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Geoffrey
Sher, M.D.
 Educated
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.
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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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