 weeks my Gyno saw a fetal pole no heartbeat I went back at 8 weeks there was the fetus no heart beat and then and 12 weeks she said the sac was empty. She said my body most likely absorbed the fetus. Is this possible? I am now supposedly 15 weeks with no symptoms of a miscarriage just a slight brown discharge. Do you think it is possible I may have had 2 sacs and she missed 1?

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Dr. Geoffrey Sher

Have another US and if the findings are the same, have a D&C.

Geoff Sher

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Jen

Hi dr.

I had a couple days of spotting after my BFP and then one day of light red spotting for a short period of time, couple hours and so my gyno wanted me to get some betas done. My first beta at 19dpo was 2876 and second beta only 3545. I do have a cervical eversion as well. Could this be a vanishing twin or am I miscarrying? I have one more beta test to do but I’m very worried. I have no cramping. Also, would this be ectopic?

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Dr. Geoffrey Sher

Itis hard to say. Wait a week and do an ultrasound evaluation for clarification.

Good luck and G-d bless!

Geoff Sher

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Bre

Hi,
On Sept 3 my levels were 15,712, on Sept 4, they went down to 7,200 and they went back up to 7,500 on Sept 8th. Progesterone also went from a 12 on the 14 back to a 24 on the 8th…thoughts?

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Dr. Geoffrey Sher

I suggest you do an US to see how the pregnancy is developing. Then discuss possible supplementation of progesterone with your treating Physician.

Geoff Sher

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Angel

Hello doctor,
I did IUI on 29th June..
My hcg levels were 22.7 on 16th July, 69.4 on 18thjuly, 180.5 on 20th July… We were happy & stopped checking.. then after 8days on 28th July it was just 337, and on 30th July it was 368. It’s 6weeks from LMP. It’s not at all doubling.. what could this be?? Could it be vanishing twin syndrome??

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Dr. Geoffrey Sher

Angel,

This sadly does not look good. In my opinion, the implantation could be failing…a chemical pregnancy.

So sorry!

Geoff Sher

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Erin

In the last year I had 2 miscarriages and afterward found out I have a blood clotting disorder. I just turned 40 but I get pregnant fast, I don’t stay pregnant sadly. But we did IUI again, this time optimistically armed with blood thinner injections and the second IUI cycle I was pregnant again. Week 6 my dr couldn’t find a heartbeat or fetal pole, week 7 we tried again and no luck. Last ditch effort 4 days later we tried again. 1 heartbeat and fetal pole, but 2 yolk sacs are found in 1 gestational sac. My dr Said oh no that’s not good and informed me we were the less than 0.1% of pregnancies called “MoMo twins” which explained the delay in development. Sadly week 8 day 6 we lost that 1 heartbeat and are now going through our 3rd miscarriage since last July. 3 miscarriages and 4 babies lost in 13 months. We have hope the next try will be the one that sticks and these crazy flukes of nature with MoMo twins and blood clotting disorders will finally let us be parents.

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Dr. Geoffrey Sher

I frankly do not believe that hereditary clotting defects (thrombophilia) cause early miscarriages. Please consider the following:

When it comes to reproduction, humans are the poorest performers of all mammals. In fact we are so inefficient that up to 75% of fertilized eggs do not produce live births, and up to 30% of pregnancies end up being lost within 10 weeks of conception (in the first trimester). RPL is defined as two (2) or more failed pregnancies. Less than 5% of women will experience two (2) consecutive miscarriages, and only 1% experience three or more.
Pregnancy loss can be classified by the stage of pregnancy when the loss occurs:
• Early pregnancy loss (first trimester)
• Late pregnancy loss (after the first trimester)
• Occult “hidden” and not clinically recognized, (chemical) pregnancy loss (occurs prior to ultrasound confirmation of pregnancy)
• Early pregnancy losses usually occur sporadically (are not repetitive).

In more than 70% of cases the loss is due to embryo aneuploidy (where there are more or less than the normal quota of 46 chromosomes). Conversely, repeated losses (RPL), with isolated exceptions where the cause is structural (e.g., unbalanced translocations), are seldom attributable to numerical chromosomal abnormalities (aneuploidy). In fact, the vast majority of cases of RPL are attributable to non-chromosomal causes such as anatomical uterine abnormalities or Immunologic Implantation Dysfunction (IID).
Since most sporadic early pregnancy losses are induced by chromosomal factors and thus are non-repetitive, having had a single miscarriage the likelihood of a second one occurring is no greater than average. However, once having had two losses the chance of a third one occurring is double (35-40%) and after having had three losses the chance of a fourth miscarriage increases to about 60%. The reason for this is that the more miscarriages a woman has, the greater is the likelihood of this being due to a non-chromosomal (repetitive) cause such as IID. It follows that if numerical chromosomal analysis (karyotyping) of embryonic/fetal products derived from a miscarriage tests karyotypically normal, then by a process of elimination, there would be a strong likelihood of a miscarriage repeating in subsequent pregnancies and one would not have to wait for the disaster to recur before taking action. This is precisely why we strongly advocate that all miscarriage specimens be karyotyped.
There is however one caveat to be taken into consideration. That is that the laboratory performing the karyotyping might unwittingly be testing the mother’s cells rather than that of the conceptus. That is why it is not possible to confidently exclude aneuploidy in cases where karyotyping of products suggests a “chromosomally normal” (euploid) female.
Late pregnancy losses (occurring after completion of the 1st trimester/12th week) occur far less frequently (1%) than early pregnancy losses. They are most commonly due to anatomical abnormalities of the uterus and/or cervix. Weakness of the neck of the cervix rendering it able to act as an effective valve that retains the pregnancy (i.e., cervical incompetence) is in fact one of the commonest causes of late pregnancy loss. So also are developmental (congenital) abnormalities of the uterus (e.g., a uterine septum) and uterine fibroid tumors. In some cases intrauterine growth retardation, premature separation of the placenta (placental abruption), premature rupture of the membranes and premature labor can also causes of late pregnancy loss.
Much progress has been made in understanding the mechanisms involved in RPL. There are two broad categories:
1. Problems involving the uterine environment in which a normal embryo is prohibited from properly implanting and developing. Possible causes include:
• Inadequate thickening of the uterine lining
• Irregularity in the contour of the uterine cavity (polyps, fibroid tumors in the uterine wall, intra-uterine scarring and adenomyosis)
• Hormonal imbalances (progesterone deficiency or luteal phase defects). This most commonly results in occult RPL.
• Deficient blood flow to the uterine lining (thin uterine lining).
• Immunologic implantation dysfunction (IID). A major cause of RPL. Plays a role in 75% of cases where chromosomally normal preimplantation embryos fail to implant.
• Interference of blood supply to the developing conceptus can occur due to a hereditary clotting disorder known as Thrombophilia.

