Although traditional full stimulation in vitro fertilization (IVF) procedures produce better pregnancy rates, minimal stimulation IVF (MS-IVF) induces ovarian follicle and egg development with less hormonal stimulation. As a result, patients going through minimal stimulation IVF incur less expense (thousands of dollars less) from meds in addition to the savings from less required monitoring and labwork. Currently, the fee for MS-IVF/MicroIVF is $3900.

Another benefit to MS-IVF is that a woman is not subjected to the high dose of gonadotropin drug stimulation eliminating the risk of hyperstimulation syndrome. It is also a lower risk to developing a multiple pregnancy and therefore results in safer pregnancies more likely to result in a live, healthy baby.

Although we get our highest pregnancy rates in young patients with lots of follicles like those with PCOS (polycystic ovarian syndrome), MS- IVF may be especially cost effective for older patients who do not respond to gonadotropin stimulation with very many follicles and eggs. We sometimes get as many eggs from a MS-IVF stimulation as a full stimulation in this group.

For patients who do not have coverage for intrauterine insemination (IUI), MS-IVF is a more cost effective, more successful, lower cost alternative and should therefore be considered as a first line of therapy before IUI especially when compared to gonadotropin IUI treatment.

If MS-IVF has all these advantages then why don’t all IVF programs offer it? The reason may be related to the fact that MS-IVF cases are counted the same as any IVF case in statistical reporting of pregnancy rates. Since success with a full stimulation is still on the average about twice that of MS-IVF, performing MS-IVFs will lower a program’s reported success rate. This is a difficult obstacle to overcome as many patients will comparison shop prior to selecting an IVF program.

For us, it is the welfare of our patients that is our concern. It is our goal to deliver the safest and most cost effective treatment to our patients that will offer our patients their best chance of building their family. We wish to make IVF accessible and safe to all those in need.

A new article appearing in Medical News Today, “Obese Women Undergoing Infertility Treatment Advised Not To Attempt Rapid Weight Loss”, suggests that weight loss just prior to conception may have adverse effects on the pregnancy, either by disrupting normal physiology or by releasing environmental pollutants stored in the fat. The article points out what is obvious to many who share the lifelong struggle to maintain a reasonable Body Mass Index (BMI): Weight loss is difficult to achieve. Few people adhere to lifestyle intervention and diets which may have no benefit in improving pregnancy in subfertile obese women.

The bias in the field is so strong that when I submitted a research paper demonstrating equivalent IVF pregnancy rates for women with excessive BMIs greater than 35 to the ASRM for presentation, it was rejected based on the notion that there was clear evidence to the contrary. Here’s the point I was trying to prove: IVF care must be customized to optimize the potential for this group.

Women with high BMI need a higher dose of medication. Those with PCOS benefit from treatment with Metformin. Their ultrasounds and retrievals need be performed by the most experienced personnel. Often their follicles will be larger than in women of lower weight. Strategies to retrieve follicles in high BMI women include using a suture in the cervix to manipulate the uterus and an abdominal hand to push the ovaries into view. Most importantly, a two-stage embryo transfer with the cervical suture can insure in utero placement of the transfer catheter and embryos without contamination caused by inadvertent touching of the catheter to the vaginal wall before insertion through the cervical canal. Visualization of the cervix is facilitated by pulling on the cervical suture, straightening the canal and allowing for easier passage of the catheter. The technique calls for placement of one catheter into the cervix through which a separate catheter, loaded with the patient’s embryo, is inserted.

Using this strategy, IVF with high BMI patients is extremely successful. With regard to the health of the high BMI woman and her fetus, it’s critical to counsel patients just as it is when dealing with women who live with diabetes or any other chronic situation that adds risk.

We refuse to share in the prejudice that is nearly universal in this field. It’s horrible and hypocritical to refuse these patients treatment. Clearly, with close attention to the needs of this population, their success is like any others.

Women who have time and motivation to lose significant weight prior to fertility therapy are encouraged to do so and I try to support their efforts. Unfortunately, many have tried and are unable to significantly reduce prior to conception.

