M.C.came to me on March 19, 2009 having never been pregnant. Today (June 2), she is referred back to her obstetrician for obstetrical care.
M.C.is a healthy, 36 year old Family Practice physician who works at a local military facility. She has been married for 7 years and the couple never used any contraception during their marriage. Their infertility was thought to be a mild male factor. She had three unsuccessful treatments using IUI. These were followed in 2005 and 2006 by 2 fresh stimulated IVF procedures with 2 fresh and one frozen embryo transfers. Again, she had no success. Importantly, she had 7remaining frozen embryos produced from her 2 stimulated IVF procedures and she wanted to have these frozen embryos thawed and transferred in her natural menstrual cycle (NC-FET) rather than in a medicated cycle. Her doctors at her IVF center refused, so she went to another IVF center who also refused to transfer her embryos in her natural cycle. In fact, they recommended that she abandon these embryos altogether since they were produced in previously unsuccessful IVF cycles. M.C., being a physician, was not going along with these recommendations.
On March 19, M.C. came to see me at Dominion Fertility. She had normal regular menstrual cycles, so I recommended that we thaw all 7 of her embryos which were previously frozen as 7-8 cell embryos. We would then grow these embryos out to blastocysts to be transferred in her natural cycle with no drugs(NC-FET). On May 11, I transferred 2 beautiful blastocysts and we refroze 3 other embryos. And today, an ultrasound exam showed a healthy pregnancy with a normal fetal heart rhythm.
At Dominion Fertility, almost all of our frozen embryo transfers are in the patient's normal natural, menstrual cycle with no injectable replacement drugs.We find this to be much easier and less stressful for the patient. We have compared our data for NC-FET and medicated FET's, and the pregnancy rates are identical.Thus, there is rarely a patient that we ever recommend hormone replacement for a FET, providing that her menstrual cycles are fairly regular. At Dominion Fertility, our patients undergoing NC-FET have only one injection (hcg) for their entire treatment cycle. We use oral estradiol and vaginal progesterone in lieu of the injections. Just one injection for the entire treatment! For many years now, we have recommended NC-FET and we see no advantage to medicated FET's for the vast majority of patients. Having tried both types of treatments,our patient, M.C. attests to the simplicity and success of Natural Cycle -Frozen Embryo Transfer. We are most happy for M.C.'s success.
-Dr. Michael DiMattina
Korean Lady Travels to Dominion Fertility for Her Ova Donor Success
E. K. lives and works in Seoul, Korea. She is a healthy 40-year-old lady, married for 18 years and using no contraception for the past 17 years. In Seoul, she underwent 8 treatment cycles of gonadotropins and IUI, followed by 7 IVF cycles, but without any success. She then traveled to Los Angeles and again underwent another unsuccessful IVF cycle. Subsequently, she came to the Washington, D.C. area and had another IVF cycle at a major infertility center, but again no success.
E.K. and her husband presented to me in 2008 seeking any possible hope. After reviewing their rather large medical records I could see that any further IVF with her ova was not in her best interest. And so, I asked E.K. to strongly consider Ova Donor IVF or adopt. Actually, she was hoping that I would recommend ova donor IVF as she had seen our statistics and was very impressed. The success of our ova donor program is, in part, because all of our ova donors are young, in their 20's. We do not use donors once they have reached the age of 30, and there is no egg sharing. Instead, all of the ova are dedicated exclusively to one infertile couple. This allows us to obtain the best embryo(s) for that couple, thus maximizing our success rates.
And so, E.K. underwent ova donor IVF in December, 2008 at Dominion Fertility and, at her request, 2 blastocyst embryos were transferred. This resulted in a twin pregnancy on her first attempt. Normally, we would recommend only one embryo for transfer, but because of all of her many previous failures, we agreed to transfer two. Additional embryos were produced and "vitrified" (please see my previous post concerning "vitrification") and she may return at some future date for a frozen thaw embryo transfer should she desire more children. At Dominion Fertility, our Ova Donor IVF pregnancy rates are about 80% per embryo transfer of 2 embryos and about 50% when one embryo is transferred. Cumulatively, with both the fresh and frozen embryo transfers, we expect the pregnancy rates to be about 90%, again attributable to only using donors in their 20's and by dedicating all of the eggs to one couple at a time.
I often see patients who live around the world and it is a pleasure to work with people from different cultures and locations. I have had the pleasure of meeting and treating people from Iceland, England, France, Germany, Georgia, Ukraine, Russia, Ghana, Sierra Leon, Vietnam, Thailand and Panama, just to name a few. In fact, I am now the "Godfather" of twins conceived by IVF in a lady who lives in Panama. (That, by the way, is also my favorite movie of all time too!) Often, we work with their local doctors and "satellite" their treatments before they travel to the United States. This shortens their stay in the U.S. and decreases some of their costs too.
For Ova Donor IVF, I would recommend that patients check out the age of their donors, ask if the eggs are shared with other patients, and of course, what are the clinics' success rates. Since extra embryos are likely to be produced, ask if the clinic vitrifies the embryos as this appears in many studies to be superior to "slow - cool" methods for embryo cryopreservation.
Well, looking forward to a happy twin delivery later this year for our Korean lady who certainly deserves her success. Perhaps I will be the "Godfather" for her children too! Ha!
-Dr. Michael DiMattina
"Hold those embryos!!!" - How We Avoid Hyperstimulation at Dominion Fertility 5/4/09Everyone fears hyperstimulation - the doctors, patients, hospitals, insurance companies, you name it. Hyperstimulation is no fun for anyone. And we all know that it can even be life threatening. So, what can be done?