2. Genetic and/or structural chromosomal abnormality of the embryo.Genetic abnormalities are rare causes of RPL. Structural chromosomal abnormalities are slightly more common but are also occur infrequently (1%). These are referred to as unbalanced translocation and they result from part of one chromosome detaching and then fusing with another chromosome. Additionally, a number of studies suggest the existence of paternal (sperm derived) effect on human embryo quality and pregnancy outcome that are not reflected as a chromosomal abnormality. Damaged sperm DNA can have a negative impact on fetal development and present clinically as occult or early clinical miscarriage. The Sperm Chromatin Structure Assay (SCSA) which measures the same endpoints are newer and possibly improved methods for evaluating.

IMMUNOLOGIC IMPLANTATION DYSFUNCTION
Autoimmune IID: Here an immunologic reaction is produced by the individual to his/her body’s own cellular components. The most common antibodies that form in such situations are APA and antithyroid antibodies (ATA).
But it is only when specialized immune cells in the uterine lining, known as cytotoxic lymphocytes (CTL) and natural killer (NK) cells, become activated and start to release an excessive/disproportionate amount of TH-1 cytokines that attack the root system of the embryo, that implantation potential is jeopardized. Diagnosis of such activation requires highly specialized blood test for cytokine activity that can only be performed by a handful of reproductive immunology reference laboratories in the United States.
Alloimmune IID, i.e., where antibodies are formed against antigens derived from another member of the same species, is believed to be a relatively common immunologic cause of recurrent pregnancy loss.
Autoimmune IID is often genetically transmitted. Thus it should not be surprising to learn that it is more likely to exist in women who have a family (or personal) history of primary autoimmune diseases such as lupus erythematosus (LE), scleroderma or autoimmune hypothyroidism (Hashimoto’s disease), autoimmune hyperthyroidism (Grave’s disease), rheumatoid arthritis, etc. Reactionary (secondary) autoimmunity can occur in conjunction with any medical condition associated with widespread tissue damage. One such gynecologic condition is endometriosis. Since autoimmune IID is usually associated with activated NK and T-cells from the outset, it usually results in such very early destruction of the embryo’s root system that the patient does not even recognize that she is pregnant. Accordingly the condition usually presents as “unexplained infertility” or “unexplained IVF failure” rather than as a miscarriage.
Alloimmune IID, on the other hand, usually starts off presenting as unexplained miscarriages (often manifesting as RPL). Over time as NK/T cell activation builds and eventually becomes permanently established the patient often goes from RPL to “infertility” due to failed implantation. RPL is more commonly the consequence of alloimmune rather than autoimmune implantation dysfunction.
However, regardless, of whether miscarriage is due to autoimmune or alloimmune implantation dysfunction the final blow to the pregnancy is the result of activated NK cells and CTL in the uterine lining that damage the developing embryo’s “root system” (trophoblast) so that it can no longer sustain the growing conceptus. This having been said, it is important to note that autoimmune IID is readily amenable to reversal through timely, appropriately administered, selective immunotherapy, and alloimmune IID is not. It is much more difficult to treat successfully, even with the use of immunotherapy. In fact, in some cases the only solution will be to revert to selective immunotherapy plus using donor sperm (provided there is no “match” between the donor’s DQa profile and that of the female recipient) or alternatively to resort to gestational surrogacy.
DIAGNOSING THE CAUSE OF RPL
In the past, women who miscarried were not evaluated thoroughly until they had lost several pregnancies in a row. This was because sporadic miscarriages are most commonly the result of embryo numerical chromosomal irregularities (aneuploidy) and thus not treatable. However, a consecutive series of miscarriages points to a repetitive cause that is non-chromosomal and is potentially remediable. Since RPL is most commonly due to a uterine pathology or immunologic causes that are potentially treatable, it follows that early chromosomal evaluation of products of conception could point to a potentially treatable situation. Thus I strongly recommend that such testing be done in most cases of miscarriage. Doing so will avoid a great deal of unnecessary heartache for many patients.
Establishing the correct diagnosis is the first step toward determining effective treatment for couples with RPL. It results from a problem within the pregnancy itself or within the uterine environment where the pregnancy implants and grows. Diagnostic tests useful in identifying individuals at greater risk for a problem within the pregnancy itself include:

Karyotyping (chromosome analysis) both prospective parents
• Assessment of the karyotype of products of conception derived from previous miscarriage specimens
• Ultrasound examination of the uterine cavity after sterile water is injected or sonohysterogram, fluid ultrasound, etc.)
• Hysterosalpingogram (dye X-ray test)
• Hysteroscopic evaluation of the uterine cavity
• Full hormonal evaluation (estrogen, progesterone, adrenal steroid hormones, thyroid hormones, FSH/LH, etc.)
• Immunologic testing to include:
a) Antiphospholipid antibody (APA) panel
b) Antinuclear antibody (ANA) panel
c) Antithyroid antibody panel (i.e., antithyroglobulin and antimicrosomal antibodies)
d) Reproductive immunophenotype
e) Natural killer cell activity (NKa) assay (i.e., K562 target cell test)
f) Alloimmune testing of both the male and female partners

TREATMENT OF RPL
Treatment for Anatomic Abnormalities of the Uterus: This involves restoration through removal of local lesions such as fibroids, scar tissue, and endometrial polyps or timely insertion of a cervical cerclage (a stitch placed around the neck of the weakened cervix) or the excision of a uterine septum when indicated.
Treatment of Thin Uterine Lining: A thin uterine lining has been shown to correlate with compromised pregnancy outcome. Often this will be associated with reduced blood flow to the endometrium. Such decreased blood flow to the uterus can be improved through treatment with sildenafil and possibly aspirin.
Sildenafil (Viagra) Therapy. Viagra has been used successfully to increase uterine blood flow. However, to be effective it must be administered starting as soon as the period stops up until the day of ovulation and it must be administered vaginally (not orally). Viagra in the form of vaginal suppositories given in the dosage of 25 mg four times a day has been shown to increase uterine blood flow as well as thickness of the uterine lining. To date, we have seen significant improvement of the thickness of the uterine lining in about 70% of women treated. Successful pregnancy resulted in 42% of women who responded to the Viagra. It should be remembered that most of these women had previously experienced repeated IVF failures.
Use of Aspirin: This is an anti-prostaglandin that improves blood flow to the endometrium. It is administered at a dosage of 81 mg orally, daily from the beginning of the cycle until ovulation.

