Our Philosophy Regarding Stimulated and Natural Cycle IVF
Stimulated or Natural Cycle IVF: Is one superior?
Which type of IVF is right for me?
Both forms of IVF are now very effective treatments. Both can be used to treat a majority of infertile patients. A little background about the two types IVF may be helpful when deciding which treatment is best for any individual patient. Having performed Natural Cycle IVF for over 9 years and stimulated IVF for more than 29 years, we believe we are best qualified to provide a balanced and authoritative statement concerning these 2 treatments.
Brief recap of Stimulated IVF:
Hormonal injections are given daily for approximately 2 weeks to induce the growth of multiple eggs. Frequent ultrasound and blood draws are performed to monitor the process. When the eggs are appropriately mature they are retrieved through a minor in-office procedure. In a successful cycle, about 6-12 eggs are retrieved and usually, there will be several good embryos available for transfer and for freezing for potential future use.
Stimulated IVF is the fastest way to ensure the highest pregnancy rate in an individual cycle. The downsides are the risks of using ovarian stimulation drugs, increased risks of multiple pregnancies if more than one embryo is transferred, as well as a higher cost.
Natural Cycle IVF:
Resurgence in the use of Natural Cycle IVF (NCIVF) has been occurring worldwide and is now beginning to occur with much more interest in the United States too. Natural Cycle IVF is routinely performed in over 50 countries but until recently, less often in the U.S. The University of Southern California IVF center has practiced NCIVF since 1989 and within the past years other U.S. clinics have begun to offer Natural Cycle IVF (1). At Dominion Fertility, we began offering NCIVF in 2007 and currently we are the largest and most experienced NCIVF center in the United States. We offer Natural Cycle IVF as an option to all patients who are a candidate for stimulated IVF regardless of their age, status of their ovarian reserve or a history of previous IVF failures, so long as they have regular menstrual cycles. And we also thoroughly embrace and, since 187, regularly perform stimulated IVF as an effective treatment for infertile patients too.
Natural Cycle IVF is not new. The first IVF baby in the world was from a natural cycle in 1978. At that time, the IVF pregnancy rates were low, so stimulated IVF using fertility drugs became the standard in order to produce more eggs and embryos so that multiple embryos could be transferred back into the uterus. Over time stimulated IVF resulted in greatly improved pregnancy rates but the use of fertility drugs also increased patient risks with a soaring in multiple pregnancies, serious side effects from the stimulation drugs such as ovarian hyperstimulation syndrome and increased costs for the patient. In the United States, the costs for fertility drugs alone for a single stimulated IVF cycle can be 6-9 thousand dollars with the total costs for a single stimulated IVF cycle costing 15 to 25 thousand dollars when including embryo cryopreservation for excess embryos and the use of ICSI.
On the other hand, the total costs for a single NCIVF cycle is about 5 thousand dollars or 20 -25 % of the total costs for a stimulated IVF treatment. And at Dominion Fertility the costs are prorated should the cycle, egg retrieval or embryo transfer be cancelled. The costs for Natural Cycle IVF are less because there are no ovarian stimulation drugs and because the technique itself is simple since only one egg and embryo are produced making it less labor intensive and easier for the laboratory. In fact, we do not charge an extra fee for ICSI as there is only one egg. Fewer office visits and ovarian monitoring with NCIVF also decrease costs.
The in-office follicle aspiration and egg collection are straightforward. With only one follicle, it takes less than 5 minutes to retrieve the egg and most patients receive a very low dose of a sedative that wears off in 1 to 2 hours. We have had some patients complete the procedure without sedatives or pain medicine in order to return to work the same day. To date, we have performed over 2,500 Natural Cycle IVF egg collections without any complications.
Our philosophy is to offer comprehensive, state of the art infertility services, that offer patients their best chances for success with minimal risks and costs. As always, “one couple at a time”.
What About the Natural Cycle IVF Pregnancy Rates?
The concern with Natural Cycle IVF has focused on the lower success rates and the need for multiple treatment cycles to achieve the same pregnancy rates as a single treatment cycle of stimulated IVF. This concern is less relevant today with modern IVF techniques and technology.
In our experience, 84% of our pregnancies occurred within the first 2 embryo transfer cycles and the clinical pregnancy rates remained constant for the first 5 transferred cycles. Indeed, in 2010, we reported a 40% and 32% implantation rates for NCIVF and stimulated IVF, respectively, in patients who were less than 38 years old (2). Thus, the embryo produced in a natural cycle is at least as competent and as likely to implant as one from a stimulated cycle. Currently, our professional society’s recommendation is to transfer one embryo for most patients to reduce the likelihood of a multiple pregnancy (ASRM.org).
