CRM : Center For Reproductive Medicine

By Guang-Shing Cheng for OB/GYN News
April 1, 2000

Minimal-stimulation in vitro fertilization may be a cost-effective option for young women who want to conceive, Dr. Gary DeVane said.

While conventional in vitro fertilization (IVF) procedures yield better pregnancy rates, minimal-stimulation IVF yields higher numbers of retrievable eggs when gonadotropins are used, according to a two-phase prospective study.

A relatively new assisted reproductive technique, minimal-stimulation IVF (MS-IVF) aims to induce ovulation with less hormonal stimulation than what is used in conventional IVF.

The problem is finding the right dose of medication that [R1] will ultimately yield acceptably high pregnancy rates while remaining cost effective, Dr. DeVane said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

The bulk of the savings from MS-IVF comes from the reduction in fertility drugs.

Although he's not sure that MS-IVF is the best method for everyone, the lower cost will make assisted reproductive technologies accessible to more women, according to Dr. DeVane of the Center for Reproductive Medicine in Orlando, Fla.

In the first, exploratory phase of the study, 106 patients underwent MS-IVF, receiving a dose of clomiphene citrate that was substantially less than that used in standard IVF, in addition to hCG.

Standard laboratory and transfer techniques were used for the procedure.

The cancellation rate was 18%; of the remaining patients who went to retrieval, 85% had eggs recovered and went to embryo transfer.

There were 20 pregnancies after transfer, translating into a 17% pregnancy rate per retrieval. The implantation rate, defined as the number of gestational sacs divided by the total number of embryos transferred in a group of patients, was 9%.

Patients under age 35--who comprised 80% of the study group--had better results:

Twenty-five percent had five or more eggs retrieved, and this cohort accounted for more than one-half of the pregnancies, Dr. DeVane observed.

MS-IVF from phase I appeared to be cost beneficial, but "we weren't very happy with the pregnancy rate," Dr. DeVane said.

For phase II, the investigators upped the ovarian stimulation with an ultrashort GnRH-A flare, given for 4 days, and avoided clomiphene altogether. They observed less spontaneous ovulation with this protocol than with the clomiphene, Dr. DeVane reported.

 

Eggs were retrieved in 34 hours and transferred on day 3. Retrieval was canceled if patients didn't have at least two follicles.

In 110 patients, the cancellation rate was 25%. Of the remaining patients, 45 pregnancies resulted, translating into a clinical pregnancy rate of 37% per retrieval and an implantation rate of 23% per transfer, clearly better than the phase I outcomes.

Of the women who had successful egg retrievals, 50% had five or more oocytes harvested. The live birth rate was 33%, but more than half of those were part of multiple gestations.

As in phase 1, women under age 35--who comprised approximately 85% of the phase II study group--had better retrieval rates.

The improvement with protocol II is probably due to the higher number of eggs retrieved.

"We got more eggs; therefore, we could choose better embryos," Dr. DeVane said.

But egg retrieval and pregnancy rates for conventional IVF have improved in recent years as well. "Some of the successes that we had may be just a reflection of [generally] better IVF techniques," he said.

The study was not intended as a formal cost analysis but as a way to provide access to patients who would not otherwise consider IVF because of the cost, Dr. DeVane said.

Discussant Dr. Barry Verkauf, an ob/gyn. in private practice in Tampa, Fla., who was not involved in the study, calculated that a phase I cycle costs $3,200, while a phase II cycle costs around $4,700 because more medication, anesthesia, and monitoring are necessary.

However, the phase II procedure may ultimately prove more cost effective, with a cost per live birth of $14,461, compared with a cost per live birth of $22,222 for phase I.

One cycle of conventional IVF can cost twice as much as the phase II protocol, according to Dr. DeVane, although he said he is not entirely convinced that MS-IVF is a cost-effective approach for everybody because of the low egg yield and other factors.

Since the trend in assisted reproductive technology is toward less stimulation, MS-IVF would be a good alternative for certain women, including younger women who are financially strapped and patients who don't want to deal with the issue of cryopreserving extra eggs, Dr. DeVane said.

"Rather than higher pregnancy rates at all costs, clearly our new paradigm is to achieve acceptable rates at acceptable costs," Dr. Verkauf said.