In this episode of The Egg Whisperer Show, I’m welcoming back renowned fertility specialist Dr. Geoffrey Sher to talk all about the causes and prevention of poor embryo quality in IVF. With over 36 years of experience and more than 17,000 IVF babies born through his work, Dr. Sher offers valuable insights into the factors that influence embryo quality and shares strategies to help improve IVF outcomes.
Key Topics:
- Embryo Competency: Exploring the critical role of embryo competency in IVF success rates and miscarriages.
- Factors Affecting Egg Quality: A closer look at how age, ovarian reserve, and the ovarian hormonal environment affect egg quality.
- Impact of Environmental Pollutants: How pollutants like bisphenol A can impact egg quality and overall reproductive health.
- Personalized Treatment Protocols: The importance of individualized ovarian stimulation protocols for optimal egg development.
- Sperm Quality’s Role: How sperm quality impacts embryo development and ways to improve it.
- Emerging Technologies: New advancements in IVF, such as PGT and video screening for embryo development, that are shaping the future of fertility treatments.
Dr. Geoffrey Sher is the founder of Sher Fertility Solutions and a pioneer in the field of assisted reproductive technology (ART). He has authored multiple books and over 200 scientific articles and has been instrumental in advancing fertility treatments worldwide.
Resources:
- Dr. Sher’s book: In Vitro Fertilization: The Art of Making Babies
- Download Dr. Sher’s free ebook “From In Vitro Fertilization to Family: A Journey with Sher Fertility Solutions“
- Download Dr. Sher’s Free ebook: “Recurrent Pregnancy Loss and Unexplained IVF Failure: The Immunologic Link” (on immunology and recurrent pregnancy loss).
- Contact Dr. Sher’s assistant Patti at [email protected] or call 702-533-2691 for inquiries.
Full Transcript:
On today’s show, I’m joined once again by Dr. Geoffrey Sher to talk about the causes and prevention of poor embryo quality in IVF. We’ll be looking at the underlying factors and exploring different kinds of preventative strategies aimed at optimizing outcomes.
Dr. Sher is the founder of Sher Fertility Solutions and is an internationally renowned expert in the field of assisted reproductive technology. He has been influential in the births of more than 17,000 IVF babies. Over the last 36 years, he has helped fashion the field of ART.
After training with the fathers of IVF, Dr. Steptoe and Dr. Edwards, he established the third IVF program and the first private IVF center in the United States in 1982. He has authored over 200 scientific articles and abstracts and has authored several books, including his most recent From In Vitro Fertilization to Family, written with his partner Dr. Drew Tortoriello, available soon.
If you want to understand why poor embryo quality can occur and what you can do to give your embryos a better chance of success, this episode is for you.
Dr. Aimee: The title of today’s show is Causes and Prevention of Poor Embryo Quality with IVF: Understanding the Underlying Factors and Exploring Preventative Strategies Aimed at Optimizing Outcomes. I’m thrilled to have famed fertility doctor, Dr. Geoffrey Sher on today’s show again. Welcome, Dr. Sher. Thank you for joining us.
Dr. Geoffrey Sher: Thank you.
Dr. Aimee: Let’s dive into this topic. My first question is what are the most common factors contributing to poor embryo quality in IVF?
Dr. Geoffrey Sher: I’ve done quite a few of these podcasts with you, but this one, the one we’re doing today is extremely important because 80% of IVF failures, as well as 80% of miscarriages, stem from embryo incompetency.
Embryo competency is defined as the potential of an embryo to propagate a viable pregnancy.
Most patients, and even some fertility specialists, erroneously point to the embryology laboratory as the major determinant of embryo quality. Of course, a good lab is essential, but when there’s an issue with embryo competency, it is in fact seldom the lab’s fault. Most good, or even average, labs can handle the processes of fertilization, ICSI, and biopsies quite well. Therefore the main focus should be on addressing those factors that affect the quality of the eggs delivered to the lab for fertilization and processing.
