Before couples come to Shady Grove Fertility, they often think that fertility treatment means In Vitro Fertilization (IVF). IVF, however, is only one of several options that infertile couples will discuss with their doctor. For example, half of all the treatments that Shady Grove Fertility performs are not IVF, but Intrauterine Insemination, or IUI. This is a simpler, lower cost treatment compared to IVF, and it is successful for many, many patients.
The decision about which fertility treatment to pursue is a personal one that requires research and deliberation. Patients must consider how treatment will affect them, physically, emotionally and financially. “Ultimately, the decision is in the hands of the patients, but we will make recommendations about the treatments we think have the best chance for success with the lowest overall burden for the patient,” says Dr. Stephen Greenhouse of Shady Grove Fertility’s Fair Oaks, VA office.
Lately, Dr. Greenhouse says, several patients have asked him about a treatment called Natural Cycle IVF. This treatment is similar to standard IVF but without the use of injectable medications. “It sounds appealing to those who dislike medications. “The problem is that these ‘natural cycles’ still require all the other costly and demanding aspects of traditional IVF,” explains Dr. Greenhouse, “the frequent appointments, a surgical egg retrieval under anesthesia, and embryo development in the lab. Yet, they have a significantly lower chance of resulting in pregnancy.”
For this reason, Shady Grove Fertility does not offer Natural Cycle IVF. “We just can’t justify putting a patient through IVF treatment with such a small chance of success,” says Dr. Greenhouse. He urges couples who are interested in Natural Cycle IVF to investigate the claims that it is less stressful, less costly, and less risky and find out how it performs on your most important criteria – delivering a baby.
During a normal monthly reproductive cycle, a woman’s ovary grows and matures a single egg inside an egg follicle. When her hormones reach a certain level, the mature egg is released and becomes available to be fertilized.
In a standard cycle of IVF, a woman takes medications for 7-10 days that stimulate both her ovaries to grow and mature multiple egg follicles. During this stimulation phase, she is monitored with ultrasound and bloodwork to track the growth of the follicles until they reach a certain size.
An egg retrieval procedure is then performed under anesthesia to remove the eggs from the follicles and fertilize them in the lab, where the embryos will be grown until the best one(s) can be identified and transferred back into the woman’s uterus. Any high quality embryos that are not transferred can be frozen for future use.
Because Natural Cycle IVF does not use medications to stimulate the ovaries, the cycle can only produce one mature egg at a time. Patients are monitored with ultrasound and bloodwork to track the development of the single egg follicle so that it is not released by the body before it can be retrieved, an event called premature ovulation.
The patient then undergoes the same type of egg retrieval that is done in a standard IVF cycle to retrieve the egg from the single follicle. If the egg retrieval is successful, an attempt is made to fertilize the egg in the laboratory. If a viable embryo develops, it is transferred back to the uterus.
“Natural Cycle IVF and a stimulated cycle of IVF look very similar in terms of the timeline and the procedures followed,” says Dr. Greenhouse. “The difference is just that the patient does not do medication injections for the Natural Cycle.”
Comparing Success Rates
“I always tell my patients that when they are evaluating treatment options, they need to look at success rates,” says Dr. Greenhouse, “and make sure they are comparing apples to apples because statistics can be presented in misleading ways. They need to ask what their pregnancy rate and live birth rate are ‘per initiated cycle’. That way, they have a sense that, if I start this treatment today, these are my chances.”
Pregnancy and live birth rates for stimulated IVF cycles are dramatically higher than those for Natural Cycle IVF. At Shady Grove Fertility, patients under the age of 37 who transfer a single high quality blastocyst have a pregnancy rate of almost 60%. One important element to that success rate is the retrieval of multiple mature eggs.
The reason standard IVF cycles use ovarian stimulation to grow a number of follicles is that not all follicles contain a mature egg. Once in the lab, not all mature eggs will fertilize, even under ideal conditions. Finally, once embryos are created, some of them will stop developing before they are mature enough to transfer into the uterus. So, the chances of a patient having success with treatment are dramatically improved when numerous mature eggs are retrieved.
“The main reason success rates for Natural Cycle IVF are so low is that without the use of medications, there is a much higher chance of a cycle being cancelled at each stage,” explains Dr. Greenhouse. For example, in approximately 25% of natural cycles, no egg is retrieved at the time of the egg retrieval. An additional 25% of cycles result in no fertilization, and therefore, no embryo. In fact, only half of patients that start a natural cycle will have an embryo to transfer back to the uterus.
The resultant pregnancy rate per initiated cycle is only 10%. “This rate of pregnancy is about the same as we achieve with Intrauterine Insemination (IUI),” says Dr. Greenhouse. “IUI is much less costly and doesn’t require a surgical procedure.”
“On top of that,” he adds, “unfortunately, 10-25% of the patients who do get pregnant will miscarry, so the live birth rate for Natural Cycle IVF is even lower.”
In addition, patients doing Natural Cycle IVF are limited to the chances of success provided by their one embryo whereas patients doing a stimulated IVF cycle have the possibility of having frozen embryos saved at the end of the cycle. Frozen embryo transfer cycles, called FETs, have the same pregnancy success rates as fresh cycles of stimulated IVF without the ovarian stimulation or egg retrieval, at a third of the cost of a new cycle. These embryos essentially provide a second or even third chance at pregnancy derived from a single stimulated cycle of IVF.
One of the claims of providers of Natural Cycle IVF is that it is less stressful because it doesn’t require medication injections. “It may be true that not having to handle the medications takes some stress out of the process,” says Dr. Greenhouse, “but you still have to do all of the morning monitoring appointments that a patient doing injections does. And, you have to go through the egg retrieval surgery, which a lot of patients find to be the most daunting part of the cycle.”
