Our Mini-IVF Results in Women with Decreasing Ovarian Reserve
Our pregnancy rates with Mini-stim IVF are not included in the SART/CDC data reporting for IVF programs. This is because Mini-stim IVF (or Mini-IVF) is not recognized as a different procedure than conventional IVF and is done by relatively few programs in the United States. However, mixing this data decreases the value of it for understanding how either IVF or Mini-stim IVF is done in this program.
Infertility Solutions’ Pregnancy Results using Mini-stim IVF for 2010-2013
We use minimal stimulation IVF techniques in different ways for different patients in different situations. As with conventional IVF, success rates very much depend on age and ovarian reserve. “Older” patients with decreased ovarian reserve are our strongest candidates for Mini-stim IVF since our results are similar to what can be achieved with conventional IVF, but the process is easier for the patient and much less expensive. A self-pay patient can undergo 3 to 4 cycles of Mini-stim IVF for the cost of one cycle of conventional IVF. This makes the cost of each child conceived much lower with Mini-stim IVF than with conventional IVF.
Fertility begins to more rapidly be lost after age 35. By age 38, most women enter a period of subfertility that lasts for about four years. IVF techniques are very useful here. After age 43, it is difficult to achieve pregnancy by any means. Not everyone is the same. If a woman has better ovarian reserve than expected for her age (appears more fertile on ultrasound), we will usually recommend conventional IVF rather than Mini-IVF as her best approach to getting pregnant and having a baby. Cost considerations and the ability to undertake more cycles may be a reason for her choosing Mini-stim IVF over conventional IVF in spite of our recommendations.
With decreasing ovarian reserve and advancing age, there is an increase in miscarriages. The medical literature suggests that miscarriages of recognized pregnancies in women above 40 occur 25% of the time. Aspects of IVF process may decrease this loss rate somewhat, but it still remains high.
What follows is a detailed summary of our results with Mini-IVF for women above age 37 to help individuals decide if this therapy is right for them. (Our Mini-stim IVF results for other age groups are discussed elsewhere.) To provide a basis for comparison with conventional IVF, a recent compilation of all (mainly conventional) IVF cycles done in the United States provides averages for conventional IVF in terms of babies delivered per embryo transfer. For women aged 38-40, the delivery rate per transfer was 27.1%. For women aged 41 or 42, the delivery rate per transfer was 16%. For women 43 and above, the delivery rate was 8.4% per transfer.
A recent trend is some programs which offer minimal stimulation procedures is to undertake several stimulations and retrievals and freeze all the embryos. A larger number of embryos are then defrosted before the best ones are transferred. Three embryos produced from 2 or 3 minimal stimulation cycles are more likely to be of better quality than three embryos produced from one high dose cycle. Thus an embryos transfer is likely to be more effective and costs are still comparable (or lower with Mini-stim). Currently our approach is transfer the best embryos in each cycle. This has a lower pregnancy rate per transfer, but is less complex and less costly for the patient.
With IVF in this “subfertile” age group, there are many biochemical pregnancies (positive pregnancy tests without ultrasound evidence of pregnancy). A clinical pregnancy is a pregnancy in which there was ultrasound evidence of the pregnancy developing in the uterus or an ectopic pregnancy. With decreased ovarian reserve as seen with advancing age, the likelihood of having a biochemical or clinical pregnancy that doesn’t develop further is more common largely because the pregnancies have an increased likelihood of being genetically abnormal. The vast majority of abnormal pregnancies miscarry rather than become babies.
A major concern about “simplified” IVF cycles has been the cancellation rate. With natural cycle IVF, this has been reported to be as high as 50%. With oral medications like clomiphene or letrozole, we decrease this greatly. A cycle cancelled before the aspiration involves little cost as it is essentially a routine IUI cycle. A cycle cancelled after the aspiration incurs more costs (laboratory) and invasiveness (egg retrieval).
Women aged 40, 41, and 42 for 2010-2013
Most women in this age group have laboratory or ultrasound evidence of at least some decreased fertility and they are the focus group for our Mini-stim IVF approach. During this time period, there were 13 patients having 20 embryo transfers. Some patients had up to three cycles.
Delivered pregnancy rate per transfer- 4/21 = 19%
Clinical pregnancy rate per transfer- 5/21 = 23.8%
Women aged 38 or 39 for 2010-2013
Delivered pregnancy rate per transfer- 3/15 = 20%
Clinical pregnancy rate per transfer- 3/15 = 20%
(There were no miscarriages.)
Women aged 38, 39, 40, 41, and 42 for 2010-2013
Delivered pregnancy rate per transfer- 7/36 = 19.4%
Clinical pregnancy rate per transfer- 8/36 = 22.2%
Comments. A good number of the patients who we treated had very low or undetectable AMH levels and single digit numbers of antral follicles in their ovaries. We recommend that all patients undertake four cycle to have the best chance of pregnancy. but the average number of cycles to date was 1.6. The maximum number of cycles that anyone attempted was three (with two patients getting pregnant on the third cycle).
We also provide treatment for patients with very poor prognosis based on age as long as they understand their prognosis. Their potential for pregnancy is low, but is still related to their ovarian reserve. We summarize our experience with these patients below.
How does this compare to conventional IVF?
SART and the CDC track pregnancy rates for conventional IVF nationally and the results are published on-line. Data are presented slightly differently from our approach, but the breakdowns are close enough that a comparison is meaningful.
The National data concluded that the delivery rate with conventional IVF who are aged 38, 39 or 40, was 27.1% per transfer and 20.9% per case (that is before cancellations). The delivery rate for women aged 41 and 42 was 16% per transfer and 11.5% per case. If we look at the ratios of our results for Mini-stim to those of conventional IVF for these two age groups, for women aged 38 and 39, the ratio per transfer is 92.3% and per case is 102.4%. For women aged 40, 41, and 42, the ratio is 93.4% per transfer and 118.3% per case. Our cycle cancellation rates are similar to what has been reported nationally for conventional IVF.
In summary, the pregnancy rate with Mini-stim IVF is the same as the pregnancy rate for conventional IVF for these age groups. However, for these age groups, the total self-pay cost of Mini-stim IVF was one-fourth to one third of the total self-pay cost of conventional IVF. Mini-stim IVF was also much more patient friendly than conventional IVF. It required less than half of the office visits and exams necessary for conventional IVF. Fewer than half as many lab tests were required and only a small fraction of the number of injections. Probably most significant was that hormone levels produced by the ovaries were much lower than with conventional IVF. (They often stayed in the normal range). This greatly decreased side effects of the fertility medications.