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Geoffrey Sher, M.D.

Dr. SherEducated in South Africa, Dr. Sher was a Senior Specialist of Obstetrics and Gynecology at the prestigious Groote Schuur Hospital (the teaching institution for the University of Cape Town), where the world's first human heart transplant was performed. In 1975, he was recruited by the University of North Carolina in Chapel Hill to assume a faculty position in the Department of Obstetrics and Gynecology. In 1979, Dr. Sher entered private practice in Nevada where he is currently a Clinical Professor of Obstetrics and Gynecology at the University of Nevada School of Medicine. In 1982, Dr. Patrick Steptoe, the father of In vitro Fertilization (IVF), afforded Dr. Sher an opportunity to study under him at Bourn Hall in England. Dr Sher returned to the United States and in January 1983 opened the nation's first private, non-university based IVF center (the fourth IVF program in the USA), in Reno, Nevada. He is Board Certified in Obstetrics and Gynecology in South Africa, England and in the United States and also has Sub-specialty Board Certification in Maternal-Fetal Medicine.

Between 1987 and 1998, Dr. Sher opened the California based Pacific Fertility Medical Centers (PFMC) with three locations. During his tenure with PFMC, Dr. Sher was largely responsible for the Group's emergence as one of the leading IVF programs in the nation. In ten (10) years he propelled PFMC into the forefront of clinical performance and research, introducing several major medical break-throughs that impacted positively on the treatment of infertility. In 1990 Dr. Sher was the first to point to the fact that ultrasound evaluation of the uterine lining prior to IVF, allows for prediction as to the likelihood of a subsequent pregnancy. In 2000 he demonstrated that the administration of Sildenafil (Viagra) to women with poor endometrial linings, improves uterine blood flow and enhances hormonal thickening. In the field of reproductive immunology, DR Sher was the first to link immunologic problems causally, to female-related resistant infertility and repeated IVF failure, introducing immunotherapies that have virtually doubled the IVF birthrates in such cases.

In 1995, Dr. Sher and his team introduced a novel consumer-friendly concept in fee structuring for IVF. This so called Outcome-Based Pricing (OBP)-arrangement granted eligible patients a 70-100% refund of medical fees, if they did not have a successful outcome after IVF treatment. In the absence of IVF insurance coverage, this risk- sharing financial arrangement was welcomed by IVF patients across the board, but was strongly criticized by almost all IVF physicians who felt that widespread introduction of such an arrangement would place them at financial risk. After waging a relentless and often single-handed crusade, Dr. Sher was successful in getting this plan accepted by SART, the IVF medical governing body, as well as by the IVF medical community. Currently, more than 50 of an estimated 350 IVF programs in the nation offer it as an option, in one form or another, to their patients.

DR Sher is a strong proponent of accountability on the part of IVF programs for the success rates they report to consumers, favoring the establishment of an accreditation process for all centers that provide IVF and related services. He believes that in order to render IVF treatment affordable to all Americans, regardless of their socioeconomic status government should mandate insurance coverage for couples undergoing IVF through providers who meet well defined, validated outcome-based performance standards.

Dr. Sher was a founding Board Member of SART. He has more than 200 accredited scientific publications and abstracts to his credit and has co-authored two consumer-oriented medical books; "Your Pregnancy," published by Simon and Schuster in the 1980's and "In vitro Fertilization, the A.R.T. of Making Babies", published by Facts on File. The latter is currently one of the most widely read consumer books on the subject of IVF, in the USA. "In vitro . . ." was written to assist infertile couples in evaluating their options with regard to the various advanced fertility procedures.

In 1998, Dr. Sher separated from PFMC to found the Sher Institute for Reproductive Medicine (SIRM), a state-of-the-art facility that offers advanced fertility treatment and research. SIRM programs are located in programs in: Las Vegas, Los Angeles, Sacramento, St. Louis, Central IL, Chicago and soon to be in New York City (Spring 2004).

DR Sher has been influential in the births of more than 6,000 of an estimated 100,000 IVF babies born in the United States, to date.

Return to StorkNet's interview with Dr. Sher.

Visit Dr. Sher's home page.

 

THE INFLUENCE OF AGE AND THE SEVERITY OF ENDOMETRIOSIS ON FERTILITY TREATMENT OPTIONS

Geoffrey Sher, M.D.