At Dominion Fertility, our incidence of severe hyperstimulation(HSS) is less than 1%. That's remarkable when you think about the national average rate for severe HSS is 1-5%. The trick is to "hold those embryos" and perform cryopreservation using "vitrification" on all of the quality embryos (see my previous patient story for more information about vitrification). Embryo transfer of the frozen-thawed embryos in a non stimulated cycle can be performed later on.
We know that severe HSS rarely occurs unless the patient undergoes a fresh embryo transfer and pregnancy occurs. Pregnancy itself produces hCG which further stimulates the ovaries to enlarge, thereby worsening the hyperstimulation. By withholding the embryo transfer in the stimulated IVF cycle, the patient does not immediately become pregnant, and the likelihood for severe HSS decreases to less than 1%. The embryos can be vitrified (frozen) and later transferred in a nonstimulated cycle. The patient rapidly improves from her hyperstimulated state and later she can undergo a frozen-thaw embryo transfer and get the same success rates for pregnancy as in a fresh IVF treatment cycle. Thus, she avoids severe HSS and later safely gets pregnant. It's a win-win situation.
Why don't more IVF clinics do this? (i.e. hold the embryo transfer in the fresh stimulated cycle, perform embryo cryopreservation and later perform an embryo transfer of the frozen thawed embryos?) In my opinion, there are 2 reasons for this. First, if the clinic does not perform a fresh embryo transfer, then their apparent IVF pregnancy rates will be artificially suppressed giving the false impression that they have a unsuccessful IVF program. Also, not all IVF clinics perform "vitrification" of the embryos, so their cryothawed IVF pregnancy rates may not be as good.
Here's a story about a patient of mine for you to enjoy and learn from her experience:
S.D. is a 31-year-old woman who had been married for 3+ years. Her husband is a 34-year-old male who suffered a testicular sports injury. His sperm count was 100,000 sperm (normal is 20-200 million) and his sperm motility was only 0.4% (normal is >50%). So, IVF was their only option to possibly have their own biologic child. In her stimulated IVF cycle, S.D. hyperstimulated, so we "vitrified" all of her quality embryos and omitted her embryo transfer. About 2 months later, she underwent a successful frozen thawed embryo transfer in her "Natural" menstrual cycle with no drugs and became pregnant. Thus, she achieved a successful pregnancy and avoided severe HSS. Please note that she achieved her pregnancy in her natural menstrual cycle without using any fertility drugs.
So, avoiding HSS is usually possible by simply "holding the embryo transfer". And the good news is that pregnancy can often be produced by later performing a frozen-thawed embryo transfer. At Dominion Fertility, we use the natural menstrual cycle to transfer the frozen embryos with the same success rates obtained as if the embryos had never been cryopreserved. So, "hold those embryos" when HSS looks probable.
-Dr. Michael DiMattina
Natural Cycle IVF When the Other Treatments Have Failed- 2 Patient Stories 4/20/09
If you like to hear stories, well then, here are two amazing ones! Both of these patients failed to get pregnant until they tried Natural Cycle IVF (NC-IVF).Then both became pregnant in their first treatment of NC-IVF.
Patient #1. T.P. is a healthy 38-year-old, who had never been pregnant and who had been trying to conceive for over 2 years. Her day 3 FSH was slightly elevated at10.8 and she had signs of diminished ovarian reserve. Her husband also had a male factor with a sperm count of 17 million with decreased sperm morphology having only 12% normal sperm (nl is >30%). So, they entered our stimulated IVF program and we used a "flare" stimulation with maximal doses of gonadotropins, ICSI, and assisted embryo hatching. We obtained 5 ova, but only one embryo and no pregnancy. Her total costs were with her ovarian stimulation drugs was about 16K. Because we had obtained only one embryo, I suggested NC-IVF as the ovarian stimulation drugs did not produce any extra embryos as we had hoped.
In April, we performed her first NC-IVF, transferring a single 8-cell embryo and she immediately became pregnant. Her total costs for this treatment were 4K.
Patient #2. D.H. is a healthy 36-year-old lady, who wished to undergo treatment using donor sperm IUI. So, she underwent 6 total cycles of midcycle monitoring for her ovulation with well-timed IUI's, but no pregnancy occurred. Understandably she became frustrated so I suggested that she try NC-IVF. Again, she became pregnant in her first treatment.
Most likely the first patient would have moved on to Ova Donor IVF or adopted as her stimulated IVF cycle was a near disaster. However, we now have many patients who have been successful trying NC-IVF prior to using an ova donor or adopting.The egg and the embryo in this patient were of very high quality in her Natural Cycle IVF treatment, but not so in her stimulated IVF treatment cycle. So, what gives? We believe that mother nature makes the best egg in a woman's monthly menstrual cycle and there is now medical evidence that supports this theory. It is well known that gonadotropins stimulate abnormal in addition to normal eggs but perhaps mother nature selects out more normal than abnormal ova. We just don't know for sure, but our experience has been that the eggs in our NC-IVFpatients are almost always of very high quality as are the embryos produced from these eggs.