Treating Immunologic Implantation Dysfunction with Selective Immunotherapy: Modalities such as IL/IVIg, heparinoids (Lovenox/Clexane), and corticosteroids (dexamethasone, prednisone, prednisolone) can be used in select cases depending on autoimmune or alloimmune dysfunction.
The Use of IVF in the Treatment of RPL
In the following circumstances, IVF is the preferred option:
1. When in addition to a history of RPL, another standard indication for IVF (e.g., tubal factor, endometriosis, and male factor infertility) is superimposed.
2. In cases where selective immunotherapy is needed to treat an immunologic implantation dysfunction.
The reason for IVF being a preferred approach in such cases is that in order to be effective, the immunotherapy needs to be initiated well before spontaneous or induced ovulation. Given the fact that the anticipated birthrate per cycle of COS with or without IUI is at best about 15%, it follows that short of IVF, to have even a reasonable chance of a live birth, most women with immunologic causes of RPL would need to undergo immunotherapy repeatedly, over consecutive cycles. Conversely, with IVF, the chance of a successful outcome in a single cycle of treatment is several times greater and, because of the attenuated and concentrated time period required for treatment, IVF is far safer and thus represents a more practicable alternative
Since embryo aneuploidy is a common cause of miscarriage, the use of preimplantation genetic diagnosis (PGD), with tests such as CGH, can provide a valuable diagnostic and therapeutic advantage in cases of RPL. PGD requires IVF to provide access to embryos for testing.
There are a few cases of intractable alloimmune dysfunction due to absolute DQ alpha matching where Gestational Surrogacy or use of donor sperm could represent the only viable recourse, other than abandoning treatment altogether and/or resorting to adoption. Other non-immunologic factors such as an intractably thin uterine lining or severe uterine pathology might also warrant that last resort consideration be given to gestational surrogacy.
The good news is that if a couple with RPL is open to all of the diagnostic and treatment options referred to above, a live birthrate of 70%–80% is ultimately achievable.
I strongly recommend that you visit http://www.SherIVF.com. Then go to my Blog and access the “search bar”. Type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.
• The IVF Journey: The importance of “Planning the Trip” Before Taking the Ride”
• Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
• IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
• The Fundamental Requirements For Achieving Optimal IVF Success
• Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the “Conventional” Antagonist Approach
• Ovarian Stimulation in Women Who have Diminished Ovarian Reserve (DOR): Introducing the Agonist/Antagonist Conversion protocol
• Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
• Human Growth Hormone Administration in IVF: Does it Enhances Egg/Embryo Quality and Outcome?
• The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
• Blastocyst Embryo Transfers Should be the Standard of Care in IVF
• IVF: How Many Attempts should be considered before Stopping?
• “Unexplained” Infertility: Often a matter of the Diagnosis Being Overlooked!
• IVF Failure and Implantation Dysfunction:
• The Role of Immunologic Implantation Dysfunction (IID) & Infertility (IID):PART 1-Background
• Immunologic Implantation Dysfunction (IID) & Infertility (IID):PART 2- Making a Diagnosis
• Immunologic Dysfunction (IID) & Infertility (IID):PART 3-Treatment
• Thyroid autoantibodies and Immunologic Implantation Dysfunction (IID)
• Immunologic Implantation Dysfunction: Importance of Meticulous Evaluation and Strategic Management:(Case Report
• Intralipid and IVIG therapy: Understanding the Basis for its use in the Treatment of Immunologic Implantation Dysfunction (IID)
• Intralipid (IL) Administration in IVF: It’s Composition; How it Works; Administration; Side-effects; Reactions and Precautions
• Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
• Endometrial Thickness, Uterine Pathology and Immunologic Factors
• Vaginally Administered Viagra is Often a Highly Effective Treatment to Help Thicken a Thin Uterine Lining
• Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
• A personalized, stepwise approach to IVF
• How Many Embryos should be transferred: A Critical Decision in IVF.
• The Role of Nutritional Supplements in Preparing for IVF

______________________________________________________
ADDENDUM: PLEASE READ!!
INTRODUCING SHER FERTILITY SOLUTIONS (SFS)
Founded in April 2019, Sher Fertility Solutions (SFS) offers online (Skype/FaceTime) consultations to patients from > 40 different countries. All consultations are followed by a detailed written report presenting my personal recommendations for treatment of what often constitute complex Reproductive Issues.

If you wish to schedule an online consultation with me, please contact my assistant (Patti Converse) by phone (800-780-7437/702-533-2691), email (concierge@SherIVF.com) or, enroll online on then home-page of my website (www.SherIVF.com).

PLEASE SPREAD THE WORD ABOUT SFS!

Geoff Sher

reply
Emme

Dr I had ivf transfer the dr insisted on transferring all 6 embryos on day 3 , one was level 2 and the rest were level 3 . Two days before End of Two week wait blood test date i severely bled for a day , but then I did my hgc day 17 pet it’s was 30 HGC and then week 5 pregnancy it went up to 375 HgC two day’s later I had lite spotting and the Hgc is 198.7 HGC might that mean that initial bleeding was the embryos that didn’t stick ? And the spotting I get yesterday was a vanished twin Syndrome ?

reply
Dr. Geoffrey Sher

This sadly does not look promising. Perhaps we should talk!
I suggest you call Patti at 702-533-2691 and set up an online consultation with me to discuss!

Geoff Sher

reply
Nadine

Hi Dr Sher,

October 28th I had my FET procedure in IFV. My doctor transferred 4 embryos, grown for 3 days then frozen and thawed for another 2 days.

My two week wait ended this last Monday the 12th. As I woke up to take my HCG blood work, I had light brown blood. That light colored blood continuing the entire day, my test results came back the next morning with an HCG level of 46.

The following day Tuesday, I was still bleeding first light brown but by the end of the day it has become dark brown. Not a drastic amount but not spotting either. I went in to get another blood test and my results came this morning at a HCG level of 38.

My bleeding is still occurring dark brown seeming to be in lesser quantity, but I am not experiencing any pelvic or back cramps, only thing I have is random painless twitches of a cramp in my left side. I am curious on your take about my situation. Should I continue to take my estrogen pills and progesterone suppositories in hopes of one or more of the embryos miscarriaging? Or is it most likely that the procedure was not a success and to cancel my first ultrasound in 2 weeks.

I appreciate your help.
Thank you

reply
Dr. Geoffrey Sher

This is a failing implantation and you should discuss stopping all meds, with your RE.

