New Form of In Vitro Fertilization
According to a recent article on STL Today, a new form of in vitro fertilization is causing quite the uproar. Under names such as low-intensity IVF, eco-IVF and even patient-friendly IVF — a technique of in vitro fertilization is increasing in use with promises to be safer, cheaper and easier on patients trying to have a baby.
The technique involves mildly stimulating a woman’s ovaries with less drugs to produce far fewer eggs than routine IVF. After the eggs are fertilized in a laboratory, the resulting embryos are usually frozen and implanted in the uterus a few months later during a woman’s natural menstrual cycle.
It may seem mathematically impossible, but St. Louis area doctor Dr. Sherman Silber says if done right, mild stimulation results in pregnancy rates equal to those with routine IVF. In older women, Silber finds dramatically better rates because the process is easier on their more brittle eggs.
“We get better quality eggs, and almost every single one of these eggs forms into a beautiful embryo,” said Silber, one of the U.S. pioneers of the technique, which he calls mini-IVF. He is one of the few in the country routinely offering mini-IVF at his office, the Infertility Center of St. Louis at St. Luke’s Hospital.
Silber says a high-quality lab and foolproof freezing process are behind his success. His findings were published a year ago in the Reproductive BioMedicine Online journal, adding to mounting questions surrounding the current aggressive method of giving women high doses of costly drugs to produce more than a dozen eggs at a time.
With routine IVF, women can experience intense moods swings and painful, swollen ovaries; or as Silber puts it, “like they swallowed a couple grapefruits whole.” The process requires numerous doctor visits, painful needle sticks and ultrasounds. Risks include hyperstimulation, a life-threatening condition that can cause rapid weight gain, vomiting and shortness of breath.
DOCTORS QUESTION MINI-IVF
Some fertility doctors, however, question Silber’s and others’ claims of success, especially when a mini-IVF cycle produces only two or three eggs for fertilization as opposed to 14 or 15. When trying to get pregnant, more is always better, they say. A large number of eggs increases the chances that some will develop into healthy embryos.
“I would rather get as many eggs as I could and get as many quality embryos as I could and transfer them fresh and freeze ones leftover,” said Dr. Randall Odem, chief of the reproductive endocrinology division at Washington University School of Medicine.
Odem and others question the claims of cost saving as well. While mini-IVF can save more than $5,000 in medications per stimulation cycle, women often require two or three cycles to get enough good embryos (two to four in older women) to transfer to the uterus with hopes that at least one will produce a baby.
“My experience is stained by the fact that myself and other doctors in our group see numerous patients who have been through this process and spent enormous amounts of money and have nothing to show for it,” Odem said. In many states, including Missouri, in vitro fertilization is not covered by insurance.
Dr. Norbert Gleicher, of Yale University’s Department of Obstetrics and medical director of the Center for Human Reproduction in New York, wrote a recent commentary “Low-intensity IVF: real progress?” that questioned Silber’s research methods and the rapid rise in popularity of minimal stimulation.
The technique should only be offered as an experimental procedure, he argues. “I’m not against the idea, but what I am against is when patients are deprived of expected pregnancy chances without them knowing about it.”
Little data show success with mini-IVF, Gleicher said. His own small study of minimal stimulation — which he acknowledged used a different technique than Silber and involved only women under the age of 38 — showed poor pregnancy results.
Minimal stimulation “is not very widespread but, unfortunately, it is increasing,” he said. “Our writing and our little pilot study will hopefully put a halt to it, at least the present way of doing it.”
Silber, however, argues the technique is not experimental. Silber published his research with Dr. John Zang, the director of New Hope Fertility Center in New York, who between them have done over 4,000 mini-IVF cycles since 2004. Doctors in Japan, where Silber learned the technique, have adopted it far more widely.
A leading IVF researcher, Dr. Suheil Muasher of the Muasher Center for Fertility and IVF in Fairfax, Va., has also called for more fertility clinics to offer minimal stimulation after finding similar pregnancy success rates with his patients. “The aggressive approach is no longer essential and has significant drawbacks in terms of cost, stress and increased complications for some patients,” Muasher wrote in a journal article published in August.
With improvements in freezing and identifying quality embryos, fertility experts have begun to question the need for high doses of costly hormones to produce eggs for in vitro fertilization, which is performed about 35,000 times each year in the U.S. and is the most common form of assisted reproduction.
BRITISH SCIENTIST LAUDS METHOD
Among the experts is the British scientist who started it all, Robert Edwards, who along with a surgeon produced the first baby born by in vitro fertilization in 1978. He wrote in 2007 that “considerable changes are afoot in the process of assisted human conception” and minimal stimulation “may well replace routine IVF.”
In 2007, the International Society for Mild Approaches in Assisted Reproduction was created to promote less expensive methods with lower risks.
Silber is known as a pioneer. He completed the first vasectomy reversal as well as the first ovary transplant. “They called me a cowboy,” he said. “When you come up with something new and innovative, you always have critics.”
Silber said he first learned of mini-IVF in 2002 while working with Japanese fertility doctors on a separate project. The foreign doctors used the decades-old cheap drug, Clomid, to stimulate the production of a few eggs. With Clomid, however, the lining of the uterus is too thin for the transfer of fresh embryos. They had to be frozen.
Freezing embryos involves very slowly dropping the temperature to prevent damage from crystallization, but many are still lost. The Japanese, instead, perfected a flash-freezing technique called vitrification. Using four times the concentration of antifreeze and an extremely cold temperature, vitrification instantly turns the embryos into a glass-like state — a process Silber calls flawless if done correctly. No embryos are damaged, he said.
“I was amazed. I thought the pregnancy rate with frozen must be half that of fresh,” he said. “I couldn’t believe they were doing this. And with Clomid? It was so different than anything in the West.”
Silber made a few adjustments in drug dosages for American women and said he was among the first American doctors to begin offering minimal stimulation six years ago. He now uses mini-IVF for all patients over the age of 38 and in about half of his younger patients. He always uses vitrification to freeze embryos.
Whether his younger patients choose mini-IVF depends on the cause of their infertility, how many children they want, their financial situation and ethical concerns, he said. Some patients do not want to face decisions over what to do with leftover frozen embryos.
Silber said he uses mini-IVF with all his older patients — many of whom would be turned away from other fertility clinics — because he sees a pregnancy rate nearly five times higher for this age group. In patients over the age of 42, he boasts a pregnancy rate of 50 percent.
But it does require two or three mini-IVF cycles, which can be done a month apart, to store up enough vitrified embryos to warrant thawing and transfer. And more waiting for the uterus to be ready.
It was worth the wait for Silber’s patient Suzanne Gastineau, 46, of O’Fallon, Mo. She had trouble conceiving when she decided she wanted a second child. At the age of 43, she went through two cycles of mini-IVF and got three eggs. Only one good embryo developed. In August 2009, her second son, Alexander, was born. “It was a miracle,” she said.
Belleville residents Linda Christian, 39, and her husband, Fred Christian, 65, had twins two years ago thanks to mini-IVF, which Linda Christian called “nearly painless.” After two cycles, she got six eggs which developed into three embryos that were transferred together.
“You are going on trust to some extent,” Christian said. “The temptation is to say, ‘Lets just stick with traditional IVF,’ but we trusted him.”