Egg Freezing

Clearly one of the biggest issues facing our patients is advancing age. We cannot turn back the biologic clock and it is not fair that Strom Thurman can become a father at age 84 and for women after age 35 fertility really starts to drop. If only we had a way to determine the number of health eggs remaining in a woman, then we could give accurate assessments of the chances for success. Unfortunately, there is no test for egg quality that is definitive.

So now that egg freezing seems to be working a bit better the use of this technology to preserve fertility has been debated. A few general issues need to be understood. First of all, although almost 5 MILLION babies have been born after traditional IVF, there have been perhaps around 500 babies born from frozen eggs. The problem is multi-factorial. Many eggs fail to freeze or thaw successfully and those that do need ICSI to endure fertilization. With the increasing adoption of vitrification (rapid freezing that instantly occurs) success rates are on the rise.

However, should this still be considered experimental?? Probably. Should patients have to pay for an experimental procedure? I guess...although this seems inappropriate to me personally (but since we don't offer fertility preservation from egg freezing -- yet, I guess my view is biased).

So this remains controversial. Here is a PDF file of the most recent position statement by the ASRM about egg freezing. It is comprehensive and pretty informative...I think.

Of course, if you want to debate egg freezing with us in person, be sure to drop by the Clarendon Barnes and Noble bookstore on Saturday January 26th from 12 noon until 2 PM. You don't even need to buy a book...

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Birth Control Pills and IVF Protocols

Many of the questions that I answer on the INCIID (www.INCIID.org) bulletin board revolve around medication protocols especially the use of oral contraceptives. Personally, I have had poor results with the use of oral contraceptives except in known high responding patients. I know that many clinics use pills in protocols without any problems but my own experience has not been very positive.

So here is today’s “Question of the Day” from the book that really needs some more reviews on Amazon.com…100 Questions and Answers About Infertility. As the snow starts to fall here in Washington paralyzing the government, I want to invite all local readers of this blog (and their friends and family) to the Barnes and Noble Bookstore in Clarendon, VA for a book signing of this book on Saturday January 26th from Noon until 2 PM.



64. My reproductive endocrinologist has recommended a protocol that uses birth control pills. Why would birth control pills be used in IVF?
Birth control pills or, more correctly, oral contraceptive pills (OCPs) can be used as a part of the IVF stimulation protocol in several different settings. First, in patients who are known or suspected to be high responders, OCPs may help mitigate the risk of ovarian hyperstimulation syndrome (OHSS; see Question 67).

Second, in patients without predictable regular menstrual cycles, OCPs can be used in combination with Lupron to initiate an IVF cycle. In our practice, we usually start OCPs in such cases after confirming with a blood test that the woman has not recently ovulated. Then, after 1 week, we add Lupron. After 1 more week, we stop the Lupron and wait for withdrawal bleeding. Once a patient has bled, we begin the gonadotropin stimulation.

Third, some clinics use OCPs for microdose Lupron (MDL) flare, traditional flare, or patients who are taking Antagon in the hope that pretreatment with OCPs will prevent one follicle from growing faster than the other follicles once the stimulation has begun. We have not routinely use OCPs with our MDL flare patients, as we have rarely had problems with the emergence of a single dominant follicle compared with the more common problem of oversuppression and a cancelled cycle. Given that prolonged OCP use can lead to oversuppression in low responders, we use these medications very carefully.

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The Politics of Natural Cycle IVF

Yesterday we discussed two major issues facing patients and their doctors: How do we completely avoid the temptation to transfer more than one embryo and also avoid the risk of OHSS completely? One answer was to use Natural Cycle IVF.

Why then would all clinics not offer Natural Cycle IVF? The procedure is already proven and familiar. We all do egg collections. We can use ICSI to ensure fertilization occurs if there is any concern. We all culture embryos. So where’s the problem?

Here’s the situation as I see it. According to the Wyden Law every fertility clinic in the US must submit its statistics to the CDC so that they can be made available to the general public. The CDC emphatically states that consumers should not use these tables to compare clinics because practice patterns can vary between clinics and physicians…yadda, yadda.

Of course, the reality is that most patients use these statistics to directly compare clinics eventhough the old adage of “there are lies, damn lies and statistics” always holds true. Honestly, if you really want to compare clinics and eliminate the influence of patient selection then look at their donor egg IVF pregnancy rates (ours is 127%) since donor egg IVF would represent a “level playing field.”

So back to Natural Cycle IVF….we believe that the best candidates for Natural Cycle IVF are patients <35 years old with a well defined fertility problem (tubal blockage, male factor, endometriosis). In these patients Natural Cycle IVF can be successful with very good pregnancy rates (although the per cycle pregnancy rates will be about 1/3 of the stimulated cycle pregnancy rates). But guess what? This patient population also represents the best candidates for stimulated cycle IVF.

Now every year I am asked to submit my statistics for my IVF program to the CDC. On each patient’s data entry form the CDC asks if this is a stimulated or unstimulated (Natural Cycle) IVF cycle. Then they ignore this piece of information and lump all the IVF cycles together to yield the tables that patients then look at when choosing clinics.