Endometriosis is a complex condition where, the lack or relative absence of an overt anatomical barrier to fertility often belies the true extent of reproductive problem(s).

All too often the view is expounded that the severity of endometriosis-related infertility is inevitably directly proportionate to the anatomical severity of the disease itself, thereby implying that endometriosis causes infertility primarily by virtue of creating anatomical barriers to fertilization. This over-simplistic and erroneous view is often used to support the performance of many unnecessary surgeries for the removal of small innocuous endometriotic lesions, on the basis of such "treatment" evoking an improvement in subsequent fertility.

It is indeed indisputable that even the mildest form of endometriosis can compromise fertility. It is equally true that, mild to moderate endometriosis is by no means a cause of absolute "sterility."

Rather, when compared with normally ovulating women of a similar age who do not have endometriosis, women with mild to moderate endometriosis are about three to four times less likely to have a successful pregnancy. Two important reasons for such reduction in fertility potential are:

a) Endometriosis is associated with the presence of local pelvic toxins that significantly reduces the fertilization potential of eggs as they pass from the ovary to the fallopian tube via the pelvic cavity and,

b) Given that the pathogenesis of endometriosis almost certainly involves an abnormal immune response, many such women tend to reject the embryo (fertilized egg) as it attempts to gain attachment to the uterine lining (endometrium).

The reported annual birth rate for normally ovulating women under 35 years old who are free of endometriosis or any other pelvic disease, is about 80%. For women 35-40 years of age, the comparable annual rate is about 50-60% and for women in their early 40's, it is approximately 20-25%. In contrast women in similar age categories who have even the mildest degree of endometriosis can expect a 3-4 fold reduction in annual birth rate.

Since, the reason for women with mild to moderate endometriosis having a much poorer reproductive performance has little to do with ovulation dysfunction or anatomical disease, it is should come as no surprise that the use of fertility drugs, surgery to ablate small endometriotic deposits and minor adhesions, and/or intrauterine insemination is unlikely to any improvement in pregnancy rate over no treatment at all. Women under 35 years who fit this profile, and who conceive following fertility hormone therapy, intrauterine insemination (IUI) or surgery, should consider that they probably became pregnant in spite of, rather than due to, such treatment. Failure to recognize this reality carries with it the risk that when it comes to planning for another baby, the woman will erroneously belief that having conceived before means that their should be no difficulty in doing so again and be lulled into a false sense of complacency. In reality, the achievement of a viable pregnancy by a woman with mild/moderate endometriosis, whether it occurred spontaneously or following such treatment does not improve her subsequent ability to conceive.

Younger women (under 30 years) with mild/moderate pelvic endometriosis (who have patent fallopian tubes, are ovulating normally and have fertile male partners), have about a 30-40% chance of having a baby within three years. Accordingly they have a justifiable choice between taking a "wait and see" approach, (avoiding surgery, fertility drugs and intrauterine insemination which in my opinion is unlikely to improve the chance of a successful pregnancy over no treatment at all) and In Vitro Fertilization which by involving the direct extraction of eggs from the ovaries and initiating the fertilization process in the Petri dish/incubator, the IVF procedure facilitates fertilization, is much likely to be successful, but might have been avoided by a "wait and see approach".

Finally, I wish to point out that in addition to the toxic "peritoneal factor" present in all women with endometriosis, our research has shown that up to 1/3 of women with endometriosis (regardless of severity), in addition have an immunologic barrier to implantation. This population of women will not conceive until the immunologic problem has been diagnosed and suppressed through selective immunotherapy. It therefore behooves all women with endometriosis who are planning to have a family to be thoroughly tested for antiphospholipid antibodies (APA), Natural Killer cell activation (NKa) and reproductive immunophenotype. These tests should only be done in a reproductive immunology reference lab of which to my knowledge no more than a half dozen , capable of performing these tests with the required sensitivity currently exist in the U.S.A.

Given the effect of the biological clock, women over 35years who have endometriosis-related infertility,do not have time to waste and should, in my opinion do IVF as a first line approach, regardless of their immunologic status.

In the absence of clear evidence of increased NK cell activity, I recommend a conservative approach in women under 35 years (who potentially have some time) and, regardless of age women who have increased NK cell activity, should in my opinion undergo selective immunotherapy with immunoglobulin G (IVIG) because we have found that without such treatment they are not likely to conceive regardless of the approach to treatment) undergo IVF.

 

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