Sorry!

Geoff Sher

reply
Libby

Hi Dr! We went for our ultrasound today. 6 weeks 5 days. There are two babies but one was hard to see and we couldn’t find the heartbeat. My Dr. said it was further up and we couldn’t get a good visual, so he’s not sure about that one. It was also measuring smaller. The other was measuring on track and heartbeat was 128bpm. What do you think?

reply
Dr. Geoffrey Sher

It could be a technical issue. So, repeat the US next Monday!

Good luck!

Geoff Sher

reply
Libby

Thank you so much for your time. You are a very nice person and I appreciate you and the time you take out to answer questions for us hopeful people.

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Laura

I’m currently 5w4d with a spontaneous pregnancy following three rounds of IVF at Sher. One didn’t take, one did but was of unknown location resulting in early miscarriage and one took and resulted in the birth of my daughter, unfortunately at 26w3d with a poor outcome.

We’re thrilled to be pregnant but experiencing some confusing lab results.

Hcg #1 8/17 – 48 (day before period “due” irregular cycles)

8/19 115

8/21 206

8/24 – spotting 209

8/26 433

8/28 1001

Of note, I’m on Crinone twice daily and when I had my successful IVF, I did a frozen transfer on day 6 after an ERA was performed.

Thoughts on possible outcomes?

reply
Dr. Geoffrey Sher

Only time will tell! You need an US in 10-14 days for a definitive answer.

Good luck and G-d bless!

Geoff Sher

reply
Courtney

Went to ER on 6/30 for spotting when I wipe. U/S says 5w1d.They diagnosed threatened miscarriage due to subchorionic hematoma. HCG 3733.Spotting stopped within 2 hours. Went to OB on 7/2 HCG 3684. Doc wants to do methotrexate even though U/S tech said everything looked as it should. Should I get a second opinion

reply
Dr. Geoffrey Sher

Respectfully,

I would get another opinion!

Good luck!

Geoff Sher

reply
Libby

Hello. We had an embryo transfer on the 18th of June. My first hcg numbers were 782 12dp5dt and 7 days later 15,893. Today I am 6 weeks and have some spotting. Should I be worried? Ultrasound is not for another 5 days.

reply
Dr. Geoffrey Sher

I think you are going to do fine:

Vaginal bleeding occurs in about 25% of all pregnancies. When it happens, it almost invariably raises the concern of pregnancy loss (miscarriage). Bleeding can also be a sign of a tubal (ectopic) pregnancy, and in cases where the distended Fallopian tube ruptures it can precipitate a life-threatening crises. However, a small amount of painless vaginal bleeding can also be the result of normal embryo implantation (i.e. implantation bleeding) or it can result a local erosion of the vagina or cervix and/or trauma during intercourse.
Notwithstanding, in virtually all cases the occurrence of early pregnancy vaginal bleeding congers concerns or even alarm regarding the possibility of miscarriage. And when this happens to women who conceived following infertility treatment, the alarm often turns into panic. However, the truth is that in most such cases the bleeding soon stops and the pregnancy proceeds unabated to the birth of a healthy baby. However, because some do progress and end in miscarriage, and in most cases, only time will tell how things will ultimately turn out, we use the term “threatened miscarriage” to describe such early bleeding. The term “inevitable miscarriage” is used once symptoms and signs confirm a miscarriage is in progress. The term “complete miscarriage” is used if all products of conception are passed, leaving the uterus “empty”. An “incomplete miscarriage” refers to cases where some products remain retained in the uterus.

Good luck!

Geoff Sher

reply
Libby

Thank you! This is our fourth transfer the last one ended in miscarriage but I had no bleeding or spotting. (Until I actually miscarried) My numbers did rise correctly and the growth was not on track the last time. I have also had an eptopic pregnancy which is what put us needing IVF. (Loss of one tube other completely blocked.) I would know that feeling, I feel like. I hope everything is going to be ok. These were our last two embryos. Thanks for a little reassurance.

reply
Raina Rollin

Hi!
I went in for my 6 week ultrasound and found baby A to have a good heart beat, baby B could not be found (blighted ovum). I’m s/p IUI with letrozole and hcg trigger. We are Repeating ultrasound in 2 weeks. If baby B does not make its debut, how soon should i be expecting “miscarriage” symptoms for baby B blighted ovum? Is this common to see with non ivf fertility treatments as well?

reply
Dr. Geoffrey Sher

You might have some slight painless bleeding, but baby B will simply absorb!

Geoff Sher

reply
Monica

Hi Doctor, similar case as described above. Repeated US in week 9, no sign of embryo b (there was no sign in week 6 also) but empty gestational sac has enlarged. Healthy embryo a with heartbeat. What do you suggest?

reply
Dr. Geoffrey Sher

If there is an empty sac, this is a blighted ovum and will miscarry or needs to be surgically evacuated.

Sorry!

Geoff Sher

reply
Radhiya Minty

Hi!! I’m 29 years old and pregnant. At 4 weeks my hcg was 4666 and then 8668,not quite doubled. So my obgyn called me in for a scan where we saw 2 gestational sacs, one larger than the other and she diagnosed vanishing twin. Hcgs in week 5 were 14053 and 19998 48hours apart, still not doubling. She decided we wait till 7 weeks to do 2 more Hcgs and a repeat ultrasound. The Hcgs were now 68000 and then 54000, so actually declining. In the ultrasound we saw one sac with a Fetal pole and a heartbeat of 140bpm. We saw another tiny sac with a pole and no heartbeat. She said she felt reassured and doesn’t feel the need to do more hcgs. I keep wondering why it dropped and what if it’s currently dropping. Do you think there is reason to worry?

reply
Dr. Geoffrey Sher

once hCG levels rise above 5,000, they often stop doubling every 48h.

No! I think things will work out fine!

Good luck!

Geoff Sher

reply
todd

Could my wife have vanishing twin syndrom with her first hcg being 400 at 4 weeks and 3 days or is that to low to be a multiple?

reply
todd

My wife has done 3 ivf transfers, one fresh two frozen. The first fresh cycle didnt work, the second resulted in a miscarriage at week 6. The second transfer had an initial hcg of 57, our current frozen embryo was transfered on the 11th of June and after 13 days our first hcg reading was 400, our second hcg was 600, we go back tomorrow for our 3rd hcg reading, is this pointing towards another miscarriage?

reply
Dr. Geoffrey Sher

My thoughts are with you!