So if I am an RE trying to make a practice decision concerning Natural Cycle IVF, then I need to think carefully about the implications of this decision. I can offer Natural Cycle IVF, which is less expensive and more patient friendly, BUT as a result I will siphon off some of my best stimulated cycle IVF prospective patients into a program that will also yield lower per cycle pregnancy rates. The end result is that I will be shooting myself in the foot in terms of my CDC IVF stats that patients love to use to compare clinics….Hmmm let me give that a great deal of thought. Guess what most clinics in the US decide…

However, I do have a solution that would determine if my assessment is correct. What I have suggested to the CDC is the following: since they already ask us to delineate between stimulated and unstimulated IVF cycles, why not publish the stimulated cycle IVF pregnancy rates and unstimulated IVF pregnancy rates as separate sets of tables? 

Currently only a few clinics offer unstimulated IVF. I predict that number would rise dramatically if the disincentive to offer Natural Cycle IVF was removed. I may be wrong on this point but I don’t think that I am…

So if you are interested in encouraging the CDC to change their approach just let me know and I will tell you who to send a letter to….hey, if we could save Star Trek in 1966, certainly we can get Natural Cycle IVF into the mainstream.

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Natural Cycle IVF, OHSS and Multiples

Happy New Year to all those wonderful people out in cyberspace who read this blog. Mom, check your mail for the family calendar that I sent you and tell Dad to stop shoveling the snow himself unless he wants to keel over from a heart attack this winter.

January is the time for New Year’s Resolutions and one of mine is to resume this blog with the regularity that I was able to maintain prior to Tatiana’s sudden death (see last post). Part of healing is moving forward without losing your connection to the past and it is in this spirit that I am taking up pen and paper to continue the work set before me of correcting all of the misinformation provided to patients by all of those REs that do not agree with my opinions (just kidding…sort of..).

So for the coming year from a clinical perspective I would love to see no twins and no cases of ovarian hyperstimulation syndrome (OHSS). These are laudable goals. As readers of this blog are aware I am not favorable inclined towards twins. Yes they make cute Christmas cards and occasionally can generate income for families by appearing on TV and in print advertising but you can’t count on that revenue stream. The problem with twins rests in the risk of prematurity. Some twins will deliver in the midtrimester and die. Some twins will deliver early and survive with significant medical problems and some twins will go full-term and end up on Christmas cards the week after delivery. We never know which outcome a patient will have….

However, unless we limit patients to transfer of a single embryo, the chance for non-identical (fraternal) twins is always present. Interestingly, a study showed that even when patients were informed of the risk of transfer of 2 vs. 1 embryo, they chose ET of 2 if putting back a single embryo dropped the overall success rate by as little as 5%.

OHSS is also a tough problem. Although the ideal number of eggs to me is 8-12 we sometimes overshoot the runway and end up with too many growing follicles. Options include cycle cancellation or retrieval of eggs and subsequent freezing of embryos without a fresh ET but this is frustrating to patients…eventhough it is often the best choice.

So how do we completely avoid the temptation to transfer more than one embryo and also avoid the risk of OHSS completely? Well there is a way to do that and it is called Natural Cycle IVF. Today’s “Question of the Day” reflects this important issue and here at Dominion the issue of Natural Cycle IVF is close to our hearts as we launched our Natural Cycle IVF program last January.

Tomorrow I want to address why the Natural Cycle IVF Bandwagon has yet to stop in your town…



63. What is natural cycle IVF? And why does my fertility clinic not offer this treatment?


The use of natural-cycle IVF (NC-IVF) has been proposed as a means of reducing the risk of multiple pregnancies, eliminating the costs and risks associated with fertility drugs, and reducing the stress and time commitment needed for traditional stimulated IVF. This approach has been espoused by a number of leaders in the field of IVF, including Dr. Robert Edwards, whose pioneering work along with Dr. Patrick Steptoe’s led to the birth of the world’s first IVF baby, Louise Brown, in 1978.

NC-IVF avoids the use of ovarian stimulation drugs, which cost about $4000 per treatment cycle. With NC-IVF the risks of ovarian hyperstimulation, multiple pregnancy, and the issues of cryopreserved extra embryos are avoided as only one embryo is produced. Total costs are about 20% to 25% of the total cost of conventional IVF.

However, NC-IVF has its own set of disadvantages. For example, by not using fertility drugs, unexpected premature “LH surging” or ovulation can occur, leading to cancellation of the planned egg retrieval. This occurs in about 20% to 30% of treatment cycles. In such cases, if the fallopian tubes are open, the doctor may recommend converting the treatment to an intrauterine insemination (IUI) to try to produce a pregnancy. Furthermore, because only one egg and one embryo are produced, the chances for pregnancy are less than with conventional IVF where two or more embryos are typically replaced.

Proponents of NC-IVF expect the “cumulative” pregnancy rate for NC-IVF to be similar to a single cycle of conventional IVF within one to four treatment cycles of NC-IVF. The best candidates for NC-IVF are patients with regular menstrual cycles who are less than 36 years old and have a normal day three FSH level. Patients with tubal-factor infertility or male factor infertility may be good candidates for NC-IVF before resorting to conventional IVF. Patients with poor ovarian reserve or unexplained infertility will probably experience poorer outcomes with NC-IVF compared with those patients with male factor or tubal factor infertility.

Many European fertility centers routinely use NC-IVF with good success rates. For a variety of reasons, the availability of NC-IVF in the United States has been limited. We believe that NC-IVF will soon become increasingly available as patients will demand less stressful and less costly fertility treatments that utilize little to no fertility drugs with good pregnancy rates.

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