The second patient illustrates the fact that placing embryos into the uterus rather than sperm further increases one's chances for pregnancy. This patient underwent 6 cycles of well-timed IUI's without pregnancy, but was immediately successful after only one treatment with NC-IVF. The patient also commented that NC-IVF was simpler than her many cycles of IUI. The nice thing about these stories isthat they are about real people and not just fairy tales. When the other treatments fail, consider NC-IVF. Best wishes,
-Dr. Michael DiMattina
More Hope for Poor Responder IVF Patients Using Natural Cycle IVF 4/18/09
If you did not respond to gonadotropin (hmg) stimulation for your IUI or IVF treatment cycle, then consider this:
A recent article published in Fertility and Sterility in 2008, ("Natural Cycle in vitro fertilization in poor responder patients: A survey of 500 consecutive cycles") showed a 17.1% pregnancy rate per embryo transfer when such patients where treated using Natural Cycle IVF (NC-IVF). Here is what I found to be so fascinating: all of the 500 study patients had been previously stimulated with gonadotropins (hmg) for IUI or IVF, but they had either no response or they only made one follicle and so their treatment cycles were canceled. Such patients are truly "poor responders" to hmg. It just doesn't get any worse than that. Yet, they were able to achieve an overall pregnancy rate of 17.1% per embryo transfer using NC-IVF. In patients less than 35 years old, the pregnancy rate was 29.2% per embryo transfer. That's right; hmg stimulation was a bust, yet 1 in every 4 patients got pregnant with NC-IVF!
The incidence of "poor responder" patients is estimated to be about 10%. Poor response is often related to patient age, where the low response to hmg reflects a decline in ovarian reserve. This occurs more frequently in women over 35 although it may occur in younger women too. In general, poor responder patients are refractory to any stimulation protocol, and although many strategies have been suggested, the results remain poor despite high doses of hmg. In such patients, NC-IVF may be a valid alternative. Indeed, the authors had previously demonstrated that NC-IVF is at least as effective as hmg-IUI in terms of pregnancy rates, and that NC-IVF should be preferred because of its favorable cost-benefit ratio.
The authors of this study commented, "in light of our results, minimal stimulation does not seem to have any advantage over natural cycles in terms of pregnancy rate improvement. Minimal stimulation is also expensive... even in low doses, are additional costs as well as stressful for the woman, without adding any improvement to the expected outcome."
Finally, the authors concluded by saying, "NC-IVF is a suitable, feasible alternative to ovarian hyperstimulation in poor responder patients, and it should be suggested by physicians as an alternative to expensive ovarian stimulation with gonadotropins or before proposing egg donation, especially in women younger than 40 years." They suggested that 4 treatments of NC-IVF were reasonable, as the pregnancy rate per cycle remained the same for each consecutive attempt. In my experience, most of our patients who have achieved a successful pregnancy with NC-IVF did so usually within their first or second treatment cycle. A few required 3 treatments and rarely did anyone require 4.
Let's just hope that the good news for our "poor responder" patients continues!
-Dr. Michael DiMattina
Her Words: "This is Easier Than IUI". NC-IVF Pregnancy at 40
4/8/09
Those were patient F.R.'s parting words to me yesterday when I referred her back to her obstetrician. I had just performed her sonogram confirming the presence of a healthy 6-week pregnancy following her first treatment with Natural Cycle IVF.
F.R. was a healthy 38-year-old high school teacher, with no children, who first came to me in October 2006 with a 4 year history of infertility. Her infertility was related to both her age and diminished ovarian reserve. She became pregnant using clomid with timed IUIs and had a healthy baby boy in March 2008.
She returned to me in January 2009 again unable to conceive. Her ovarian reserve had further deteriorated and now she was 40+ years old. Things looked bleak. So, I suggested that she proceed immediately with NC-IVF. On March 17, I transferred a single embryo and she became pregnant with her first treatment.
F.R. could not believe just how simple the entire NC-IVF process was compared with her previous treatments with clomid and IUI. She recalled the side effects with clomid and the fact that her first pregnancy required more treatments compared with her current pregnancy. And the total cost for her NCIVF treatment was less than her total costs for her Clomid - IUI treatments.
Most of our patients who have achieved pregnancy with NC-IVF did so in either their first or second treatments. A few patients underwent 3 treatments before they conceived, and only a few underwent four. To date, no one has undergone more than four NC-IVF treatments in order to achieve pregnancy. I am most pleased for F.R.'s success.
-Dr. Michael DiMattina
She Never Gave Up - Finally, Her Successful IVF Pregnancy With a Surrogate 4/1/09
This case took me to my knees. None of us ever gave up. I strongly believed that sooner or later, we would fine a cure. Now, she and her husband will have their own biological child with the help of a surrogate.
S.R. is a wonderful, delightful, intelligent 28-year-old lady, who came to me in August 2004. She and her husband had been trying to conceive for one year and she had unexplained infertility (UI). In general, UI is best treated with IVF and ICSI. She first tried to conceive by simply trying Clomid with IUI, but this was unsuccessful. In December 2005, she underwent IVF with 2 Grade 1 embryos transferred, but no pregnancy occurred. A second IVF procedure with transfer of 2 Grade 1 embryos was again performed, but still no success. This was followed by an unsuccessful frozen embryo transfer. Three embryo transfers and no baby. What gives? At Dominion Fertility it is rare for us to perform more than 2 IVF procedures on any women who is less than 34 years old and not have a successful pregnancy.
In her IVF treatments, I observed that her endometrium was always 7 to 8 mm thick, so I performed an endometrial biopsy. Sure enough, it showed a luteal phase defect of 6 - 7 days which is not compatible with implantation. By prolonging her follicular phase with estrogen, I was able to normalize her endometrium and so we thought that her problem was solved. Indeed, in November 2006, I performed another frozen embryo transfer and this resulted in pregnancy, but, unfortunately, she miscarried at 12 weeks. This was clearly a bummer for us all. The couple took a break in 2007. In 2008, I strongly recommended that she consider using a surrogate with her eggs and her husband's sperm. S.R. was not ready for that, so she underwent another fresh IVF with 2 blastocyst embryos transferred in February 2008 and this resulted in a biochemical pregnancy. Finally, after a total of 5 embryo transfers and no baby, she agreed to use a surrogate.