What right do we have to deny these women the right to build their families?

It can be hard to deal with obesity and even more so when combined with infertility. If you are feeling sad or depressed, it may help to talk to a counselor or to others who have the condition. I advise you to ask your doctor about support groups and for treatment that can help you including fertility treatment.

Remember, though this condition can be annoying, aggravating and even depressing, seek an REI who is interested in supporting you and helping you build your family and reject those who simply tell you to return after you have lost sufficient weight.

PCOS

PCOS is the most common hormonal disorder of reproductive age women, occurring in over 7% of women at some point in their lifetime.  It usually develops during the teen years.  Treatment can assist women attempting to conceive, help control the symptoms and prevent long term health problems.

The most common cause of PCOS is glucose intolerance resulting in abnormally high insulin levels.  If a woman does not respond normally to insulin, her blood sugar levels rise triggering the body to produce more insulin.  The insulin stimulates your ovaries to produce male sex hormones called androgens.  Testosterone is a common androgen and is often elevated in women with PCOS.  These androgens block the development and maturation of a woman’s ovarian follicles preventing ovulation resulting in irregular menses and infertility.  Androgens may also trigger development of acne and extra facial and body hair.  It will increase lipids in the blood.  The elevated blood sugar from insulin resistance can develop into diabetes.

Symptoms may vary but the most common are acne, weight gain, extra hair on the face and body, thinning of hair on the scalp, irregular periods and infertility.

Ovaries develop numerous small follicles that look like cysts hence the name polycystic ovary syndrome.  These cysts themselves are not harmful but in response to fertility treatment can result in a condition known as Hyperstimulation syndrome.  Hyperstimulation syndrome involves ovarian swelling, fluid accumulating in the belly and occasionally around the lungs.  A woman with Hyperstimulation syndrome may become dehydrated increasing her risk of developing blood clots.  Becoming pregnant adds to the stimulation and exacerbates the condition leading many specialists to cancel cycles in which a woman is at high risk of developing Hyperstimulation.  They may also prescribe aspirin to prevent clot formation.

These cysts may lead to many eggs maturing in response to fertility treatment also placing patients at a high risk of developing a high order multiple pregnancy.  Due to this unique risk it may be advantageous to avoid aggressive stimulation of the ovaries unless the eggs are removed as part of an in vitro fertilization procedure.

A diagnosis of PCOS may be made by history and physical examination including an ultrasound of the ovaries.  A glucose tolerance test is most useful to determine the presence of glucose intolerance and diabetes.  Hormone assays will also be helpful in making a differential diagnosis.

Treatment starts with regular exercise and a diet including healthy foods with a controlled carbohydrate intake.  This can help lower blood pressure and cholesterol and reduce the risk of diabetes.  It can also help you lose weight if you need to.

Quitting smoking will help reduce androgen levels and reduce the risk for heart disease.  Birth control pills help regulate periods and reduce excess facial hair and acne.  Laser hair removal has also been used successfully to reduce excess hair.

A diabetes medicine called metformin can help control insulin and blood sugar levels.  This can help lower androgen levels, regulate menstrual cycles and improve fertility.  Fertility medications, in particular clomiphene are often needed in addition to metformin to get a woman to ovulate and will assist many women to conceive.  The use of gonadotropin hormone injections without egg removal as performed as part of an IVF procedure may result in Hyperstimulation syndrome and/or multiple pregnancies and therefore one must be extremely cautious in its use.  In vitro fertilization has been very successful and offers a means for a woman with PCOS to conceive without a significant risk for developing a multiple pregnancy especially when associated with a single embryo transfer.   Since IVF is much more successful than insemination or intercourse with gonadotropin stimulation, IVF will reduce the number of potential exposures a patient must have to Hyperstimulation syndrome before conceiving.

It can be hard to deal with having PCOS.  If you are feeling sad or depressed, it may help to talk to a counselor or to others who have the condition.  Ask your doctor about support groups and for treatment that can help you with your symptoms.  Remember, PCOS can be annoying, aggravating even depressing but it is fortunately a very treatable disorder.