Minimal stimulation IVF options

Published: 20th December 2011
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The recent popularity of Mini-IVF (minimal stimulation IVF), Micro-IVF, natural cycle IVF, IVM attests to the changes taking place in the practice of advanced reproductive technologies. The differences between these technologies are not easy for most people to understand. Because these terms are used differently between different groups and because some of these procedures have significantly evolved over time, it can be confusing to understand exactly what is meant by these terms. Our objective here is to try to make them more understandable. We will also try to point out some of the strengths and weakness of the above procedures in terms of our understanding of them.

A common feature all of these procedures share is the use of less infertility medications. The reduction in medication use compared to a normal IVF cycle ranges from a 50% to a 100% reduction. If less medication is used, then less monitoring is required (blood tests and ultrasounds). The amount of reduction in monitoring depends on the procedure being done and the philosophy of the medical practice. For most of these approaches, fewer eggs are involved, which may mean there is less work for the laboratory to do. Some programs will discount their routine laboratory charges compared to regular IVF; others may not. Generally, IVM involves more embryology work than routine IVF.

The process of IVF can be difficult for some patients. Monitoring requires missed work or the disruption of a woman’s schedule. Blood tests are unpleasant. Medications cause major changes in hormone levels and result in bloating and discomfort. The most significant risk of IVF, severe ovarian hyperstimulation syndrome, is decreased in all of these procedures and completely eliminated in some (pure natural cycle IVF and IVM). This can be very important for some women with severe PCOS who are at increased risk for significant discomfort or even (rarely) hospitalization with routine IVF approaches.

The biggest “ variable” in assessing the effectiveness of IVF technologies is the patient. The same approach can yield vastly different results depending on the subset of patients it is applied to. Some programs are gentler in their use of IVF medications than other programs; some physicians are more effective than others. All IVF variations work better on a younger patient population. This makes comparing these IVF variation procedures difficult since the number of patients reported on in the medical literature is unlikely to large enough to smooth over the variables likely to cause some differences in results. The IVF cycle data reporting program managed by the CDC does not distinguish between different approaches to IVF. It considers them all to be IVF, which diminishes the value of this data reporting in comparing programs or better understanding the efficacy of these procedures.

Natural cycle IVF generally refers to a process in which patients are monitored during their regular menstrual cycles, and in mid-cycle, one or two mature eggs are harvested from their ovaries from large developing follicles. Eggs are harvested as they are in routine IVF and the laboratory process is the same as with routine IVF (except fewer eggs are involved). One of the bigger problems with natural cycle IVF (and it variants) is its high cancellation rate (estimated at 40% due to inadequate response, premature LH surge (20% by itself), or no embryos to transfer).

Natural cycle IVF has been an appealing idea to many physicians and there are a number of publications over the years which have documented the results. A generally accepted on-going success rate for natural IVF is 7% per cycle with a range of 0% to 14%. This compares to an overall IVF success rate of 30.5% take home baby rate per started cycle (US CDC data). It is estimated that total natural cycle IVF costs are ¼ that of a routine IVF cycle. One paper suggests that four cycles of natural IVF have a pregnancy rate similar to routine IVF. Advocates feel that since natural IVF is so much easier for patients than routine IVF, this pregnancy rate is reasonable since patients can do more cycles.

Natural cycle IVF has been modified in many ways with the use of clomiphene citrate, antagonists (like ganirelix) and gonadotropins (75-300 units/day). Published pregnancy rates with these approaches differ widely, for example, 8.3% for good prognosis patients in one study, 13.3% for patients with severe male factor in another, 0% in poor prognosis patients in a third. Some of these cycles are not distinguishable from what some physicians have more recently been calling minimal stimulation cycles.

We feel that natural cycle IVF can best be combined with IVM. (This is one of the approaches that we take.) Because we then have both mature and immature eggs to work with, the pregnancy rate is higher and the patient does not have “more” to go through. In some programs, the pregnancy rate with natural cycle IVF/IVM is the same as for routine IVF (for patients under 38) and it has a very low cancellation rate. (In appropriately selected patients, this has been our experience.)

Minimal stimulation IVF, mini-IVF or micro-IVF is the advanced technology procedure that is used to describe the widest range of procedures and is potentially the most misleading terminology. The IVF consumer should be aware that most IVF practitioners want to use the lowest amount of medications that will achieve their objectives with conventional IVF. Generally, patients who are given higher doses of medications are patients with poor responses in prior cycles, decreased antral follicle counts on ultrasound, or advanced age (>37 years old). None of these lower dose IVF technologies have been shown to work better than conventional IVF in any of these groups.

The definition of “minimal stimulation IVF” appears to mean using a slightly different ovulation induction protocol from routine IVF and attempting to produce follicles likely to contain mature eggs. The harvesting, fertilization, culture and transfer of those eggs/embryos does not differ from conventional IVF. Generally these cycles are cancelled if a minimal number of reasonable sized follicles are not produced or if there are not embryos growing well enough for transfer after 3 to 5 days of culture. A high cancellation rate is may a problem with this type of cycle. Our objective with Mini-stim IVF is to obtain one or two mature eggs based on the likelihood that there are likely to be as similar quantity of quality eggs as in a more aggressive conventional IVF cycle. Our cancellation rate is similar to that of conventional IVF.

IVM involves in vitro maturation of immature eggs in the laboratory. Much of the literature looks at the maturation of immature eggs that were obtained during a stimulated IVF retrieval. These eggs mature at a low rate and are usually chromosomally abnormal. Some babies have been born by this technique, but the current view is that most eggs that don’t mature after a routine IVF ovulation induction are likely to be abnormal. The current approach to IVM uses eggs that have not received stimulation or have received minimal stimulation. All of these use no to minimal fertility medications. All require minimal monitoring and all are easier for the patient than routine IVF. The cancellation rate for these cycles is very low. Hyperstimulation for patients with PCO undergoing IVM has not been reported.

Pregnancy rates with these techniques have been reported in several programs and they range from slightly lower than conventional IVF in that program to the same as conventional IVF (25-50%/cycle) in that program. Reports of any substantial size restrict IVM to good prognosis patients (younger and with adequate ovarian reserve). However, there are small reports of success with IVM in more difficult to work with patient groups. Our view is that older patients and patients with ovarian reserve problems are best served with other IVF approaches.

Patients with isolated male or tubal factor are generally the best candidates for minimal stimulation IVF techniques. Even if only a few eggs are obtained, injecting them with sperm results a high rate of pregnancy for whatever techniques used. ICSI is simply the most targeted effective therapy for male factor. Any IVF harvesting technique bypasses tubal issues. If the cost of a minimal stimulation therapy is low enough, this is the most cost effective way to achieve pregnancy when male factor is present.

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