Incidentally, I noticed that S.R. was progressively making fewer eggs with each successive IVF treatment and her ovarian reserve diminishing. She never produced a large number of eggs before, but now she was producing even fewer eggs at her young reproductive age. So, time seemed to be of the essence. In October 2008, we performed another fresh IVF but S.R. only produced 3 ova. Two embryos were transferred into her surrogate but no pregnancy occurred. Yes, her ovarian reserve was definitely diminishing. I recommended that they try one more time and FINALLY, in February 2009, we established a successful pregnancy after ET of 2 blastocysts into her surrogate! Wow! I was walking on cloud 9 that day, but so was everyone else.
So, what do we learn from S.R.'s story? Perhaps her infertility is now explainable. A uterine factor seems to be the etiology of this couples' infertility, which only became apparent after many failed embryo transfers of high quality embryos in a young reproductive age female. It was most difficult for the couple to finally agree to use a surrogate, but they are most pleased that they did. They have formed a close, strong relationship with their surrogate during the course of their treatments and delivery is expected later this year.
Uterine factors, when the uterus is thought to be normal, is fortunately rare and usually diagnosed only after multiple failed IVF cycles when everything seems to have gone well, but no pregnancy occurs. This couple proves to me that the single most important factor to establishing a successful pregnancy is persistence. Kudos to this wonderful couple!
-Dr. Michael DiMattina
They told her it was a sham. Now she's pregnant! 3/31/09
That's what N.F.'s infertility specialist told her in Columbia, S.C. when she asked if she could try Natural Cycle IVF. She proved them to be wrong.
N.F. is a wonderful, intelligent 30-year-old lady who teaches at her local university. She has been trying unsuccessfully to have a baby for the past 3 years. Her husband has a severe male factor with only 2 million sperm/ml and only 1% normal sperm morphology. Their only hope to have their own biological baby was to use IVF with ICSI, but she did not wish to use ovarian stimulating drugs. She found Dominion Fertility on the internet and came to Arlington, Virginia to see me for a consult in early January 2009.
One month later, on February 19, I transferred a single 8-cell embryo. On March 19, I sent her back to her local Ob/Gyn for routine obstetrical care. She only traveled to Arlington for 3 separate visits: her initial consultation, her egg retrieval and finally, 3 days later, her embryo transfer. She is currently about 7 1/2 weeks pregnant and doing very well. It seems NC-IVF wasn't such a sham after all!
N.F. is thrilled that her NC-IVF treatment at Dominion Fertility worked on her very first cycle. However, she feels that she was not given good advice by her former dcotor and is now on a mission to tell her story. She recently informed me that National Public Radio is interviewing her so that she can get the word out that NC-IVF is no "sham". N.F. believes that many women feel the same as she does, i.e. they want simpler, less expensive infertility treatments that offer good pregnancy rates with few or no risks- without using ovarian stimulation drugs.
NC-IVF is a logical treatment of choice for many patients who have male factor infertility. IUI, with or without fertility drugs, most likely would not have resulted in pregnancy for this couple as they had a severe male factor causing their infertility. But there was no reason to subject this patient to expensive ovarian stimulating drugs and produce many eggs/embryos. We only transfer one embryo in such patients, thereby almost eliminating the possibility of a twin pregnancy. So, no "sham" here, just another baby on the way!
-Dr. Michael DiMattina
Dominion Fertility Announces: "Another First That's a Second" 3/27/09
Dominion Fertility has great news today! A 32-year-old patient at Dominion Fertility has successfully conceived for the second time through fertilization with Natural Cycle IVF (NCIVF). Her pregnancy represents the first successful sibling NCIVF pregnancy in the Washington, D.C. area.
Here's her story: When we met, M.M. was a 30-year-old female who had never been pregnant. She is married to a local anesthesiologist and they had been trying to conceive for about 2 years. Their infertility was related to a male factor with low sperm count, motility and morphology. At another infertility clinic, she underwent treatment using clomid/gonadotropins with IUI for 3 cycles. This did not result in pregnancy, so her doctor recommended IVF. Sound familiar to anyone out there?
M.M. came to me in April 2007 to see if she could try NCIVF. Two months later, we performed her first NCIVF and she became pregnant. She delivered a healthy son in February 2008. In August 2008 she returned to our clinic to try for her second child. In November 2008 we performed NCIVF, but there was no egg in her follicle. Of course this was disappointing, but fortunately this rarely happens as most follicles contain a healthy egg. So, she tried again.
On February 18th, I transferred a single 8-cell embryo. Today M.M. has a healthy 7-week pregnancy and has been referred back to her OB/GYN for continued obstetrical care. One egg, one embryo, no fertility drugs. Natural Cycle IVF is far less expensive than stimulated IVF, and has virtually no risks. What's not to like? The patient is almost speechless since she had been told by the other IVF clinic that she would require drugs for IVF. We are very happy for M.M.'s success!!!
Dominion Fertility is currently in the process of writing up and submitting for publication our 2+ year experience with NCIVF. Many doctors from around the country are now asking us about our program and seem most interested in NCIVF. We believe that patients are intelligent, have a great interest in their healthcare, and are interested in technologies that are effective, less expensive and simpler. Although NCIVF is not a cure all, we believe that it has a definite place in the treatment of many couple's infertility.
-Dr. Michael DiMattina
IVF Hope- Natural Cycle IVF "Thinking Outside the Box" 2/24/09
"Albert Einstein's 1905 burst of creativity was astonishing. He had devised a revolutionary quantum theory of light, helped prove the existence of atoms, explained Brownian motion, upended the concept of space and time , and produced what would become science's best known equation e = mc2." Einstein, His Life and Universe by Walter Isaacson, 2007.