Whenever a patient fails to achieve a viable pregnancy following embryo transfer (ET), the first question asked is why! Was it simply due to, bad luck?, How likely is the failure to recur in future attempts and what can be done differently, to avoid it happening next time?.
It is an indisputable fact that any IVF procedure is at least as likely to fail as it is to succeed. Thus when it comes to outcome, luck is an undeniable factor. Notwithstanding, it is incumbent upon the treating physician to carefully consider and address the causes of IVF failure before proceeding to another attempt:
1. Age: The chance of a woman under 35Y of age having a baby per embryo transfer is about 35-40%. From there it declines progressively to under 5% by the time she reaches her mid-forties. This is largely due to declining chromosomal integrity of the eggs with advancing age…”a wear and tear effect” on eggs that are in the ovaries from birth.
2. Embryo Quality/”competency (capable of propagating a viable pregnancy)”. As stated, the woman’s age plays a big role in determining egg/embryo quality/”competency”. This having been said, aside from age the protocol used for controlled ovarian stimulation (COS) is the next most important factor. It is especially important when it comes to older women, and women with diminished ovarian reserve (DOR) where it becomes essential to be aggressive, and to customize and individualize the ovarian stimulation protocol.
We used to believe that the uterine environment is more beneficial to embryo development than is the incubator/petri dish and that accordingly, the earlier on in development that embryos are transferred to the uterus, the better. To achieve this goal, we used to select embryos for transfer based upon their day two or microscopic appearance (“grade”). But we have since learned that the further an embryo has advanced in its development, the more likely it is to be “competent” and that embryos failing to reach the expanded blastocyst stage within 5-6 days of being fertilized are almost invariably “incompetent” and are unworthy of being transferred. Moreover, the introduction into clinical practice about 15y ago, (by Levent Keskintepe PhD and myself) of Preimplantation Genetic Sampling (PGS), which assesses for the presence of all the embryos chromosomes (complete chromosomal karyotyping), provides another tool by which to select the most “competent” embryos for transfer. This methodology has selective benefit when it comes to older women, women with DOR, cases of unexplained repeated IVF failure and women who experience recurrent pregnancy loss (RPL).
3. The number of the embryos transferred: Most patients believe that the more embryos transferred the greater the chance of success. To some extent this might be true, but if the problem lies with the use of a suboptimal COS protocol, transferring more embryos at a time won’t improve the chance of success. Nor will the transfer of a greater number of embryos solve an underlying embryo implantation dysfunction (anatomical molecular or immunologic).Moreover, the transfer of multiple embryos, should they implant, can and all too often does result in triplets or greater (high order multiples) which increases the incidence of maternal pregnancy-induced complications and of premature delivery with its serious risks to the newborn. It is for this reason that I rarely recommend the transfer of more than 2 embryos at a time and am moving in the direction of advising single embryo transfers …especially when it comes to transferring embryos derived through the fertilization of eggs from young women.

4. Implantation Dysfunction (ID): Implantation dysfunction is a very common (often overlooked) cause of “unexplained” IVF failure. This is especially the case in young ovulating women who have normal ovarian reserve and have fertile partners. Failure to identify, typify, and address such issues is, in my opinion, an unfortunate and relatively common cause of repeated IVF failure in such women. Common sense dictates that if ultrasound guided embryo transfer is performed competently and yet repeated IVF attempts fail to propagate a viable pregnancy, implantation dysfunction must be seriously considered. Yet ID is probably the most overlooked factor. The most common causes of implantation dysfunction are:

a. A“ thin uterine lining”
b. A uterus with surface lesions in the cavity (polyps, fibroids, scar tissue)
c. Immunologic implantation dysfunction (IID)
d. Endocrine/molecular endometrial receptivity issues
e. Ureaplasma Urealyticum (UU) Infection of cervical mucous and the endometrial lining of the uterus, can sometimes present as unexplained early pregnancy loss or unexplained failure following intrauterine insemination or IVF. The infection can also occur in the man, (prostatitis) and thus can go back and forth between partners, with sexual intercourse. This is the reason why both partners must be tested and if positive, should be treated contemporaneously.
Certain causes of infertility are repetitive and thus cannot readily be reversed. Examples include advanced age of the woman; severe male infertility; immunologic infertility associated with alloimmune implantation dysfunction (especially if it is a “complete DQ alpha genetic match between partners plus uterine natural killer cell activation (NKa).
I strongly recommend that you visit http://www.DrGeoffreySherIVF.com. Then go to my Blog and access the “search bar”. Type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.

• The IVF Journey: The importance of “Planning the Trip” Before Taking the Ride”
• Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
• IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation (COS)
• The Fundamental Requirements for Achieving Optimal IVF Success
• Use of GnRH Antagonists (Ganirelix/Cetrotide/Orgalutron) in IVF-Ovarian Stimulation Protocols.
• Ovarian Stimulation in Women Who have Diminished Ovarian Reserve (DOR): Introducing the Agonist/Antagonist Conversion protocol
• Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
• Human Growth Hormone Administration in IVF: Does it Enhances Egg/Embryo Quality and Outcome?
• The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
• Blastocyst Embryo Transfers should be the Standard of Care in IVF
• IVF: How Many Attempts should be considered before Stopping?
• “Unexplained” Infertility: Often a matter of the Diagnosis Being Overlooked!
• IVF Failure and Implantation Dysfunction:
• The Role of Immunologic Implantation Dysfunction (IID) & Infertility (IID): PART 1-Background
• Immunologic Implantation Dysfunction (IID) & Infertility (IID): PART 2- Making a Diagnosis
• Immunologic Dysfunction (IID) & Infertility (IID): PART 3-Treatment
• Thyroid autoantibodies and Immunologic Implantation Dysfunction (IID)
• Immunologic Implantation Dysfunction: Importance of Meticulous Evaluation and Strategic Management 🙁 Case Report)
• Intralipid and IVIG therapy: Understanding the Basis for its use in the Treatment of Immunologic Implantation Dysfunction (IID)
• Intralipid (IL) Administration in IVF: It’s Composition; how it Works; Administration; Side-effects; Reactions and Precautions
• Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
• Endometrial Thickness, Uterine Pathology and Immunologic Factors
• Vaginally Administered Viagra is Often a Highly Effective Treatment to Help Thicken a Thin Uterine Lining
• Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
• A personalized, stepwise approach to IVF
• How Many Embryos should be transferred: A Critical Decision in IVF?
______________________________________________________
ADDENDUM: PLEASE READ!!
INTRODUCING SHER FERTILITY SOLUTIONS (SFS)
Founded in April 2019, Sher Fertility Solutions (SFS) offers online (Skype/FaceTime) consultations to patients from > 40 different countries. All consultations are followed by a detailed written report presenting my personal recommendations for treatment of what often constitute complex Reproductive Issues.

