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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.

 

Geoffrey Sher, M.D.'s

Basic Comprehensive General Infertility Work-up

Prepratory Tests:

  1. On the third day of a spontaneous or progesterone withdrawal menstruation, blood is drawn for the measurement of Estradiol (E2), FSH, LH and Inhibin-B. The specimen of blood should be sent to Millenova Laboratories in Chicago (312) 274-1928 by overnight Federal Express for the performance of the Inhibin-B test.
  2. Blood should also be drawn (any time) for the measurement of Prolactin, TSH and antisperm antibodies (ASA).
  3. Commencing on the second day (2nd) of the menstrual cycle, a basal body temperature chart should be initiated. A thermometer is placed in the mouth for a period of two (2) minutes upon awakening (prior to the ingestion of food/liquid and brushing of your teeth). The temperature should be documented graphically on the basal body temperature chart provided.
  4. For women less than 35yrs without evidence or symptoms sugesting underlying organic pelvic disease (eg; endometriosis, chronic inflamation, pelvic adhesions, fibroids etc):

    A hysterosalpingogram (HSG) should be performed within a week of the cessation of menstruation. This out-patient procedure involves injection of a radio-opaque dye which outlines the Fallopian tubes allowing the diagnosis of tubal blockage. To a lesser degree, it permits the detection of surface lesions inside the uterine cavity.

    OR

    For all women over 35yrs of age and for younger women who have evidence or symptoms pointing to underlying organic pelvic disease (eg; endometriosis,chronic inflamation,pelvic adhesions, fibroids etc):

    A laparoscopy/hysteroscopy should be performed within a week of the cessation of menstruation. Laparoscopy is a procedure where a telescope-like instrument is introduced through the belly button into the abdominal/pelvic cavity allowing diagnosis and treatment of ovarian cysts/endometriomas/benign tumors, uterine fibroids, tubal blockage, ectopic pregnancy, appendicitis, pelvic adhesions etc. Laparoscopy is usually performed as an out-patient procedure with the patient under general anesthesia. It is one of the only ways to diagnose early pelvic endometriosis acurately. Hysteroscopy is a procedure where a telescope-like instrument is inserted, via the vagina through the cervical canal into the uterine cavity, for the evaluation of the interior of the uterus. It is an important procedure because it allows for diagnosis and treatment of small surface lesions inside the uterine cavity (e.g. polyps, scarring or adhesions) tha adversely affect the ability of an embryo to attach to the uterine lining. Such lesions are often missed through the performance of an HSG.

  5. Commencing at least 17 days before te expected next menstrual period (ie; usually about 10 days following the initiation of menstruation), urine should be collected twice daily and tested for the onset of the spontaneous LH surge. The initiation of the LH surge usually precedes ovulation by 8 to 36 hours. In order to detect the onset of the LH surge as early as possible, it is important that urine be tested at least twice daily. This is done as follows:

    The bladder is emptied first thing in the morning, upon awakening. One half-hour later urine is collected (only a very small amount is required) and tested using an over-the-counter LH - kit (obtainable over the counter at a drug store). The earliest sign of any color change should be documented. It need not be a pronounced color change as suggested by the insert in the kit. Any alteration in coloration is significant. The same process of testing is then repeated at night before retiring.

At the earliest sign of a color change the couple should:

  • have intercourse, arrange to have the first in-office physician's assessment within 6- 18 hours following intercourse.
  • the woman should RUSH IN to the physician's office ASAP to have her blood drawn for the measurement of estradiol (E2) l level ( NOTE: timing is critical because within approximately 6 hrs of detecting LH in the urine, (which roughly coincides with 12 hours after the actual onset of the LH surge), blood estradiol levels start to fall precipitously and if blood is drawn too late, the measurement of estradiol will be of little value.

Note: If the color change is observed in the early morning, the woman should schedule the "first in-office assessment" at the doctor's office for the afternoon of the same day. If it occurs at night, the doctor's office should be contacted first thing the next morning and the "first office assessment" should take place within hours.