When analyzing our data of 821 cycles from 2007 through 2011, cycle cancellation due to a premature LH surge was reduced to 15% per started cycle. At egg retrieval, 86% of our patients had successful egg retrieval and 60% had an embryo transfer. In patients less than 30, 31-34, 35-39 and 40-42 years old, our clinical pregnancy rates were 49%, 29%, 33% and 18% per embryo transfer, respectively. These are amazing rates considering that with Natural Cycle IVF there is only one egg and one embryo. (See DiMattina et al. Natural Cycle IVF Implantation Rates Compared to Stimulated IVF & Role of Serum Anti-Mullerian Hormone Levels – IVF Lite, March, 2014 Vol 1)
Current medical literature contains many reports from outside the United States showing acceptable clinical pregnancy rates using Natural Cycle IVF ranging from 15-25% per embryo transfer when including patients who are known to be “poor responders” to gonadotropins (3-7). In September 2011, we treated a 48 year old nulliparous woman using NCIVF and she successfully conceived and delivered a healthy baby using her own egg after only one embryo transfer. This patient had failed to become pregnant after 3 treatments of stimulated IVF three years earlier at another infertility clinic. Such successes are rare but remarkable and we are pleased for her success. Of course, older and outdated literature show much lower success rates with both stimulated and Natural Cycle IVF.
Why has Natural Cycle IVF been less popular in the United States?
There are several compelling reasons as to why Natural Cycle IVF has not been utilized in the U.S.First, compared with stimulated IVF, there is an increased rate of cycle cancellation with NCIVF because of LH surge, fertilization failure or embryo arrest. While the majority of our oocyte retrievals (61%) resulted in an embryo transfer, we agree with previous studies that recommend NCIVF as a series of treatments to obtain a successful cumulative pregnancy rate. We and many other clinics have found that some patients have a strong preference for Natural Cycle IVF over stimulated IVF and are willing to undergo a greater number of simpler, less risky, and less expensive treatments in order to obtain a successful pregnancy (8,9). Recall, however, that 84% of our pregnancies at Dominion Fertility occurred within the first 2 embryo transfers.
Secondly, the current system used by the Center for Disease Control (CDC) for reporting clinics IVF success in the United States has adversely impacted the willingness of many clinics to perform Natural Cycle IVF. The CDC “lumps” together the NCIVF and stimulated IVF success rates that a clinic reports (10). Thus, the “apparent” success of a clinic that performs Natural Cycle IVF is clearly diminished and therefore, necessarily lower than a clinic that only reports stimulated IVF as more embryos may be transferred in patients treated with stimulated IVF, whereas only one embryo is transferred using NCIVF.
Dominion Fertility’s Philosophy Regarding Stimulated and Natural Cycle IVF
At Dominion Fertility, we perform NCIVF on any patient who has regular menstrual cycles regardless of their FSH, AMH or status of their ovarian reserve or a history of previous stimulated IVF failures.
At Dominion Fertility, we believe that Natural Cycle IVF should be especially considered when patients are facing the high costs of stimulated IVF. In general, if a patient has not been successful after 2 or 3 embryo transfers using the less expensive NCIVF, then we would suggest trying stimulated IVF if appropriate. We also view Natural Cycle IVF as another option or a “bridge” before one uses ova donor IVF or adoption.
And finally, our philosophy is to offer comprehensive, state of the art infertility services, that offer patients their best chances for success with minimal risks and costs. As always, “one couple at a time”. We invite you to visit our Natural Cycle IVF success rates since 2007.
We do not consider either treatment to be superior to the other. They are simply different options and approaches. We perform both treatments with high success rates and our office walls are full of baby pictures born through both procedures. Both treatments should be considered for any patient considering IVF.
- Paulson RJ, et al. In vitro fertilization in un-stimulated cycles: the University of Southern California experience. Fertil Steril. 1992; 57(2):290-3
- Celia GF et al. Natural cycle IVF produces similar implantation rates compared with stimulated IVF. Fertil Steril. 2010;94(4):S162
- Aanesen A et al. Modified natural cycle IVF and mild IIVF: a 10 year Swedish experience. Reprod Biomed Online. 2010;20(1): 156-62
- Matsuura T et al. Natural IVF cycles may be desirable for women with repeated failures by stimulated IVF cycles. J Assist Reprod Genet. 2008;25(4):163-7. PMCID: 2582079
- Pelinck MJ et al. Cumulative pregnancy rates after a maximum of nine cycles of modified natural cycle IVF and analysis of patient drop-out: a cohort study. Hum Reprod. 2007;22(9): 2463-70
- Philips SJ et al. Controlled natural cycle IVF: experience in a world of stimulation. Reprod Biomed Online. 2007; 14(3): 356-9
- Schimberni M et al. Natural-cycle in vitro fertilization in poor responder patients: a survey of 500 consecutive cycles. Fertil Steril. 2009;92(4):1297-301
- Hojgaard A et al. Friendly IVF: patient opinions. Hum Reprod. 2001;16(7):1391-6.
- Pistorius EN et al. Prospective patient and physician preferences for stimulation
or no stimulation in IVF. Hum Fertil (Camb). 2006;9(4): 209-16.
- Gordon JD et al. Utilization and success rates of unstimulated in vitro fertilization (IVF) in the United States: an analysis of the Society for Assisted Reproductive Technology (SART) database. Fertil Steril. 2010;94(4):S157-S8