If you wish to schedule an online consultation with me, please contact my assistant (Patti Converse) by phone (800-780-7437/702-533-2691), email (concierge@SherIVF.com) or, enroll online on then home-page of my website (www.SherIVF.com).

PLEASE SPREAD THE WORD ABOUT SFS!

Geoff Sher

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Todd

This is our second round of ivf, first one resulted in miscarriage, my wife had her first hcg check and it was 400, 48 hours later it was 600, we go back 2 days for another hcg check, she is having nausea, breast tenderness, light cramps every now and then, back ache, spotting here and there, she is 4 weeks 6 days. Since her first two numbers didn’t double does this point to another miscarriage?

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Dr. Geoffrey Sher

The next hCG test will provide more information. The level, 48h after the last test should be >1200.

Ultimately, an US done at 7 weeks will be definitive.

Good luck!

Geoff Sher

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Anna

At 3 weeks 2 days I had a hcg of 211 which is so high! 48 hours later hcg is up but not doubled (282). Possible vanishing twin?

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Dr. Geoffrey Sher

Could be…but it will take an US at 6-7 weeks to tell!

Good luck!

Geoff Sher

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Koshiga

Hello!

My hcg levels started off 59,195,613,1180 every 72 hours. I went to ER for some cramping and brown spotting where hcg was 1280. U/s was done and 2 avascular fluid filled areas were seen (1.4×1.3×0.4cm and 1.9×1.2×0.9cm) however no definitive gestation sac. Then it rose to 1400 3 days later and dropped to 1290 an hour later (at different labs). Again ultrasound was done and they saw a gestation sac measuring 5.8 weeks with probably yolk sac along with a subchorionic hemorrhage. Does this sound like a vanishing twin? I am so confused and don’t know what to think. Can a sac show up 3 days later with fluctuating hcg?

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Dr. Geoffrey Sher

This could be a vanishing twin or a “compromised” implantation. A repeat US in 1 week should be definitive.

Good luck!

Geoff Sher

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Shannon Smith

Hello,

We had a great rising HCG < 48 hours up until this weekend where it slowed considerably at about 6 weeks. I'm wondering if this means impending miscarriage or if it could be due to a vanishing twin:

DPO14 141
DPO17 541 Doubling of 37.1 hours
DPO18 764 Doubling of 48.2 hours
DPO20 1,714 Doubling of 41.2 hours
DPO25 11,876 Doubling of 43.0 hours
DPO28 17,869 Doubling of 122.2 hours

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Dr. Geoffrey Sher

It looks promising to me. Remember, the rate of the rise in hCG level slows down after goes above 6,000.

Good luck!

Geoff Sher

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Yasmin

Hello,
My hcg at 5w0d was 6,914 then 11,293 at 5w2d then 12,300 at 5w5d. I was told these levels were high for how far along I am, but now i’m super concerned because they’re nowhere close to doubling. Please Advise!!!

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Sophie Croutear

Hello,

I have been having regular early ultra sounds which have shown 2 sacs but only one has ever been seen with an embryo/ Fetus).

Baby one is showing on track and normal for 10 weeks the other is confirmed blighted ovum.

Does this constitute as vanishing twin?

Is there an increased risk of birth defects for the baby?

Thank you

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Dr. Geoffrey Sher

The blighted sac should absorb without consequence and NO…there should not be an incease in the risk of a birth defect. whether to do prenatal genetic testing should be based on age, family genetic history and other unrelated criteria.

Good luck!

Geoff Sher

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Dr. Geoffrey Sher

After hCG levels reach 4,000-5,000 the rise slows down. I suggest you have an US done for confirmation of viability.

Geoff Sher

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Ashley

Hello, I had an ultrasound yesterday (5w4d) showing one well formed gestational sac with yolk sac (no fetal pole) and one that was irregular ( looked collapsed) with no yolk. I assume this is a vanishing twin and my main concern is that my hcg at 21dpo was 9565 and at 23dpo only 12661. I have been more than doubling all the way till now. I also had one day of bleeding day 22dpo which has since stopped.

Do you think the entire pregnancy is compromised or could this slow and increase be from the vanishing twin and the levels are leveling out now?

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Dr. Geoffrey Sher

I would do a repeat US in 10 days for a definitive answer.

Good luck!

Geoff Sher

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Jaclyn

Hi. I have done4 IUI, and IVF twice. First IVF didn’t take, second worked with 2 embryos transferred. At 5w5d, HCG was around 6000. I had some light bleeding, and then a large gush of blood and large clots. Slight cramping after. All bleeding stopped the next morning. 2 days later we were heading to our first u/s and the light bleeding started. U/s was done and showed 1 embryo with a heart beat. No hematoma seen, no blood seen. On the drive back home, same thing sudden large gush of blood and clots. My HCG that day was >10,000. 2 days later it’s 1,100.
Can it really drop that fast? Was this 2 miscarriages? We did Genetic testing both were 4AA. This is my 4th miscarriage, and no one can provide any answers.

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Dr. Geoffrey Sher

This does not look good. I suggest you do another US to see.

So sorry!

Geoff Sher

Lisa

I am 5.5 weeks with 2 gestational sacs (one contained a YS at 5 weeks The other was smaller and nothing inside). My HCG was 5900 at 24 hours after my ultrasound, Doubling every 1.5 -2 days up until then.
3.5 days later my hcg only goes to 9900, moderate increase but not doubling. Does this look like a potential vanishing twin or would there be more likelihood of both pregnancies ending?

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Dr. Geoffrey Sher

It could be such. However, 5.5 weeks is really too early to make a confident US assessment. Repeat in 7-10 days.

Good luck!

Geoff Sher

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Shaina

I had my et on 11 th September with 2 blasts..! 14 days post et upt was positive and hcg was 840.. 2 days later hcg was 1240( not a good rise..) then again 2 days later it was 1500( again not a good rise) . I am experiencing all symptoms of pregnancy..and there is no cramping no spotting..! But my hcg levels are not doubling and are weird.. Can it be a vanishing twin thing.,? Please help..!

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Dr. Geoffrey Sher

It could be a vanishing twin. I would have an ultrasound examination done.

Geoff Sher

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Shaina

Thanks..! I got my 1st usg done.! It shows intrauterine gestational sac and yolk sac at 5 1/2 weeks of pregnancy..!

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Shaina

Thanks..! Is there still any hope..? Bcoz my doc was saying chances are only 1percent..!