Without doubt Einstein thought "outside of the box". He was not afraid to challenge existing theories and try something new. And his theories proved to be so right in so many scientific areas. Einstein humbly stated, "I have no special talents, I am only passionately curious".
And that is how our "IVF Hope" Natural Cycle IVF program began, thinking "outside of the box" and with much curiosity. But I do believe that at Dominion Fertility, we have a very special staff who have very special talent. Because of our high success rates with our Natural Cycle IVF program (44% per embryo transfer in 2008), we decided to launch the "IVF Hope" program to allow patients who were told that there was no hope to achieve pregnancy with their own eggs, another chance.
Since beginning IVF Hope in November, 2008, we have already established a 12 week pregnancy in a 39 year old patient, with a Day 3 FSH level of 20, and who had failed stimulated IVF at another local IVF center. That center told her to adopt or use donor egg IVF. And recently, we had 2 other patients experience "biochemical" pregnancies following treatment with Natural Cycle IVF. One was a 39 year old local dermatologist, who has been infertile for the past 4 years. We performed one cycle of NC- IVF, transferring an 8 cell embryo, but this did not result in pregnancy. She immediately repeated NC-IVF, and this time we transferred a blastocyst embryo which resulted in her biochemical pregnancy. She plans to try again. The third patient was a 38 year old, with a 5 year history of infertility and a Day 3 FSH level of 15.8. She failed treatment with gonadotropins and IUI with a very poor response to the ovarian stimulating drugs. We transferred a blastocyst embryo and she had a biochemical pregnancy in her first attempt. She also plans to try again.
All of these patients had less than a 5% chance for pregnancy, but we are getting results that seem to be "outside of the box". It is too early for us to truly know how many patients will ultimately achieve a successful pregnancy in our extended Natural Cycle IVF program, but we know, so far, that at least one patient has, and at least 2 others were very close.
Let me take a moment to briefly describe our extended NC-IVF program. Simply stated, it is an extension of our existing Natural Cycle IVF program for patients who were told that there is no hope for pregnancy with their own eggs. Such patients traditionally would be best treated using Ova Donor IVF or adoption. NC-IVF allows patients a last chance for pregnancy with their own ova before using donor egg IVF or adoption. We recently transferred two 47 year old patients using NC-IVF but unfortunately, neither achieved pregnancy. Clearly, their chances for pregnancy were less than 1 %, but the embryos were astoundingly high quality 8 cell embryos upon embryo transfer. Both patients plan to try again.
Candidates for the Dominion Fertility Extended NC-IVF Program:
Age: Less than 60 years old and in good health
Menses: Must have regular menstrual cycles
Day 3 FSH: Not restricted
Previous IVF: Patients may have previously failed IVF or have been told that they are not now a candidate for stimulated IVF with their own eggs.
The cost for Dominion Fertility's Natural Cycle IVF is $4,000 total. And it is prorated if the cycle is not completed in the following ways:
If the cycle is cancelled prior to egg collection with no IUI: Cost to the patient is $1,000.
If the cycle is cancelled prior to egg collection with IUI: Cost to the patient is $1,900.
If no egg is obtained, then the cost to the patient is $2,500.
If no embryo transfer is performed, then the cost to the patient is $3,500.
The credits can be used for another attempt or simply refunded, but the total cost for a completed treatment cycle is $4,000. Preliminary testing is required prior to treatment and such testing is not included in the the above costs. (Please speak to a financial counselor for the most up to date costs as prices are subject to change.)
I hope that this post gives everyone a good understanding of our Natural Cycle and IVF program. Dominion Fertility takes pride for "thinking outside of the box". In 1986, we produced the first Gift baby in the Washington DC area, immediately followed by the first Zift babies. We developed Gift and Zift because the IVF pregnancy rates at that time were horrendously low and Gift and Zift resulted in better pregnancy rates for our patients, again, thinking "outside of the box". But with increasing knowledge and technology, the pregnancy rates for IVF boomed and Gift and Zift became obsolete. Because of the high success rates with Dominion Fertility's stimulated IVF program, we decided to embark on Natural Cycle IVF in January, 2007, and because of its success, we have extended this program to include an even wider range of patients.
We invite you to learn more about our Natural Cycle IVF programs on our web site, dominionfertility.com and to continue with your own curiosity. I encourage you to think "outside of your box".
All best wishes, Dr. Michael DiMattina
Natural Cycle IVF for the "Poor Responders" 1/24/09
What can be done for the IVF patient who poorly responds to her ovarian stimulating drugs and now is told to adopt or use ova donor IVF as her only options? And what can be done for the patient who is not a candidate for IVF because of her advanced reproductive age or because her day 3 FSH level is too high and abnormal?
Now comes a recent study in Reproductive Biology online (2008, vol 17, no 2, p 207-212) reporting a 20% pregnancy rate in patients treated with Natural Cycle IVF (NC-IVF) who had previously responded poorly to gonadotropins in a stimulated IVF cycle. In fact, those patients who underwent stimulated IVF had a 5-15% pregnancy rate compared with those who had NC-IVF. The authors concluded that NC-IVF may be a reasonable treatment choice for patients who respond poorly to gonadotropins and who don't make many eggs or embryos. They also pointed out that the patients who used NC-IVF did not incur the expenses of fertility drugs or the pain of multiple daily injections. What I find to be particularly interesting is that this clinic only used NC-IVF as a "last resort" in women with high FSH levels and prior IVF cycle cancellations due to poor response to conventional stimulation protocols. Yet, the pregnancy rates were higher in those patients who underwent NC-IVF compared with those treated with stimulated IVF.