He adds, “I personally think the stress level with natural cycle might be higher because the chances of the cycle being cancelled are higher. You have to worry about premature ovulation or the possibility of no egg being retrieved.”
It is undeniable that fertility treatment is time-consuming and intensive. Shady Grove Fertility believes that the best way to make treatment less stressful is to provide individualized care in an ethical and supportive environment. Besides being given clear and honest information by our physicians, each patient has a dedicated nurse that is always available to answer questions and provide resources. We provide an injections class that teaches patients about medications and reduces anxiety about administering them. Our Facebook community is active in supporting one another, and our Psychological Support Services staff provides support groups, discussion groups, one-on-one and couples counseling.
Natural Cycle IVF costs less than a standard IVF cycle because it uses fewer medications. However, medications are not the biggest expense associated with an IVF cycle. “The biggest costs in an IVF cycle are the monitoring, egg retrieval and laboratory costs,” says Dr. Greenhouse. “Maintaining a top-notch embryology lab with the latest equipment and highly trained staff is costly, but it’s critical to the success of IVF. Whether or not your IVF cycle is stimulated, you’ll still be relying heavily on the work of the embryology lab.”
He adds, “If you’re looking at value rather than the cost of a single cycle, the choice is very clear. For the money you spend doing a standard IVF cycle, your chances of pregnancy and live birth are far greater than with a natural cycle. In fact, your chances are better with one standard cycle than they are with two or even three cycles of Natural Cycle IVF. Add to that the possibility of having frozen embryos available at the end of a stimulated cycle of IVF and its value becomes even greater.”
Frozen embryos not only provide you with another chance for pregnancy if the first cycle doesn’t work, they provide you with the possibility of having additional children years later from the same cycle. “If you are 37 or older, age should factor heavily into your decision,” says Dr. Greenhouse, “because frozen embryos are a way of stopping the aging process that can be so detrimental to fertility.”
At Shady Grove Fertility, we’re aware that the cost of treatment can be a significant burden for the many patients without insurance coverage. That’s why we offer a number of financial programs that help patients afford treatment. In 2011 alone, over 2,000 patients used a Shady Grove Fertility financial program.
The most popular program is our Shared Risk 100% Refund program. This program provides up to 6 IVF cycles and all the related Frozen Embryo Transfer cycles for one flat fee. If patients do not take a baby home from the hospital, 100% of their money is refunded (some exclusions apply).
Other programs include Shared Help, which provides discounted treatment based on a couple’s income level, Multi-Cycle Discount, which provides discounted fees for pre-payment of multiple cycles and Fertility Finance, which can help patients find loans for treatment.
Fertility medications are also an expensive part of treatment, but many patients who don’t have coverage for fertility treatment do have coverage for some or all of their medications. “If affording the medications is an issue, patients should let us know,” says Dr. Greenhouse. “because we have a lot of resources we can share with you. We usually know which pharmacies have specials and which drugs are cheaper. Sometimes the drug companies themselves will have a special or provide coupons for certain medications.”
In addition, patients at Shady Grove Fertility have a dedicated financial counselor who can help them get the most out of their insurance coverage and find the best path for affording treatment and medications.
Undergoing ovarian stimulation with medications does carry one risk that is not experienced by patients doing Natural Cycle IVF. It is called ovarian hyperstimulation. Ovarian hyperstimulation happens when a woman’s body over-responds to the medications. This can cause fluid to build up in the abdomen and pelvis. In rare but severe cases, the condition can lead to more serious issues like blood clots. Mild cases of ovarian hyperstimulation resolve on their own. In more serious cases, the excess fluid will be removed by a physician.
“At Shady Grove Fertility, we only see severe ovarian hyperstimulation in about 1% of cases,” says Dr. Greenhouse. “It is very rare. The reason is that patients are monitored very closely throughout their ovarian stimulation. If there are any signs that a patient might be moving toward hyperstimulation, we can reduce the amount of medications she is taking to minimize it.” Additionally, Shady Grove Fertility has protocols specifically designed to help reduce the risk of ovarian hyperstimulation.
“Some patients may feel uncomfortable about the medications, but I can reassure them that numerous studies have shown that they are safe and effective,” says Dr. Greenhouse.
Proponents of Natural Cycle IVF also tout that their patients avoid the risk of multiples – twins and triplets – because only one embryo can be transferred into the uterus per cycle. While there is a chance that a single embryo could split into two on its own, transferring one embryo at a time is the best way to avoid high risk multiple pregnancies.
“We also work very hard to reduce the risk of multiples within our traditional IVF cycles by promoting eSET, which stands for elective Single Embryo Transfer,” says Dr. Greenhouse. In fact, Shady Grove Fertility has been a leader in the field in this area; patients using eSET and only transferring one embryo have a 1.7% chance of multiples and a 0% chance of triplets.
The Best Chance for a Child
Treatment decisions can be difficult when there are several options to consider. Patients need to weigh the factors that are most important to them and address their concerns with their medical care team. Dr. Greenhouse believes that when he discusses all the pros and cons of Natural Cycle IVF versus traditional IVF with his patients, the choice becomes clear.
“I urge my patients to look at the whole picture,” he says. “Their goal is to have a child. If they are going to do IVF, then a stimulated cycle of IVF is, without a doubt, the most effective and efficient treatment available. It gives couples the best chance of reaching their goal in the shortest amount of time.”
For more information or to schedule an appointment with one of our physicians, please speak with one of our friendly New Patient Liaisons by calling 888-761-1967.
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