ART Stimulation in the Next Decade: An Overview

Minimal Simulation and Natural Cycle In Vitro Fertilization, Allahbadia, G and Nitzschke, M, 2015

ART Stimulation in the Next Decade: An Overview (Castellon, L)

Dr Daiter’s summary of this chapter

The author points out that there are more than 80 million couples suffering from infertility worldwide, and yet, most of these couples have no access to new reproductive technologies primarily due to the cost of treatment in their area.

More recently, there has been an increasing interest in milder approaches to IVF treatment, including minimal stimulation IVF and natural cycle IVF.  These treatments are

  1. less costly,
  2. decrease the physical stress from the medications (less complications),
  3. decrease the psychological distress patients feel, and
  4. increase patient convenience.

The main disadvantage of natural cycle IVF is its low efficiency per cycle, partly related to the high rates of cycle cancellation due to premature LH surge and premature ovulation (detected at the time of egg retrieval).  This problem is reduced for physicians that develop significant skills for early detection of these events.

Embryos of older patients seem to develop more slowly than those of younger patients, and this may lead to a problem synchronizing the embryo’s stage of development with the endometrial development.  Because of this, many centers cryopreserve through vitrification the embryos once they reach blastocyst stage and replace them in a subsequent cycle.  This also allows the patients to “bank” several cycles of embryos prior to transfer and also allows the centers to perform preimplantation genetic screening (PGS) using trophectoderm biopsy from blastocysts and comparative genomic hybridization (CGH) techniques.  The implantation rate of genetically normal blastocysts from older patients is similar to that of younger patients, according to the author.  One report from 2012 suggests that implantation rates for good frozen blastocysts can reach 46% per transfer.

The authors point out that there is a strong tendency in affluent countries to consolidate infertility care within a few big IVF clinics or chains of clinics, where smaller clinics are bought by bigger clinics or groups (this industry’s markets are “heading to an oligopoly”)

Dr. Daiter’s review of this chapter

Dr. Castellon is a member of the Department of Gynecology and Obstetrics “Instituto Mexicano de Infertilidad” in Mexico and he makes some very important points in this chapter of this important book.

There are several advantages associated with natural cycle IVF and mini IVF, including lower cost per cycle, reduced complications, possibly less stress (I am not sure how the “psychological distress” was measured or if this was a personal observation), and increased convenience.  In addition, I think that there are many patients that find conventional IVF to be VERY artificial and they would prefer a more natural form of IVF based on personal, moral or ethical reasons.

The point that older embryos can be tested for chromosomal abnormalities is interesting, in that the author states that the implantation rates of older “genetically normal” (per limitations of the testing parameters) blastocysts reach that of younger patients.  Unfortunately, the genetic testing described is very expensive in the USA, and this offsets one of the main advantages (cost) of natural cycle and mini IVF.

It absolutely does seem to be the case that infertility centers are coupling together into larger and larger aggregate centers and the “writing on the wall” seems to predict that IVF will ultimately be controlled by a few major IVF centers that “standardize” protocols across large groups of patients.  This may have a serious disadvantage for couples that want or need an individualized form of care.

My hope would be that a couple of smaller IVF centers will survive the “new age” of medicine in the USA to continue to provide affordable IVF treatments for couples that require highly individualized care.

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