When a stimulated cycle IVF fails it is devastating to say the least....all that money, all those shots, all those morning visits, the bloating, the cramping, the PIO shots....yikes, it's a wonder we can convince anyone to try it again. Thank goodness the husbands don't have to go through all that or our business would fold overnight!
So following a failed stimulated IVF it is typical to ask what other options do I have. In cases of poor responders who may have not even made it to retrieval the answer has been "not much." Some of these patients will still conceive on their own, others will try a new protocol (or add DHEAs or human growth hormone or snake oil or miracle grow..). Donor egg or adoption are great options but not every couple will consider these as viable choices. So can NC IVF work in such a setting? "Certainly not," the critics of NC IVF would opine! After all, this approach to IVF is a terrible choice for any patient and how could this approach work in cases where our best treatment has already failed.
Sound logic. However, it just happens to be disproven on a near weekly basis by our patients who pursue NC IVF. Last year I asked what readers wanted from this blog and the majority stated they wanted patient stories so here are 2 vignettes that illustrate the use of NC IVF in patients over 35 with diminished ovarian reserve and failed stimulated cycle IVF!
Patient #1: Bonus baby with NC IVF after being told FSH levels precluded another IVF attempt!Just received a wonderful email from a lovely couple who traveled all the way from Georgia to do NC IVF here at Dominion. Having had a previous IVF/ICSI baby in 2006 they had returned to their RE for another attempt at IVF. Previously the response to medications had been poor and this time the response was even worse with no retrieval even attempted. Her FSH was 18.9 and they were told that essentially no good options existed in terms of IVF. Fortunately, they had heard about NC IVF and we had a phone consult in April with an IVF attempt in June. Her AMH was <0.16 consistent with diminished ovarian reserve.
Her NC IVF cycle was picture perfect and they ended up with a beautiful early blast for transfer then headed back home. I received the good news that the blood pregnancy test was positive and rising fast. Then came the first shock...it was a twin pregnancy. Yup identical twins. Then came the second shock...the twins were sharing the same sac (in medical terminology they were mono-amniotic, mono-chorionic twins). Then the final shock...there was possibly a third sac.....Fortunately, this last shock turned was not true...there was just a probable blood clot that ultimately went away.
Pregnancy went amazingly well and the girls were delivered at 32 and a half weeks. They spent 2 days in the Intensive Care Nursery and should be home soon. What a great outcome to such a surprising story...one egg, one embryo, TWO healthy babies!
Patient #2: Ongoing pregnancy with NC IVF at 40 with FSH of 17 and AMH of <0.1Back in 2009 I met DM who was turning 38 and been referred to me by one of my patients who had succeeded with NC IVF after being told donor egg was her only option. We discussed NC IVF versus stimulated IVF and elected to try stimulated IVF. On a MDL flare protocol we got 3 follicles but only one egg and she failed to conceive with transfer of that embryo. I suggested we consider NC IVF rather than pursue additional medicated cycles.
Her first NC IVF cycle resulted in a pregnancy but unfortunately she had a miscarriage. The second NC IVF cycle resulted in a healthy full term baby. She returned this Fall to try again. On day 3 of that third NC IVF attempt her FSH was 17. But we got a nice egg, a beautiful embryo and she conceived again. That makes her 3 for 3 using NC IVF. Currently she had an ongoing pregnancy and here's hoping for another successful outcome.
Again this demonstrates the limitation of ovarian reserve testing when applied to NC IVF. When one eliminates the use of fertility drugs all bets are off when it comes to ovarian reserve. Makes our job difficult since patients assume that diminished ovarian reserve = poor egg quality and the relationship just isn't that simple!
Frequently I am asked about IUI compared to IVF and specifically about NC IVF compared with IUI. Although IUI can be successful, there are clear limitations to an IUI. First of all, unless pregnancy occurs an IUI does little to explain why a couple has failed to conceive.
Could the tube have failed to catch an egg(s)?
Could the sperm have failed to find an egg(s)?
Could the sperm have failed to fertilize an egg(s)?
Could the fertilized egg(s) have failed to grow?
Could the embryo(s) have failed to make it to the uterus and failed to implant?
The answer to all of these questions following a failed IUI is "we don't know."
This is the reason that IVF is a powerful diagnostic as well as therapeutic tool. It is so difficult to counsel a patient undergoing a stimulated IUI cycle with multiple dominant follicles. On the one hand you have to say "well, there are 6 good follicles so we could end up with 0-6 babies..." Then when it fails (which is more often than it succeeds) you have to say "well, we really have no idea why it didn't work." Very frustrating indeed.
The FASTT Trial aimed to look at the impact of omitting FSH/IUI for patients with unexplained infertility who were <40 years old. Its results clearly demonstrated the superiority of IVF first compared with FSH/IUI then IVF if FSH/IUI were unsuccessful. I think that NC IVF is also superior to IUI. Perhaps the comparable option would be CC/IUI but I think that NC IVF is likely superior to even FSH/IUI in cases where a couple has no previous pregnancies or there is possible male factor or possible tubal factor or endometriosis. Since many patients do not have a laparoscopy these days, it could be that many of them have an element of tubal disease or endometriosis and clearly IVF would be superior in these patients.
So for those wanting to conceive FAST.....think about the results of the FASTT trial and give strong consideration to IVF. It is not the only option but it may be the best option...whether it is NC IVF or stimulated cycle IVF.
Good luck.
DrG
A randomized clinical trial to evaluate optimal treatment for unexplained infertility: the fast track and standard treatment (FASTT) trial.
Fertil Steril. 2010 Aug;94(3):888-99. Reindollar et al.
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