Although not exclusively so, the competency of an embryo is largely a function of its chromosomal integrity, which primarily stems from the egg and is the most crucial factor in achieving successful pregnancy. While sperm quality certainly contributes to determining embryo “ competency”, with the exception of cases where the man has severe sperm issues, it is not nearly as important as the egg in this regard. The reason is that the egg has a remarkable ability to select the best sperm from the thousands that attach themselves to the surface of the egg, to fertilize it . So, if there are healthy sperm present, the egg will usually select the right one for fertilization. Simply stated, In about 80% of cases, the main factor in determining embryo competency is the egg, not the sperm. And it is egg chromosomal/genetic integrity that is by far the most important factor that determines embryo competency and a healthy pregnancy. It therefore follows that, by and large, it is the factors affecting chromosomal and genetic integrity of the egg that will determine success or failure of IVF.
The question then becomes: what can we do to give eggs the best chance of being chromosomally normal (euploid), since only euploid eggs can result in euploid, “competent” embryos. So if we wish to optimize embryo competency and IVF outcomes, we need to focus our attention on the variables that determine egg competency. Here, it boils down to three major factors that play a role:
- AGE
The first is the woman’s age. As a woman ages, her eggs undergo “wear and tear,” which impacts their chromosomal integrity during reproductive division (meiosis) which commences about 40 hours following the LH / hCG trigger administered prior to egg retrieval. This process is crucial in preparing the egg’s chromosomes for orderly fertilization. As the age of the woman advances beyond her mid-30’s, the meiotic is progressively compromised through wear and tear of her eggs that have been in her ovaries from prior to birth, making it progressively more difficult to produce chromosomally normal eggs.
- Ovarian Reserve
The second factor is ovarian reserve, or the number of eggs remaining in a woman’s ovaries. A woman is born with all the eggs she will ever have. In the past, ovarian reserve was assessed by measuring hormones like FSH, LH, inhibin B, and through antral follicle counts. Today, we primarily use Anti-Müllerian Hormone (AMH) to assess ovarian reserve. A level above 2ng/ml (or 15 pmol/L) is considered optimal for fertility, Although lower levels are not always absolutely prohibitive of a successful outcome, an AMH level below 1.5ng/ml or 10pmol/L suggests an emerging problem where egg production is likely to be curtailed and this is referred to as significantly diminished ovarian reserve (DOR). An AMH of below 0.5 no/ml or 5 pmol/L indicates a severe degree of DOR and that egg production will be significantly compromised.
It is important to recognize that the existence of DOR doesn’t just mean fewer eggs. Often, women with DOR also have elevated levels of the pituitary hormone LH, which leads to excessive ovarian testosterone production. This can disrupt follicle development, causing premature luteinization, which also severely compromises egg’s growth quality.
- Ovarian Hormonal Environment
The third factor is the ovarian hormonal environment. While we can’t reverse a woman’s age or increase her ovarian reserve, we can influence the ovarian hormonal environment. A well-designed ovarian stimulation protocol can limit overexposure to LH-induced testosterone, giving eggs the best chance to develop normally. Individualized treatment protocols that manage hormonal balance during stimulation are key to improving outcomes, especially in older women (40 years and up) and those with DOR.
Dr. Aimee: I’d argue that ovarian rejuvenation can help some women. I’ve had patients in their 40s who, after five failed IVF cycles, were able to produce euploid embryos after ovarian PRP treatments. It doesn’t help everyone, but I’ve seen it work.
Dr. Geoffrey Sher: I remain skeptical, but I’m always open to being convinced by success stories.
Dr. Aimee: It’s still very experimental, but I’m hopeful it will continue to show promise.
Dr. Geoffrey Sher: I’ve always thought uterine PRP might have a place, but I’m still unsure about ovarian PRP. We need more evidence of benefit.