Last week at Dominion Fertility, we treated two 47 year old patients using NC-IVF and both underwent a successful embryo transfer in their first treatment cycle. At this time, they are the oldest patients that we have treated with NC-IVF. Both of these patients were advised that their best chances for pregnancy were with Ova Donor IVF, but both had wanted a chance to try IVF with their own eggs knowing that their chances for success were less than 1% at their age. Amazingly, one patient had a Grade 1, 8 cell embryo for transfer and the other, an early morula. We are firmly convinced that mother nature selects the best egg each month in the natural menstrual cycle as most of the eggs and embryos that we get from NC-IVF patients appear to be of very high quality even in those patients of advanced reproductive age. The above recent report further supports these beliefs.
Also last week, we are pleased to announce that we have referred back to her obstetrician for OB care, our previously reported 39 year old patient who was successful in our NC-IVF program. Her day 3 FSH level was 20 and she was a "poor responder" in her stimulated IVF cycle performed at another local infertility clinic which was unsuccessful. They told the patient to either adopt or do Ova Donor IVF. She then came to Dominion Fertility and underwent one NC-IVF treatment and was successful in her first attempt. This patient had three serious infertility factors, her advanced age, diminished ovarian reserve (day 3 FSH 20), and a poor response to ovarian fertility drugs, yet she became pregnant in her first treatment with NC-IVF. Congrats to her for "hanging in there"!!!!!
-Dr. Michael DiMattina
Natural Cycle Success (patient J.M.) 1/17/09
J.M. is a healthy 36 year old lady with primary infertility (previously never been pregnant) who came to me in June, 2008. Her HSG showed a right hydrosalpingx (a blocked tube full of embryo toxic fluid), that was clearly preventing her from conceiving. In July, a laparoscopy confirmed the hydrosalpingx and the tube was removed as it was irreparably damaged.
Because J.M. was 36 years old, she also had an age factor and was showing some diminished ovarian reserve on both her sonogram and with her serum antimullerian hormone level (AMH) which was only 0.7. She wanted to be aggressive in treating her infertility but she did not wish to immediately go through IVF because of the stress, costs and fertility drugs. So, I suggested Natural Cycle IVF as a less stressful, less costly alternativewhich does not use any ovarian stimulating drugs either.
On November 26, we obtained a single egg produced in her normal natural menstrual cycle, in our office with minimal conscious sedation. The egg collection took less than 3 minutes once the needle was placed into her follicle. During her monitoring, she had only 4 total office visits.
The egg fertilized but on day 3 after the aspiration, the embryo was developing slowly with only a 4-5 cell embryo. Typically, on day 3 a normal embryo would be 8 to 10 cells. Therefore, we continued to culture her embryo to see if the embryo was healthy or whether it had arrested in its growth. Fortunately for JM the embryo continued to grow and a healthy blastocyst embryo was easily transferred back to the patient's uterus. On December 30, a transvaginal ultrasound exam confirmed a 7 week normal appearing pregnancy. The patient could not believe how simple the entire process was.
JM was my last obstetrical sonogram for 2008, and I am most pleased for her. The lesson we learn here is that "what you see may not be what you get". On day 3 her embryo was clearly lagging behind in its development but this does not necessarily mean that all is bad. By allowing the embryo to continue to culture in our lab, it was later evident that there was hope and JM's hope is quickly becoming her reality!
-Dr. Michael DiMattina
Extended Natural Cycle IVF at Dominion Fertility 1/12/09
We just had a 36 year old patient who had failed IVF at another local major center become pregnant after only one treatment with Natural Cycle IVF. What's amazing is that her Day 3 FSH level was 20 (normal is< 10)! And the other center refused to do IVF again with her own eggs, instead recommending ova donor IVF as her only option.
Now, Natural Cycle IVF is clearly no "cure all" for one's infertility but it is so very different from conventional IVF because there are no ovarian stimulating drugs. This allows the body to select out the "best egg" for that cycle and this may offer an advantage compared with conventional IVF.
Dominion Fertility has just begun offering Natural Cycle IVF to patients who have failed to achieve pregnancy using other methods or whose Day 3 FSH level is elevated. This patient is the first in our extended NC-IVF program to become pregnant!
-Dr. Michael DiMattina
Does your infertility clinic use vitrification when freezing blastocyst embryos? They should. 1/8/09
Blastocyst embryos cryopreserved by vitrification and later transferred back into the uterus have the same pregnancy rates as freshly transferred embryos. In other words, using vitrification, the chances for pregnancy are now the same whether the embryos were freshly transferred or cryopreserved and later transferred in a frozen-thaw cycle. This is a major breakthrough in reproductive medicine and most patients are unaware of this. But not all infertility clinics are utilizing this superior method. Many are still using the "slow cooling" method for freezing their blastocyst embryos which results in inferior embryo survival and pregnancy rates(Lieberman, 2003). In view of the excellent survival rates and better implantation rates, we at DF have decided in 2007 to exclusively vitrify all blastocysts for embryo cryopreservation. And you should know that vitrification is no longer considered experimental. The FDA recently approved this process for Day 5, blastocyst cryopreservation.
Let me explain this process some more and then give you another patient success story. Cryopreservation, or freezing of embryos, is one of the most common procedures performed in the IVF lab. Couples choose to freeze their embryos for many reasons, although the most common is to increase their chances for pregnancy at a later date should the fresh embryo transfer not be successful, thereby avoiding another oocyte aspiration. Also, if the extra embryos are successfully frozen and stored, the couple can elect to have only one or two fresh embryos initially transferred, knowing that they can rely on the frozen-stored embryos as a "backup".
