Minimal IVF

If you or your partner are interested in pursuing fertility treatments, but want to do so with less medication, then Minimal IVF might be a good option for you. Minimal IVF is an alternative IVF treatment in which less medication and less aggressive ovarian stimulation is performed mimicking a more natural cycle as well as being a less costly alternative to a Standard IVF cycle especially for those patients without insurance coverage.  

In a Standard IVF cycle, daily injectable medications (gonadotropins; Gonal-F, Follistim, Bravelle, Menopur, Repronex) are used for about 8 to 12 days to aggressively stimulate the ovaries to produce as many mature eggs (follicles) as possible. In addition, a medication called Lupron (an injectable daily medication used to suppress the body from ovulating) is given in combination with the stimulation medications to help prevent a spontaneous ovulation. During the stimulation cycle, multiple ultrasounds (follicle scans) and blood work are needed to monitor the growth of the ovaries and their response to the daily medications. Once there are an adequate number of mature follicles , an injection of is given to finish maturing the eggs and allow for ovulation to occur. 

Prior to the ovaries releasing the eggs  a retrieval is performed to aspirate the eggs and isolate them in the embryology lab. During the egg retrieval, you will be deeply sedated so as not to feel any discomfort during the procedure. A sperm sample from the partner or donor sperm is then washed and prepared to allow insemination (placing sperm directly with the eggs in a petri dish) in the embryology lab or in some cases Intracytoplasmic Sperm Injection or ICSI is performed where the embryologist can pick a normal sperm and inject it directly into the egg to increase chance of fertilization.   For fertilization to occur, a sperm must penetrate the outer shell of the egg and penetrate the outer layer of the egg.  ICSI is generally recommended if there are severe sperm abnormalities present or if there is concern for fertilization problems or issues such as in "unexplained infertility" and severe endometriosis cases.  In general, only 65-80% of mature eggs will fertilize normally and become embryos even when ICSI is performed for male factor. Once the eggs are fertilized, they will grow in the lab for 5 days before an embryo transfer is performed with use of a thin catheter to place the embryo into the uterine cavity through the cervix under ultrasound guidance to ensure proper placement. 

The day of embryo transfer is determined by the number of good quality embryos available. In general, there needs to be at least 4 to 5 good quality embryos available on Ideally, the embryo transfer will be performed on Day 5 or blastocyst stage (a highly developed embryo with a high potential for pregnancy success). This also allows us the ability to select the best embryo(s) to transfer to the uterus. In cases where there are only a few embryos available, a Day 3 ET is performed since the uterus is a better incubator than the embryology lab. In general, only 1 blastocyst embryo is transferred. . If there exists remaining high quality blastocysts available after the embryo transfer then freezing or cryopreservation can be done for future frozen embryo transfer(s) and attempts at pregnancy. In addition, patients will need progesterone supplementation often in the form of daily intramuscular injections (IM) for about 2 weeks and an additional 2 to 3 weeks if pregnant. 

In a Minimal IVF cycle, medications such as Clomid or Letrozole (Femara) which are oral medications are taken on cycle days 3 through 7 initially and then several days of injectable medications are then added to help gently stimulate the ovaries to produce several mature eggs (2 to 5 follicles) versus in a Standard IVF cycle where often there can be 10 to 15 follicles or more. Another medication may be given to prevent ovulation as well if needed. Usually there will be 2-4 monitoring visits (ultrasounds, bloodwork, urine LH testing) needed to determine timing of trigger shot and egg retrieval as in a Standard IVF cycle.

If only 1 or 2 dominant follicles develop during Minimal IVF stimulation, it might be necessary to cancel the IVF cycle. In cases where the tube(s) are open or patent, then an intrauterine insemination (IUI) can be performed rather than proceed with the egg retrieval since there would only be 1 or 2 possible eggs retrieved, and fertilization must still occur (at the usual rate of 65-80%) for the eggs to become embryos, resulting in very low numbers of embryos (1 or 2 or possibly none). If the woman has tubal factor (blocked or missing tubes), the cycle probably should be cancelled and a Standard IVF cycle be attempted later. Since no medications are given to prevent the natural LH surge (spontaneous ovulation), there exists the possibility that up to 30% of Minimal IVF cycles may have a spontaneous LH surge on their own which could result in the early release of the eggs before the retrieval can be performed. This could result in fewer eggs retrieved or even in some cases no eggs obtained since they would have already been ovulated or released. A lighter sedation can also be used for the egg retrieval since there are generally fewer eggs to aspirate. Once the eggs are fertilized, a Day 5 embryo transfer will usually be performed but, there is generally lower number of embryos available. Embryo freezing is also less likely to occur since there will be fewer eggs resulting in fewer embryos to work with. In addition, progesterone vaginal suppositories are used instead of IM injections for pregnancy support.

