Question 59. What is natural cycle IVF? And why does my fertility clinic not offer this treatment?

As readers of this blog are well aware, we have a particular interest in Natural Cycle (unstimulated IVF). All I can say is that the past 4 years have been filled with outcomes that I would never have believed if these were not my own patients. Although it is not surprising that young healthy women with tubal factor infertility can conceive with Natural Cycle IVF, it is the patients that we thought were clearly long-shots that stick in your memory.

Once recent patient was B.W. (not her initials) who was a 41 year old whose husband had a vasectomy reversal 3 years earlier but had failed to conceive. Her evaluation revealed an FSH of 23 and an AMH that was < 0.16 (essentially zero!). We discussed donor egg and donor embryo and adoption. She was really not interested at this time in pursuing those options even though the success rates were clearly markedly superior to those with her own eggs.

So we elected to attempt NC IVF and during the treatment cycle her day 3 FSH came back at 40! I wasn't even sure if she would have normal follicle development but she did and we were able to get a mature egg. It fertilized with ICSI. It grew into a perfect looking blastocyst. She had an easy ET and her first beta was very positive. She currently has a normal ongoing pregnancy. I actually just called her this morning and she had her 20 week anatomy scan and all looks well!

If you made up cases like this, then no one would even believe it because it seems to fly in the face of conventional wisdom. So here is a bit of conventional wisdom from 100 Questions and Answers about Infertility, 2nd Edition...

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

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, using NC IVF in 1978.

NC-IVF avoids the use of expensive ovarian stimulation drugs and their associated cost of 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 cost of Natural Cycle IVF is about 20% to 25% of the total cost of a conventional IVF cycle.

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 10% to 15% of treatment cycles. In such cases, if the fallopian tubes are open, the doctor may recommend converting the treatment to an intrauterine insemination (IUI) and possible a successful pregnacy. Furthermore, because only one egg and one embryo are produced, the chances for pregnancy are less than with conventional IVF when two or more embryos are transferred. 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 three 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 normal ovarian reserve. Patients with tubal-factor infertility or male factor infertility may be good candidates for NC-IVF before resorting to conventional IVF. Older patients, patients with previous stimulated cycle IVF failures, patients with poor ovarian reserve or unexplained infertility all can be considered for NC-IVF but may experience lower pregnancy rates compared with younger patients with well defined fertility issues and no previous fertility treatments.

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 demand less stressful and less costly fertility treatments that utilize little to no fertility drugs with good pregnancy rates. In our clinic we have routinely demonstrated pregnancy rates of 25% per successful egg collection and 30-40% pregnancy rate per embryo transfer with NC-IVF. We have seen success in patients who had previously failed stimulated IVF and were told that donor egg IVF was their only option so NC IVF may represent a viable treatment option for many infertile couples even those with a poor prognosis with stimulated cycle IVF.