Natural Cycle IVF
Natural Cycle IVF – Is It a Viable Treatment Option?
Recently, “Natural Cycle IVF”, “Minimal Stimulation IVF”, and “Patient Friendly” IVF have received renewed attention as alternatives to conventional IVF. These techniques have been tried before and abandoned due to poor success rates and minimal change in the surgical and financial risks compared to conventional IVF. Many critical studies and commentaries have been published on this technique, some very recently. Most experts consider the better term to be “minimally effective IVF ” rather than minimal stimulation IVF.
In a natural menstrual cycle, only one dominant follicle with a single oocyte (egg) inside typically develops. Natural cycle IVF is a form of in vitro fertilization without the use of medication to stimulate the ovary to produce multiples eggs. Patients are monitored with several ultrasound and blood tests to follow the development of the single follicle. Operative egg retrieval is then performed to try to remove an egg from the single follicle. If the egg retrieval is successful, an attempt is made to fertilize the egg in the laboratory in the same way as conventional IVF. If a viable dividing embryo is produced, it is transferred back to the uterus.
The proposed benefits of natural cycle IVF are the use of less medication, lower medication costs and no risk of ovarian hyperstimulation syndrome; in some cases, there is less monitoring with ultrasounds and blood tests. The same procedures for egg retrieval, laboratory fertilization and growth and embryo transfer are used, incurring the same or similar costs, but for only the one egg or embryo.
Drawbacks Limit Use of Treatment
The significant drawbacks of this method have limited its use. For example, in approximately 20% of “natural” cycles, no egg is retrieved at the time of surgery. An additional 20% of cycles result in no fertilization and therefore no embryo. Only half of patients have an embryo to transfer back to the uterus. The resultant pregnancy rate after transfer is only 10%, a percentage which is not higher than non-IVF therapy with ovarian stimulation and intrauterine insemination (IUI). Unfortunately, 10-25% of patients who successfully achieve a pregnancy with this therapy go on to miscarry. Committing patients to this approach exposes almost 95% of women to the rigors of an IVF cycle monitoring, the surgical egg retrieval and laboratory techniques but with a very low likelihood of success.
“Minimal Stimulation IVF” utilizes lower doses of fertility drugs to try to stimulate 2-4 mature eggs to mature, and then proceeds in the same way to attempt egg retrieval, fertilization and embryo transfer. This attempt to have it both ways – more ‘patient friendly” than conventional IVF but better success than natural cycle really is an admission of the multiple benefits of multiple egg production to IVF success, but without realizing that success.
Although these methods are described as patient friendly, proponents often advise that patients undergo multiple cycles – with their repeat operation, anesthesia and cost of egg retrieval, in order to achieve a successful pregnancy. Repeating a procedure with a 7-10% success rates four or five times is NOT the same as doing a single procedure with 40 – 50% chance of delivery in one cycle. In addition, with one egg there is no possibility of additional embryos to cryopreserve for future use, embryos which retain their potential for pregnancy even if the mother experiences a further decline in fertility over time.
A recent Editorial was published in the American Society of Reproductive Medicine’s official journal Fertility and Sterility.
Copyright considerations keep us from reproducing the Editorial in its entirety, but we have received permission from the Editors to provide our patients extended excerpts’ as part of the education and information process about these techniques. The Editorial can, however be best summed up in the following two quotes:
- “The ‘‘less is better’’ thesis has tremendous emotional appeal, because patients inherently dislike taking medications for any reason, viewing it as unnatural. Minimal stimulation techniques thrive on this appeal. However, promoters of minimal stimulation protocols largely use theoretic arguments to support their methods, rather than scientiﬁc proof, pointing to effects that might occur. It is a challenge to counter arguments that lack signiﬁcant proof or data. What is possible illogically trumps what is known. A recent review of abstracts presented at the First World Congress on Natural Cycle/Minimal Stimulation reports ‘‘doubts,’’ theory that ‘‘requires conﬁrmation,’’ claims that ‘‘stressed . uncertainties,’’ and procedures that ‘‘might be superior’’ (10). The lack of deﬁnitive statements is telling. We do not claim that concerns regarding safety and attempts to create more efﬁcacious treatment are not valid, just that without proof they do not justify serving our patients poorly.”
- “Making minimal stimulation IVF synonymous with patient-friendly stimulation is an example of a marketing neologism overcoming science. George Orwell warned against this kind of “newspeak,” by which words are, “deliberately constructed … intended to impose a desirable mental attitude upon the person using them.” The opposite of minimal stimulation is not maximal stimulation, but optimal stimulation, a goal toward which we should all strive, and because the intent of medicine is always to achieve the best outcomes this adjective rarely needs to be explicitly stated.”
Shady Grove Fertility Rejects Natural IVF as a Viable Option
After a thorough review of the literature and for all the reasons stated above, with the main reason being the fact that it is not a procedure that offers simplicity or even improved pregnancy rates for patients, the physicians at Shady Grove Fertility have made the decision not to offer this as a treatment option. We encourage patients to ask the following questions with regard to this controversial treatment.
- What is the delivery rate per initiated cycle in your program?
- How many cycles will I have to do to achieve a healthy birth? How much will they cost?
- Will I be able to save any embryos for another pregnancy when I am older?
- Are you recommending this because you think I am a poor candidate for conventional IVF?
- Schimberni. IVF with natural cycle in poor responder women. Fertility and Sterility 2008.
- Fertility and Sterility Vol 88 No3, Sept 2007 pages 547-549.
- Aragona. IVF in poor responder patients: a controlled trial between natural cycle and micro-dose GnRH analogue flare. Fertility and Sterility 2003.
- Barri. A controlled trial of natural cycle versus microdose gonadotropin-releasing hormone analog flare cycles in poor responders undergoing in vitro fertilization.
- Fertility and Sterility 2004.