The First In-Office Assessment:

A.

A Post-Coital Test (PCT) or Huhner test is performed on the cervical mucus. The purpose of the PCT is to assess sperm survival within the mucus. Since sperm can only survive for six hours in the vagina, a positive PCT is indicative of:

  1. Good quality sperm.
  2. Good sperm - cervical mucus interaction suggesting that there will be safe passage of sperm to the uterine cavity.
  3. Absence of ASA antibodies in the sperm or mucus.
  4. That the production of estrogen is adequate.
  5. That the endometrial lining is well primed by estrogen, which is essential for adequate preparation of the uterine lining for implantation.

B.

Cervical mucus is cultured for:

  1. Ureaplasma Urealyticum (this requires a specialized medium to transport the specimen to the laboratory).
  2. Chlamydia and Gonococcus (these also require a specialized transport medium).
  3. Aerobic and anaerobic pathogens.
C. A cervical mucus evaluation: A sample of the cervical mucus is allowed to dry on a glass slide and is examined under the microscope for specific features such as "ferning," which is indicative of an adequate estrogen effect.
D. A vaginal ultrasound examination is performed to detect the presence of at least one dominant follicle that measures18 mm in mean diameter thus helping confirm that ovulation is imminent. It also allows for the assessment of the thickness and appearance of the endometrial lining. A normal endometrium should measure at least 9 millimeters in sagital diameter at this time.

The Second In-Office Assessment

This visit is scheduled three (3) days after the first office assessment. At this visit a vaginal ultrasound exam is performed to check whether ovulation has occurred (i.e. whether the egg has been released). The presence of small amount of fluid collecting in the lower most region of the pelvis or a change in the shape of the follicle is suggestive of ovulation.

The Third In-Office Assessment

The third visit takes place five (5) days after the 2nd visit. At this visit blood is drawn for the measurement of progesterone (P4) and E2.

The Fourth In-Office Assessment

The fourth and final visit is scheduled for five (5) days after the office assessment.At this visit an endometrial biopsy is performed. This is a simple in-office procedure, whereby a slither of uterine lining (endometrium) is removed and sent to the laboratory to evaluate histologic changes in the endometrium.

Intercurrent Testing (i.e. any time in the cycle)

Tests On The Female Partner

  1. An immunologic work-up: May be required in certain cases of female infertility or where there is a past history of recurrent pregnancy loss: Measurement of: antiphospholipid antibodies (APA), antithyroid antibodies (ATA) and a Natural Killer Cell activity test (NKa). Blood should be sent Millenova Laboratory in Chicago. (312 274-1928) as such tests can usually not be performed in a regular Reference Laboratory because the methods they employ are neither sensitive nor specific enough to be of value in cases of reproductive failure.
  2. For who anticipate going into an In Vitro Fertilization cycle sometime in the near future: Bood should be drawn for the measurement of HIV, Hepatitis B surface antigen, Hepatitis C antibody and RPR (a Syphilis test). Blood grouping and RH testing as well as a Rubella antibody test . Such tests will usually not be required in the course of a routine basic infertility work-up. Their performance should be confined to cases where it is anticipated that Assisted Reproductive Technology (ART) procedures such as In Vitro Fertilization or GIFT, will be the primary approach.

Tests on the Male Partner

  1. A semen analysis is required for accurate measurement of sperm motility and count. Sperm morphology is assessed employing "Kruger criteria." Semen should also be cultured for Ureaplasma Urealyticum, Chlamydia, Gonococcus and for aerobic/anaerobic pathogens.
  2. In addition, the man's blood should be tested for antisperem antibodies (ASA).

  3. If it is anticipated that In Vitro Fertilization is being considered, the man should also undergo blood testing for Hepatitis B surface antigen, Hepatitis C antibodies, RPR (Syphilis) and HIV.

Return to StorkNet's interview with Dr. Sher

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