Dr. Geoffrey Sher

Sorry Shaina, I lost the thread! You would need to re-post the original question along with this one.

Geoff Sher

Shaina

I had my et on 11 th September with 2 blasts..! 14 days post et upt was positive and hcg was 840.. 2 days later hcg was 1240( not a good rise..) then again 2 days later it was 1500( again not a good rise) . I am experiencing all symptoms of pregnancy..and there is no cramping no spotting..! But my hcg levels are not doubling and are weird.. Can it be a vanishing twin thing.,? Please help..!
U replied
Get an usg done
My usg is showing gestational sac and yolk sac at 5 1/2 weeks..of pregnancy..!
U replied
Gud luck..! Get a scan done in 1-2 weeks
Now my question is :- is there any hope, as my doc was saying chances are less..!
Thanks ..!

Dr. Geoffrey Sher

The chances are guarded but it is possible that it is a viable pregnancy.

Geoff Sher

Shaina

Hi i got my ET done on 11thsep day 5 blast transfer . My first hcg value was 843 on 25th sep , subsequent values were 1230 on 27/9 , 1543 on 29/9 , 2343 on 4/10 . So the hcg is not doubling and rising as it should be . So i got a scan done on 5/10 which showed a gestational sac with a yolk sac on roughly 5 and a half week . My doc has asked me to repeat a scan after 10 days but she says chances are very less as hcg is not rising appropriately. So can you pls tell that is everything ok or is there anything to be worried ?

Dr. Geoffrey Sher

Thew prognosis is guarded based on this attenuated rise in hCG. However, only an ultrasound in about 10 days from now can offer definitive information.

Sorry!

Geoff Sher

Shaina

Hello doctor.. usg at 6 weeks 5 days shows fetal pole, fetus with crl 7 mm, and a heart beat which was 95 initially but in fraction of seconds it increased to 115.. Doc was saying heart beat is too feeble and flickering.. Is there any hope..?
Thanks..!

Dr. Geoffrey Sher

Shaina,

Unfortunately only time will tell. If the HB is normal in a week from now, it could be fine.

Geoff Sher

Shelbi Smith

I found out I was pregnant on Sept 1st. On Sept 4th (4wk+3) I had super light spotting. Was diagnosed with uti. Hcg was 288.7. Went Sept 8 (5wk+0) to have levels checked again and was at 574.2. I’ve had light, light spotting everyday since 09/04. Today, Sept 10th I was cramping pretty irritably morning through mid-afternoon constantly and it’s died off to an on and off dull pain. The pain and cramping has mainly been on my right side and shoots down my front right thigh and knee. Spotting this morning was bright red and more than other days have been. Only there when I wipe, don’t need a pad or pantiliner. It has tappered down but still wiping very very slight pink spots. My hcg levels were checked this morning and the dropped to 569, so just a few points. The father is a feternal twin, so the chances are slightly higher. Could this be “vanishing twin?” Or should I prepare for a full miscarriage and how does it take to start actually passing tissue? I go again to get levels checked Monday, in 4 days.

Dr. Geoffrey Sher

This is not an encouraging sequence of events. Th hCG level is not rising appropriately.

Ask your RE to be on the lookout for an ectopic pregnancy…just to keep you safe.

Sorry!

Geoff Sher

Dr. Geoffrey Sher

It could be a vanishing twin, bur if so, your next beta hCG …2 days from the last one, should be around 2,000.

Please keep me in the loop!

Geoff Sher

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Ramy

I had a hcg level of 333 at first which on 48 hours increased to 442 which is less than 35% and then 442 reduced to 249 in next 48 hours. Could you tell me ifthis us a miscarriage?..Not yet experienced any vaginal bleeding except for mild cramps in abdomen

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Dr. Geoffrey Sher

Unfortunately, this sounds like a failing implantation. I hope I am wrong but I do not think I am.

G-d bless!

Geoff Sher

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Ethan

Dr. Sher we transfered a single embryo and at our 6week ultrasound we found one sac with a healthy heart beat and a second sac that was empty! Is this considered a VT? And if so does that mean a grim prognoses for the sac with the baby that has a heart beat?

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Dr. Geoffrey Sher

If the one baby is healthy and viable, it should not be lost due to the other being a blighted ovum. BUT only time will tell!

Good luck!

Geoff Sher

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Stephanie

Hello I am 5 weeks and 6 days today according to my calculations. I had hcg levels 127 then 636 then 1276 then 3500 then they dropped to 3400. Had an ultrasound today that showed two sacs. Neither had a fetal pole. They said twin pregnancy vs possible bleeds. I’m have my levels checked in a couple days again to see how they are trending. Is it possible for both sacs to be blighted ovum?

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Eve

my first ultrasound at 5 weeks showed one sac, my second ultrasound at 5 weeks 6 days showed a second sac but MD stated its empty and called the sac a vanishing twin. Is there a possibility medically for the second sac to still grow and i have twins?

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Dr. Geoffrey Sher

5-6 weeks is a little early. I would advise repeating the US at 7 weeks.

Geoff Sher

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dan

We did IVF & are 10weeks pregant. There was vanishing twin. What are our options for testing for genetic disorders for the fetus that is progressing normally? I’ve read the blood work that would normally be done to test for genetic disorders can give a false positive result due to the vanishing twin. Thank you for any info you can provide.

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Dr. Geoffrey Sher

Blood work is quite good but in my opinion, CVS now or amniocentesis in a month or so is the way to go!

Good luck and G-d bless!

Geoff Sher

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Nana22

We had 3 embryo transferred Via IVF. hCG level was 276 then 1930 then 4216 then 5809 however 4 days after the last hcg of 5809 my hcg dropped to 4400. 2 days before the hcg drop.. we had a scan with one sac found… a fetal crl 2.1mm with cardiac activity gestational sac 9mm and i was measured at 5 weeks 5 days… im worried that my hcg fell… however is this because of vanishing twin… please advise…

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Dr. Geoffrey Sher

You possibly started with >1 baby and have reduced down to one. This could explain the slight drop in hCG.

Good luck and be safe!

Geoff Sher

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Betsy palmer

Hello
I wonder if you can help me. It’s been confirmed that although I started with a twin pregnancy only one of the fetus had a heart beat ( the other one has a fetal pole and appears to have grown from 8mm to 12mm in the last week). The healthy fetus is the right size of 8 weeks 2 days. Is it more likely that the fetus will be absorbed by the body or that I will miscarry? Thank you

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Dr. Geoffrey Sher

It is more likely that the healthy one will survive and develop appropriately.