Cryoprervation has always had one major drawback, i.e. poor survival and low pregnancy rates relative to embryos from a fresh cycle. This is because the process of freezing and thawing of embryos exposes the cells to a number of harsh and damaging conditions, such as ice crystal formation. Take a look at the items in the back of your freezer sometime and you can understand the stress placed on embryos using traditional "slow cooling" freezing methods. Fortunately, vitrification has allowed us to overcome these drawbacks.
Vitrification (from the Latin word vitreous, meaning "glass like") is the process of cooling a liquid so quickly that ice crystals do not form, thus eliminating the sharp points that damage embryos during freezing. This process has been shown in numerous studies to consistently increase embryo survival rates and decrease the amount of damage sustained by the embryo. Blastocysts are embryos that have reached the stage of development that directly precedes implantation (the attachment of the embryoto the uterine wall) and represents the completion of a critical step in genomic activation indicating a high developmental potential. In other words, a good blastocyst has a really good chance of making a baby! When combined, the vitrification of blastocyst embryos affords the patient the greatest chance of becoming pregnant from a frozen embryo transfer. The pregnancy rates are so high in fact, that several studies have shown them to be equivalent to a fresh embryo transfer.
What does all of this mean for a patient? It means that vitrified blastocysts now represent a useful and dependable step in the treatment of infertility. With such a high degree of reliability, frozen embryo transfers need not be used as only a backup for a failed IVF cycle, but can be used by patients when considering how many embryos to transfer in a treatment cycle. You really don't need to put all of your eggs in one basket (so to speak) when you consider that a frozen embryo transfer using vitrified blastocysts has the same pregnancy rates as a fresh IVF cycle.
Now for our patient success story: J.M. is a 40 year old patient of mine with no children. She was unable to achieve a successful pregnancy with her own ova and so we agreed to use donor ova IVF. By design,all of her embryos produced were vitrified as blastocysts and stored. In June, 2008, 2 blastocysts were thawed and transferred and she is now at 29 weeks gestation and expecting to deliver in the near future. She has 5 more vitrified blastocysts stored and available should she desire to have further children.
In my opinion, all IVF clinics should be utilizing blastocyst vitrification as it is no longer considered experimental and it results in superior pregnancy rates compare with the "slow cooling" method.
- Dr. Michael DiMattina
Avoiding Hyperstimulation Syndrome (patient E.M.) 12/12/08
At Dominion Fertllity our incidence of severe hyperstimulation syndrome (HSS) is less than 1%. That's less than the reported national average of 1 - 5%. Why does HSS occur less often for our patients who are using ovarian stimulation drugs?
Upon seeing that a patient is showing signs of HSS, we will advise that she omit her fresh IVF embryo transfer, and instead have all of her quality embroys frozen and stored for later embryo transfer in an unstimulated cycle. By doing this, her ovaries are able to recover and this greatly reduces her risk for severe HSS. Also, our frozen thawed embryo transfer rates exceed 65%, so we belive this approach is the safest and most effective method to obtain a successful pregnancy.
Example:
E.M. is a healthy 28 year old female with no children. The couple's infertility evaluation was normal and they tried to conceive using Clomid with IUI three times without succcess. So, they opted for IVF.
She stimulated very well with 22 eggs obtained, but she began to experience some HSS. Therefore, her fresh embryo transfer was cancelled and all of her 14 embryos were frozen and stored. This allowed her ovaries to promptly recover and avoid severe HSS. Two months later, one frozen thawed embryo was transferred in her normal natural menstrual cycle with no drugs and she became pregnant.
The lesson here is that most patients can often avoid severe HSS by using our approach described above. Our pregnancy rates using fresh or frozen thawed embryos are virtually equivalent and there are no increased risk for birth defects in babies born from frozen thawed embryos.
A Misdiagnosis? (patient M.B.)
At DF we often provide second opinions to infertility patients who are not getting pregnant elsewhere.
M.B. is a healthy 32 year old female with primary infertility. Previously, she was diagnosed by two other local infertility clinics as having premature ovarian failure (menopause). She came to DF seeking ova donor IVF. Prior to her seeing us, she went to one of the other clinics and was treated with 3 cycles of gonadotropins with no response or eggs produced. She was told that her ovaries were resistant to the drugs and to go adopt or use ova donor IVF.
At her first visit at DF, her records were reviewed and we believed that she was misdiagnosed. We believed that she did not have premature ovarian failure and that she could get pregnant with her own eggs. We advised her to try the gonadotropins again, but we informed her that it may take 30 to 60 days before she would see a response to the stimulation drugs.
Indeed, after 46 days of stimulation, her ovaries began to demostrate such an excellent response that in order to avoid a multiple pregancy we decided to convert her treatment to IVF. Seven eggs were obtained and 2 fresh embryos transferred. She became pregant with twins and was sent back to her OB/GYN ecstatic over this turn of events. Furthermore, 4 additonal embryos were frozen and stored for future use. This is a pretty amazing outcome given that she had originally been told that her only options were adopt or ova donor egg IVF!
Her proper diagnosis was hypothalamic amenorrhea, which is a hormone imbalance of the brain, and not an uncommon cause of amenorrhea.
Persistence can pay off (patient PH)
The age related decline in fertility is a factor in many of our patients. Although it is inequitable, a woman's age matters more than a man's age when considering fertility treatment and success. Over the age of 35, a woman's fertility begins to decline and the rate of pregnancy loss increases leading to lower odds of success. Unfortunately, there is no test that can predict what percentage of a woman's eggs are healthy (able to produce a healthy child). However, persistence can pay off in such cases and in this light let us review the case of PH.
PH was about to turn 41 when she and her husband of 6 months came to see me as a new patient. After routine testing revealed no clear etiology to their infertility except PH's age of 41, the couple elected to pursue an aggressive path of treatment with IVF.
