Heard of LOW DOSE IVF?

A fertility expert tells us about a more affordable version of in vitro fertilisation that gives hope to more people and holds many other benefits too.

“One afternoon a domestic worker came to my office,” says Dr Goolam Mohamed, chair of the Sandton Fertility Centre in Johannesburg. “She was a single 38 year-old with a deep sadness on her face. She told me that she had had two ectopic pregnancies and her fallopian tubes had been cut off. She said she was depressed and had no desire for anything except a child.

“I knew she could not afford traditional in vitro fertilisation, so I tried a different process at a very low cost.

“An ultrasound showed that she had a good number of eggs, so instead of injecting hormones, I administered oral ovulation induction agents. To my delight, she produced six follicles, which I then harvested using local anaesthesia to save costs. Five eggs were harvested. “Because she was single, we got sperm from a donor. Fortunately, out of the five, two eggs grew to a day-five embryo of a high quality. These embryos were transferred into her uterus, and to her luck, she conceived twins.

“The babies were delivered at a government hospital. A year later, she came back to see me with the two children in her arms. Before me was a different woman, full of zest and purpose – and that has given me immense joy.”

HOW DOES IT WORK?

In vitro fertilisation (IVF) starts with the harvesting of oocytes (or eggs). These can be harvested during your natural menstrual cycle or through follicle stimulation. There was a belief

– it still persists today – that many eggs are required for a successful pregnancy, explains Dr Mohamed. Just over a decade ago, though, some clinics started using a milder form of follicle stimulation, with a view to collect fewer (but still healthy) eggs. It is a more affordable process. Conventional IVF is still commonly used. It produces more eggs and good results, but it is expensive, tedious and can cause a lot of discomfort.

The “light” form of IVF with which Dr Mohamed has had success is known as mild-stimulation IVF, or MS-IVF.

AS GOOD AS NORMAL IVF?

MS-IVF has certainly become more popular, but some doctors are still reluctant to incorporate this approach into their practice because they worry that fewer eggs harvested will not produce similar pregnancy success rates as conventional IVF, Dr Mohamed says. “In fact, this is not the case, because with MS-IVF, the hormonal environment in the ovary is closer to that of a natural cycle. So, while fewer eggs are harvested during MS-IVF, there will be similar numbers of competent, normal eggs available for fertilisation compared to conventional IVF. Mild stimulation also produces an appropriately synchronised womb lining to receive the embryo.”

These days, MS-IVF is used for older patients, and even for those classified as “poor responders” with pregnancy success rates that are as good as with conventional IVF.

More good news is that there are other benefits to this milder form of treatment.

BETTER FOR YOU AND BABY

There are still many disadvantages to conventional IVF. Apart from the cost and discomfort, the two most devastating complications of conventional IVF are ovarian hyper-stimulation syndrome

(OHSS) and multiple births.

“I am reminded of a past case that ended up being the most frightening one I have had to deal with yet,” Dr Mohamed says. “The patient was diagnosed with polycystic ovary syndrome, meaning she would produce many oocytes with minimal stimulation, and she was at risk of being hyper stimulated and developing OHSS. I started her stimulation with the lowest possible hormone dose in the conventional programme. In this protocol, we need to first give an injection to make the ovaries inactive, so that we can stimulate growth of the eggs. She then produced 20 oocytes. I transferred two, and she conceived.

“A few days later she came back to my office short of breath, with a greatly distended abdomen and waterlogged legs. She had indeed developed OHSS and had to be admitted to the intensive care unit for monitoring and treatment.

“I sat at her bedside for four days and eventually had to drain the liquid from her tummy in order to get her out of this

life-threatening condition. Fortunately, she recovered and delivered one baby, but this case still shows how dangerous conventional IVF can be.”

Of course, multiple births, which are typical of fertility treatment, also pose extra risks, in that they predispose you to high blood pressure, diabetes, premature birth and miscarriage, and they increase your chance of delivering via a caesarean section.

For the foetus, there’s an increased risk of prematurity and cerebral palsy.

RISK AVOIDANCE

Dr Mohamed says that the newer technology used in MS-IVF decreases the chances of OHSS and multiple pregnancy. “OHSS results from an excess in hormones and causes ovaries to swell and become painful, but thanks to the way MS-IVF triggers ovulation, it is not common at all. Furthermore, because MS-IVF produces good-quality embryos, we need only transfer one embryo at a time, which is a much safer option that reduces the incidence of multiple births to zero.

“Perhaps most importantly, babies born after MS-IVF have also shown a higher birth weight compared to those born from high-dose stimulation because the process is softer, requires lower hormone doses and is sometimes even shorter. It is better tolerated than the high-dose protocol, and symptoms of depression and anxiety in the mother are also much less.”

And then there is the cost. Medication is the biggest cost in IVF, and with mild stimulation it is possible to cut out some medication completely and lower the dose of others, which decreases the cost significantly, says Dr Mohamed.

IS IT FOR YOU?

So how do you determine if you are a viable candidate for MS-IVF? This method is useful for both young and older patients, poor responders and hyper responders. In today’s environment, a tailored protocol for each individual is possible, so it is best to be assessed by a fertility specialist and ask about it. The main disadvantage of MS-IVF is that cycles have to sometimes be cancelled due to poor responses, meaning that fewer than three eggs are obtained. But in many selected patients, two or three high-quality oocytes are all that’s needed for a positive result. Cycle-cancellation rates depend on age, the number of eggs available and the protocol used. In properly selected patients, cancellations can be brought down to the bare minimum. ●

MEDICATION IS THE BIGGEST COST IN IVF, AND WITH MILD STIMULATION IT IS POSSIBLE TO CUT OUT SOME MEDICATION COMPLETELY AND LOWER THE DOSE OF OTHERS, WHICH DECREASES THE COST SIGNIFICANTLY.