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Mini-stimulation IVF, Frozen Embryo Transfer, or Surrogacy?
a blog by Suzanne Rico, August 13, 2013
My friend Gina is 39 years old. She’s a super-responder, with great embryos, but every time she tries IVF she ends up with a BFN. She’s at the end of her rope (not to mention her baby-making window) and I can’t blame her because ten years ago, I was in the same boat.
Thankfully, things have changed since 2003. Women with unexplained infertility have more options than ever, with technology bounding ahead to bring success rates up when innovative techniques are tried. After three BFNs of my own, I ended up using a surrogate and when my doctor transferred five embryos into her womb, she got pregnant with triplets! We lost one at 6 weeks and one at the end of the first trimester, but my son’s strong heartbeat somehow continued and he was born two days late at 8 pounds six ounces. My point is that while no one thought my infertility had anything to do with my uterus, I think this shows that it probably did.
So what should Gina do in 2013? Should she go the minimal stimulation (mini-stim/ mini-IVF) route and hope that quality not quantity will get the job done? Or should she do a frozen embryo transfer next time in hopes her physician can get her womb more ready for implantation? Or, if she can scrape the money together, should she bypass her own womb altogether and give a surrogate a try? I asked three experts to weigh in on these options: Dr. Arthur Wisot, a mini-stim expert, Dr. Bruce Shapiro, whose success rates with frozen transfers are way above average, and Dr. Dan Potter, who has helped over 150 couples get pregnant via surrogacy.
Dr. Bruce Shapiro, The Fertility Center of Las Vegas - "There are two challenges for the patient. The first is her age. Although she still makes a large number of eggs, the incidence of chromosomal anomalies in embryos from women 39 years old is significant and could have been a contributing factor to the previous failures. Preimplantation genetic screening (PGS) can be used in a future cycle to both identify whether this is a factor for the patient and to facilitate transfer of only those embryos with a normal chromosome number.
The second problem is her history of cycle failures following fresh transfer. The problem of disturbed uterine receptivity in fresh transfer cycles as a side effect of ovarian stimulation is well documented. However, the problem can be circumvented by freezing the embryos and then transferring them in a subsequent thaw cycle to avoid the effects of ovarian stimulation and make the uterine receptivity optimal.
I would therefore offer this patient preimplantation genetic screening (PGS) followed by embryo cryopreservation and then transfer in a subsequent thaw cycle where the uterine receptivity can be optimized. We have had a great amount of success this treatment approach."
Dr. Dan Potter, HRC Fertility - "Most cases like this should not require surrogacy. In the face of repeated failures in a high responder with good embryo quality, I would recommend the following course of action:
1. The patient should be evaluated for both auto- and alloimmune issues and treated with Lovinox and/or Intralipid if indicated.
2. The patient should be evaluated for insulin resistance and treated with metformin if indicated. High responders are at increased risk for insulin resistance. High insulin levels negatively impact all aspects of reproduction.
3. Have IVF with a day 5 embryo biopsy for PGD followed by freezing of all embryos. Start metformin prior to stimulation if indicated.
4. Have PGD performed on the biopsy specimens using Natera Parental Support 24-chromosome technology. This will allow you to eliminate all chromosomally abnormal embryos. It is also the only technology that will tell you whether the abnormalities are coming from the sperm or the egg. This can be critical information if there is failure due to having no normal embryos.
5. Do an FET cycle transferring 1-2 chromosomally normal thawed embryos. Treat with Intralipid at both the cycle start and embryo transfer and then also at the time of a positive pregnancy test if indicated.
6. Enjoy your new pregnancy!
Dr. Arthur Wisot, Reproductive Partners - "Gina's problem of repeated failed IVF cycles despite good egg production and embryo quality is frustrating to both her and her doctors. But minimal stimulation is not her answer. That's for the woman, who despite aggressive stimulation, cannot produce more than one or two eggs. Minimal stimulation can help a woman create one or two eggs at a time, fertilize them, and freeze the embryos to collect enough to make a frozen embryo transfer worthwhile.
The solution to Gina's dilemma might lie in checking her embryos for unsuspected chromosomal abnormalities with PGS, evaluating her endometrium for endometritis with a pre-transfer biopsy and transferring her best embryos only in a frozen embryo transfer cycle. Another option would be to use a surrogate with a proven record of successful pregnancies."
These opinions are given in the abstract—none of these respected fertility doctors have consulted with Gina, but she is a real person, needing real and helpful advice so she doesn’t get timed out on having a biological child. Fertility treatment hasn’t been perfected yet, but it’s no longer a “one size fits all approach” and the good news for patients these days is success rates continue to rise.