IVF #1 resulted in 10 eggs and 5 perfect day 3 embryos were transferred and 3 cryopreserved. The pregnancy test was negative.
IVF #2 resulted in 15 eggs and 5 high quality day 3 embryos were transferred. The 3 cryopreserved embryos were thawed, but none were of sufficient quality to transfer. The pregnancy test was negative.
IVF #3 resulted in 18 eggs, 8 excellent quality embryos were transferred on day 3 and 8 were cryopreserved. The pregnancy test was positive. Initially there were 3 gestational sacs, but 2 were empty with no fetal pole inside. PH delivered a healthy 8lb 15 oz girl at full term.
But the story doesn't end there...last year PH returned at age 44 for a frozen embryo transfer (FET) of her remaining embryos. These had been frozen on day 3 so we elected to thaw all of them and transfer the viable embryos on day 5. PH had 5 blastocysts and one morula transferred, and again the pregnancy test was positive. Although initially there were 2 sacs, only one contained a fetus with a heartbeat and she was sent off to her OB Gyn for pregnancy care!
This story clearly demonstrates the impact of age upon fertility. It took 33 eggs to find one good one for PH's first pregnancy. However, it is amazing that the 3rd IVF cycle went so well including the fact that the frozen embryos yielded a dividend a few years later. Sometimes good things happen to nice people, and PH was an excellent patient, asking appropriate questions but understanding her options clearly.
Secondary Infertility Can Be Tough to Treat (patient SG)
Although many of our patients have never been pregnant there are a significant proportion who suffer from secondary infertility. To illustrate just how unpredictable fertility treatment can be here is the story of SG.
When SG initially presented for discussion of fertility treatment, none of us thought that her case would be very difficult. She was 30 years old and she and her husband had 2 previous pregnancies (one resulted in the birth of her son and the other was an early pregnancy loss). However, she and her husband had failed to conceive after a year and were getting frustrated.
Initially the thought was that this was a timing issue but when she failed to conceive after 3 clomid/IUI cycles in spite of all the tests (HSG, semen analysis, hormones) being normal it was time to up the ante and consider IVF.
She elected to enroll in the financial guarantee program (FGP) and I felt very confident that we would soon see success. Her first IVF went well but the stimulation (luteal lupron with 125 Follistim and 75 Menopur) was failrly mild and 7 eggs resulted in 3 embryos. Interestingly, sperm attachment to the eggs appeared poor suggesting that perhaps their issue was inefficient fertilization. Unfortunately, she failed to conceive and very soon afterwards attempted IVF again.
The 2nd IVF cycle was better both in terms of eggs and embryos. We switched to microdose lupron flare and the cycle yielded 14 eggs and ultimately 4 excellent blastocysts. We transferred 2 but again the pregnancy test was negative. Finally, we did a natural cycle FET and she conceived. She delivered a full-term healthy girl earlier this year.
So what lessons can we learn from this story? First of all, it is tough to predict what treatment will yield success. If you had told me after initial testing that this couple would require MDL flare IVF with ICSI to have another child, then I would have shaken my head in disbelief. Yet, that is exactly what we needed to do to gain success.
Secondly, the benefit of the FGP approach can be seen here as the couple clearly received more treatment than they paid for initially with 2 fresh IVF cycles and an FET. Finally, their story demonstrates that physicians need to look at each couple with fresh eyes when treatment is not yielding the desired results. Finally, I did tell this couple to use birth control if they didn?t want any more children as I have seen spontaneous pregnancies in such cases.
Fertility Treatment Is Dynamic (patient BE)
Medicine is a dynamic discipline and all patients respond differently and even the same patient may demonstrate different responses to the same treatment. It is important to individualize care to each patient and not practice cookie-cutter medicine. The case of BE is an example of how a patient may need a flexible approach to her treatment plan.
BE presented as a new patient at age 30 with over a year of infertility. She had been diagnosed with PCOS by her Ob Gyn but had failed to conceive with 5 cycles of Clomid at doses of 50 and 100 mg. We began treatment with metformin (Glucophage) and she conceived within 4 weeks. Her pregnancy was uneventful and she delivered a healthy 6lb 11 oz baby.
She returned 2.5 years later desiring another baby. She had restarted metformin 6 months earlier and had again failed to conceive with 6 months of clomid with her Ob Gyn. She and her husband elected to undergo ovulation induction with Gonal F. After 3 excellent cycles yielding a single mature follicle she had failed to conceive.
The couple then elected to pursue IVF. We started stimulation at a low dose of 75 IU of Gonal F and 75 IU of Menopur. Her response was excessive and after 24 eggs were retrieved we elected to freeze all of the embryos to avoid severe OHSS. 9 embryos were frozen and she underwent an FET of 2 embryos that resulted in a twin pregnancy. One of the sacs contained no fetal pole but she eventually delivered a healthy boy weighing 7 lb 8 oz.
One year after delivery she underwent another FET but failed to conceive. In spite of their concerns about OHSS the couple elected to pursue another IVF cycle. This time I cut her dose in half to 37.5 IU of both Gonal F and Menopur. The stimulation was perfect with 8 eggs retrieved and 2 blastocysts transferred. She had no symptoms of OHSS. She conceived and just delivered her second son who weighed a hefty 8 lb 11 oz.
This case demonstrates the dynamic nature of our branch of medicine. Here a patient conceived and delivered 3 healthy children through 3 different approaches. This case also reveals the need to consider past response to fertility meds when planning future cycles. There are few patients that will respond so well to fertility shots at age 36 that you can prescribe such a low dose. However, this is where the art of medicine comes into play as the patient relies upon the experience and judgment of her physician to make the best decision possible on her behalf.