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.