Geoff Sher

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Tracie Futterman-Alvarez

Two things-Is it true that eggs go through a 3-4 month cycle so anything you change (Adding CoQ10, change in diet-more protein to gain weight, change in exercise, acupuncture, etc) will not affect egg quality if you are doing an IVF cycle that next month or two?
I am 33, with normal AMH and FSH but had one IVF with only One normal blast and it didn’t implant, second IVF, high responder with 14 fertilized but no genetically normal blasts out of 5, and now doing a third IVF with 16 fertilized awaiting day 5 results then PGS results.
How would you explain poor quality for my age and normal reserve/levels?
Protocol for IVF 1 was a study, so only stimmed with menopur, then ganerlix, then HCG trigger
Protocol for ivf 2 and 3 was gonal F/follistim with low dose HCG to stim then ganirelix, then lupron. trigger. This protocol for 2nd and 3rd time got me 17 mature eggs retrieved, then 20 mature retrieved.
Thanks!!
Tracie

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Dr. Geoffrey Sher

I cannot be sure, but one of the common reasons relates to the protocol used for ovarian stimulation (see below). I would need a great deal more information to comment authoritatively.

I strongly recommend that you visit http://www.DrGeoffreySherIVF.com. Then go to my Blog and access the “search bar”. Type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.
• Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
• IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation(COS)
• The Fundamental Requirements For Achieving Optimal IVF Success
• Ovarian Stimulation for IVF using GnRH Antagonists: Comparing the Agonist/Antagonist Conversion Protocol.(A/ACP) With the“Conventional” Antagonist Aproach
• Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
• The “Biological Clock” and how it should Influence the Selection and Design of Ovarian Stimulation Protocols for IVF.
• A Rational Basis for selecting Controlled Ovarian Stimulation (COS) protocols in women with Diminished Ovarian Reserve (DOR)
• Diagnosing and Treating Infertility due to Diminished Ovarian Reserve (DOR)
• Controlled Ovarian Stimulation (COS) in Older women and Women who have Diminished Ovarian Reserve (DOR): A Rational Basis for Selecting a Stimulation Protocol
• Optimizing Response to Ovarian Stimulation in Women who Have Compromised Ovarian Response to Ovarian Stimulation in Women who Have Compromised Ovarian Reserve: A Personal Approach.
• Human Growth Hormone Administration in IVF: Does it Enhances Egg/Embryo Quality and Outcome?
• The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
• Blastocyst Embryo Transfers Should be the Standard of Care in IVF
• Why did my IVF Fail
• Preimplantation Genetic Testing (PGS) in IVF: It Should be Used Selectively and NOT be Routine.
• Preimplantation Genetic Sampling (PGS) Using: Next Generation Gene Sequencing (NGS): Method of Choice.
• PGS in IVF: Are Some Chromosomally abnormal Embryos Capable of Resulting in Normal Babies and Being Wrongly Discarded?
• PGS and Assessment of Egg/Embryo “competency”: How Method, Timing and Methodology Could Affect Reliability
• IVF Failure and Implantation Dysfunction:
• The Role of Immunologic Implantation Dysfunction (IID) & Infertility (IID):PART 1-Background
• Immunologic Implantation Dysfunction (IID) & Infertility (IID):PART 2- Making a Diagnosis
• Immunologic Dysfunction (IID) & Infertility (IID):PART 3-Treatment
• Thyroid autoantibodies and Immunologic Implantation Dysfunction (IID)
• Immunologic Implantation Dysfunction: Importance of Meticulous Evaluation and Strategic Management:(Case Report
• Intralipid and IVIG therapy: Understanding the Basis for its use in the Treatment of Immunologic Implantation Dysfunction (IID)
• Intralipid (IL) Administration in IVF: It’s Composition; How it Works; Administration; Side-effects; Reactions and Precautions
• Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
• Endometrial Thickness, Uterine Pathology and Immunologic Factors
• Vaginally Administered Viagra is Often a Highly Effective Treatment to Help Thicken a Thin Uterine Lining
• Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
• Traveling for IVF from Out of State/Country–
• A personalized, stepwise approach to IVF
• How Many Embryos should be transferred: A Critical Decision in IVF.
• The Role of Nutritional Supplements in Preparing for IVF

Please call or email Julie Dahan, my patient concierge. She will guide you on how to set up an in-person or Skype consultation with me. You can reach Julie at on her cell phone or via email at any time:
Julie Dahan

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Christine

Vanishing twin
I can’t understand why I have lost one of my twins they said it wasn’t growing but never told me there wasn’t a heart beat I am having another scan in 3 weeks time but I am scared there going to say both have gone

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Mika Lowry

Hi Dr. Sher:
I transferred two embryos & found out at 6 weeks that I was pregnant with twins. At 7 weeks, we only heard Baby A’s heartbeat. We could see that Baby B had a flickering heart, but when we would zoom in to listen to it, it sounded static. Still, they both measured the same size and were growing. Beta on this day was over 18,000+. Would seeing a flickering heartbeat and hearing it both be a good sign in your opinion? Or does this most likely mean a VT? Next ultrasound is not for another 10 days and I’m worried every day. I’ve heard one twin may not be heard until the following week, crossing my fingers that’s true in my case.

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Mila

I meant would seeing a flickering heartbeat but not hearing it* still be a good sign..

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Mika Lowry

Thank you so much! Is it common with twins that we hear one sooner than the other?

Dr. Geoffrey Sher

I would regard the flickering HB as a “promising sign”!

Geoff Sher

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Georgia

Hi Dr. Sher!
We had iui after treatment with Clomid and Ovitrelle inj.(3 eggs) on 19/6/20. My b-hcg was 4,07 on 3/7/20 and then started bleeding for 6 days (Iike menstruation). However, on 17/7/20 I noticed light bleeding again, had a positive home pregnancy test and blood b-hcg was 220,42. Does it sound like a potentially viable pregnancy to you? Could that bleeding be related to a “vanishing twin”? Thank you in advance.

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Dr. Geoffrey Sher

It could be…however this is not an optimal response. I suggest an ultrasoung at about 6-7 weeks for a definitive answer.

Good luck!

Geoff Sher

Aydde Hurtado

I has 2 5d frozen embryo transer done on 7/12/16 on 7/21 had my first beta hcg level of 11. On 7/33 my hcg level dropped to 4. My re and staff can only say it’s not a negative and we’ll see you on monday. Can you please explain what’s happening?

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Dr. Geoffrey Sher

Respectfully, this does not look promising Aydde,

So sorry!

Geoff Sher

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