Dr. Aimee: Thanks. What preventative measures can women with aging mitochondria take to improve embryo quality?
Dr. Geoffrey Sher: First, women should avoid certain environmental toxins. Pollutants like bisphenol A (found in plastics and reusable food containers,) organochlorines, pesticides, and dioxins can negatively impact egg quality. Other pollutants, resulting from traffic emissions and industrial byproducts, may also disrupt ovarian function.
Diet also plays a role. I recommend a Mediterranean-style diet rich in whole grains, vegetables, fruits, legumes, nuts, and fish. Certain supplements, including folic acid, CoQ10, inositol, melatonin, vitamin D3, fish oil, vitamin E, zinc, and B vitamins, may also help as antioxidants.
I’m not a believer in DHEA, especially for women with diminished ovarian reserve, because it increases testosterone, which can harm egg quality especially in older women and those with DOR.
Dr. Aimee: I agree with you—DHEA is terrible for egg quality, especially in women with endometriosis.
Dr. Geoffrey Sher: Exactly. But undoubtedly, selection of a targeted and individualized ovarian stimulation protocol is central to trying to preserve egg quality, especially in older women and those with DOR where the wrong protocol can lead to overexposure to testosterone and poor egg quality. It’s crucial to use a customized protocol to ensure the best results.
Dr. Aimee: What about sperm quality? We know 80% of embryo quality is egg-related, but sperm still plays a role.
Dr. Geoffrey Sher: Improving sperm quality is more challenging. The best we can do is select the healthiest sperm through techniques like PICSI. Antioxidants in male fertility blends like Proceptin can help, but there’s no way to truly rejuvenate sperm. Lifestyle factors like avoiding alcohol, smoking, and exposure to pollutants can improve sperm over time, as sperm take about three months to regenerate. However, issues like varicoceles can impair sperm quality, and treatments like varicocele ablation can sometimes help.
Dr. Aimee: I tell my male patients to ejaculate every other day starting 30 days before egg retrieval to reduce sperm DNA fragmentation. It’s a myth that saving up sperm is helpful.
Dr. Geoffrey Sher: Absolutely. It’s about the quality of sperm, not the quantity. I also recommend maintaining a healthy lifestyle and diet.
Dr. Aimee: Are there any emerging technologies or research areas focused on improving IVF outcomes?
Dr. Geoffrey Sher: We developed a test called HLAG (human leukocyte antigen G) to assess the fluid around the embryo for competence, but it didn’t take off. Video monitoring of embryo development is another emerging technology, though I’m not convinced of its efficacy.
Ultimately, as stated earlier, the most important factor is the chromosomal integrity of the embryo. Only embryos that reach blastocyst stage within five or six days should be considered for transfer or genetic testing (PGT).
Dr. Aimee: What about transferring day 3 embryos versus day 5 blastocysts?
Dr. Geoffrey Sher: I generally prefer transferring blastocysts, especially after PGT-A, as they have a higher likelihood of being chromosomally normal. However, if a patient prefers, day 3 transfers can be done, but it’s important they understand the potential for false hope if the embryo isn’t genetically normal.
Dr. Aimee: Exactly. Some patients just want the experience of an embryo transfer, and I respect that.
Dr. Geoffrey Sher: At the end of the day, our job is to provide information and allow patients to make informed decisions.
Dr. Aimee: I appreciate your wisdom and passion for helping patients. How can people work with you?
Dr. Geoffrey Sher: Anyone interested can contact my assistant, Patti, at [email protected] or (702) 533-2691. She’ll arrange a full consultation, and I’m happy to discuss their case with them.
Dr. Aimee: Thank you so much for joining me today, Geoff. Your insights are invaluable.
Dr. Geoffrey Sher: I hope that those who listen to this podcast will walk away with a better understanding of why their IVF cycles might not have worked. ……Thank you. It’s always a pleasure to exchange ideas with you.
Dr. Aimee: Same. Thanks again!
