Saturday, July 9, 2011

Mini-stim IVF, Mini-IF and Micro-IVF

There is an increased awareness of the availability of minimal stimulation IVF procedures, equivalently referred to as Mini-stim IVF, Mini-IVF and Micro-IVF procedures, as an alternative to conventional IVF primarily because of its decreased cost compared to conventional IVF. Although there are many differences in the approaches taken by programs which use these labels to describe the procedures they perform, there is limited awareness of these differences by patients seeking these procedures. In this paper, we will review some of these differences and reasons that patients may or may not wish to utilize a procedure incorporating them.

The first and most important issue is to be clear about the program’s objective for the ovulation induction. Is the objective to produce as many eggs as possible for the given ovulation induction (as is commonly the objective for conventional IVF, or is it to produce the one or two best eggs that the patient is able to produce? Producing more eggs leads to using more medications both for greater stimulation and to avoid an “LH surge”. How to optimize egg quality is less understood, but appears to be achieved at times with low dose stimulation protocols. Faucer showed that the same numbers of chromosomally normal eggs were obtained using both gentle and more aggressive ovulation inductions. The primary financial saving of a Mini-stim IVF cycle is achieved by decreased medication use and less need of intensive monitoring. Thus gentler ovulation induction protocols will save the patient money. At times, a gentler ovulation induction regimen will also lead to a cancelled cycle that could have been rescued by a higher dose or longer ovulation induction. This may increase patient costs in having to do extra cycles.

ICSI is a powerful technique that bypasses the need for the sperm to be able to enter the egg on its own and thus solves almost all (recognized and unrecognized) male factor problems. We use ICSI routinely as a component of Mini-stim IVF which makes it a powerful alternative to conventional IVF for the young couple with isolated male factor infertility. ICSI enables us to more accurately assess the quality of eggs than if ICSI is not used because the multi-layer of granulosa cells that are found around the egg are removed for ICSI, whereas they need to be left on if ICSI is not used. ICSI is used with conventional IVF in 20-90% of patients depending on the program (with an average use > 50%). Medical coding enables separate billing for ICSI and thus some programs add it to the cost of their Mini-stim IVF program. In our program ICSI (and assisted hatching if needed) are included in the cost of the package price for Mini-stim IVF.

Eggs are identified by the lab in the follicular fluid that is aspirated in conjunction with transvaginal ultrasound. We routinely flush the follicles until the lab finds an egg. Follicle flushing is currently done in a minority of conventional IVF programs for complex reasons. However, if you only have one or two follicles to work with you need to find an egg in each of them. Sometimes we find it in the first aspirate and most of the time by the second flush, but occasionally it is not found until the tenth flush. This is an aspect of Mini-stim IVF that is more difficult than conventional IVF. Follicle flushing increases the amount of time that a case requires.

Some form of anesthesia, usually deep IV sedation, is used in almost all conventional IVF cases. In order to save costs, some programs do not use IV sedation for Mini-stim IVF. The thinking is that since only a few needle punctures are required, patients are willing to trade off the discomfort for the cost savings. We don’t view this as appropriate. In addition to the humanist aspects of providing anesthesia, anesthesia enables the physician to spend the time required for follicular flushing without patient discomfort which enhances the effectiveness of egg retrieval. Also the ovaries frequently are situated in the abdomen in positions that make aspiration more difficult (or even impossible), but they can be pushed to positions to optimize retrieval. However, moving the ovaries around is uncomfortable without some anesthesia. Again anesthesia optimizes egg retrieval which is especially important if only a small number of follicles are available.

Mini-IVF is a great technique which could replace a significant proportion of conventional IVF procedures without decreasing the pregnancy rate. The benefits to the patient are a much easier ovulation induction, fewer side effects from the medications and significant cost savings (1/2 to 2/3rds in our program). Mini- IVF, Mini-stim IVF and Micro-IVF are still evolving as procedures. We feel that the above components are important for a good program.
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