Advantages of Minimal IVF versus Standard IVF

Advantages of Minimal IVF include less medications, daily injections and monitoring visits as well as overall costs (see table below). In addition, minimal IVF usually causes less discomfort from enlarged ovaries and significantly less incidence of Ovarian Hyperstimulation Syndrome due to less medication being used.

Disadvantages of Minimal IVF versus Standard IVF

Disadvantages of Minimal IVF include higher cycle cancellation rate (25-30%) because of lower ovarian response to less medications (fewer large follicles), increased risk (25-30%) of spontaneous LH surge (ovulation) leading to cycle cancellation or fewer or no eggs successfully retrieved, less eggs available for fertilization, less embryos available for use. Generally a Day 3 embryo transfer will be performed and there is significantly lower possibility of excess embryos to freeze. In addition, Minimal IVF pregnancy rates are usually less than half as successful as Standard IVF pregnancy rates due to these above factors. 

It is very important to realize that not all ovarian follicles will contain an egg, that not all eggs are good eggs and that not all eggs will fertilize to form embryos. In addition, not all embryos will be good embryos and not all good embryos will become pregnancies.

 Previous studies have shown that only 20% to up to 50% of embryos may make it to the blastocyst stage. This will also affect the number of embryos that may be available for freezing (cryopreservation) since we only freeze embryos that have developed to the Full or Expanded blastocyst stage. 

Treatment Specific Pregnancy Rates:

  • Successful Pregnancy Rates for a normal, fertile couple is around 20% to 25% chance per month with timed intercourse. However, pregnancy rates in women decrease with advancing age and miscarriages and risks of abnormal pregnancies (Down's and Turner's syndrome) increase with age.
    • Fertility rates are highest in women in their late teens to late twenties (30% chance per month)
      • >35 years of age: 15% chance per month
      • >40 years of age: 5 to 10% chance per month
      • >43 years of age: <5% chance per month
      • Background miscarriage rates for any pregnant couple is around 15 to 20% chance
      • Age 35, miscarriage rate if >25%
      • Age 40, miscarriage rate is >30%
      • Age 45, miscarriage rate is >50%
  • Couples who are infertile have less than a 5% chance of pregnancy per month without treatment but this does depend on the infertility factors present (no sperm, blocked tubes or ovarian failure have a zero% chance).
  • Most infertility treatments are designed to try and improve the <5% chance per month to closer to the normal rate (20%) if possible (depends on female age and other infertility factors such as ovulation disorders, sperm abnormalities, tubal disease, pelvic adhesions, endometriosis, etc.).  
  • These below quoted pregnancy rates are based on female age <35 years old. In women over age 35, these quoted pregnancy rates will be lower, especially in women over age 40 (unless using Donor eggs).
    • No treatment
      • <5% chance per month
    • Ovulation induction (Clomid or Femara and hCG injection)
      • 5 to 12% chance per cycle
    • Ovulation induction and intrauterine inseminations (IUI)
      • 8 to 15% chance per cycle
    • Stimulated Ovulation and IUI (SOIUI; using injectable gonadotropins)
      • 10 to 25% chance per cycle
    • Minimal IVF
      • 20 to 35% chance per cycle
    • Standard IVF
      • 40 to 60% chance per cycle
    • Frozen embryo transfer (if had excess available embryos to freeze)
      • 40% chance per transfer cycle
    • Donor Egg IVF
      • 50-70% chance per cycle
    • PREG IVF Refund Program
      • Qualifying program with inclusion and exclusion criteria.
      • 3 full Standard IVF cycles with all frozen embryo transfers and if no successful pregnancy then a 90% refund returned (medications are not included in this program)
    • Multi-Cycle Plan
      • Non-qualifying, no refund program. 2 full Standard IVF cycles with all frozen embryo transfers to be completed within 12 months (medications are not included in this program)

NOTE: All medications and treatments are approximate and subject to change.