Early trigger modified natural cycle IVF/IVM as an attractive option for poor responders. Women with unexplained poor quality embryos

Explained by: Seang Lin Tan, MBBS, FRCOG, FRCSC, FACOG, MMed(O&G), MBA, OriginElle Fertility Clinic & Women’s Health Centre
Category:
From this video you will find out:
  • What is IVM?
  • What are the indications of In Vitro Maturation in infertility treatment?
  • Natural IVF cycle, modified cycle, mild IVF and conventional IVF – what are the differences?
  • How does GnRha early trigger work?
  • What are the advantages of IVM in unstimulated ovaries? What is the cost?
  • What are the patient case studies of women who had success with this method?
 

Is modified natural IVF cycle suitable for poor responders?

In this session, Dr. Seang Lin Tan, MBBS, FRCOG, FRCSC, FACOG, MMed(O&G), MBA, Professor in Obstetrics and Gynecology, Medical Director, OriginElle Fertility Clinic and Women’s Health Centre; Founding Director, McGill Reproductive Centre has been talking about IVM as an option for poor responders and how can it improve their chances to achieve pregnancy.

Is modified natural IVF cycle suitable for poor responders? - Questions and Answers

In my surrogate, ‘a functional cyst’ has been found when my doctor checked her when she visited the clinic at the beginning of her cycle, so she could not be given the Diphereline shot to start the process. The doctor gave her some medication and will check it again to see if it was gone. She could take the Diphereline at the beginning of her next period. Is this something I should be worried about?

I don’t think this is something you should be very worried about. This can happen to some patients, we are talking here about preparing the surrogate for embryo transfer. Sometimes, some women especially, if they’re young do produce functional cysts, and this functional cyst may stay there for a month or two months or three months, but they invariably go with themselves. I think here is where patience is of the virtue because the surrogate is obviously young, I would just wait for the surrogate to have the cyst disappear before starting the cycle. In the meantime, freeze the embryos for the transfer in preparation for the surrogate, that’s all.

Could someone with an AMH level of 0.44 get a successful pregnancy with IVM?

We’re talking here about a potential poor responder with a low AMH level. I would say that in most cases, we would try IVF in the first instance. Here, in Montreal and Ottawa, we have had healthy babies born with IVF even if the AMH level is lower than that level. Having said that, if we get a poor response to IVF, then in the case we would use IVM, and we’ve had healthy babies born with IVM. These patients are the ones who are likely to b poor responders.

I’m 41years. My AMH is 0.2, FSH 32, I have very irregular periods. In a recent blood test, the doctor said my AMH is undetectable? Can I take DHEA, or what else can I do? I am a poor responder, I had only 3 follicles respond to stimulation during the last cycle.

I would need to know a bit more details about that previous cycle. In principle, as I said, an FSH of 32 and an AMH at 0.2 obviously says that there is an ovarian failure. The irregular periods are probably because of ovarian failure. Now, if the doctor wishes to do IVF, you can try IVF first. However, if you try IVF and you’ll find that there are virtually no eggs, you are the type of patient that is the topic of today’s lecture, we could try IVM. If you live in North America, we would have you come to Montreal for about two weeks and do everything here. If you live in Europe, we could work together with the center in Europe, do a telephone consultation, you would give them our protocol, they could do all the blood work and the essential, tests in Europe, have the first one or two ultrasound scans are done there, and we might give them a small dose of Puregon or Gonal-F f on day-4, day-6, then day-8, as I showed you on the slide. After that, as soon as the biggest follicle is 8-10 millimeters, you would need to come to Montreal or Ottawa, and then after that, as soon as the biggest follicle is 12 to 14 mm, we trigger and collect the eggs. The length of time you’ll need to spend in Canada will be about a week to 10 days if you’re doing a fresh transfer. We can also freeze the embryo, you fly back to Europe, and then you come back as a subsequent time to do the transfer. Nowadays, flying from Europe to Canada is pretty easy except for the pandemic obviously, which changed our lives but normally there are daily flights from London, Paris, Rome, Spain, all the major capitals in Europe, so coming to Montreal or Toronto is very easy. From Montreal, for example, it’s a 1.5 hour or 2-hour drive to Ottawa. We can fly directly to Ottawa as well, then have a stopover in Montreal.

What’s the cost of IVM at your clinic (Originelle, Montreal)?

If you exclude the cost of drugs an IVM cycle, we’re talking about 4 to 5 thousand dollars. The cost of drugs depends on where you buy them, you need a bit of a drug. I would suggest buying drugs in Europe because the cost of drugs, in Europe, is a fraction of the cost of drugs in North America. Drugs in North America for IVM might add an extra 1 or 2 thousand dollars, but in Europe, it might cost a couple of hundred dollars.

I have recently experienced a failed ICSI cycle after getting 11 fertilized eggs. Unfortunately, none were of good quality after day-3 and seemed not viable for transfer by day-6. Egg donation was recommended for me now. Would IVM be an option for me?

IVM would be an option. Whether it would be the best option for the next cycle, I can’t really know. In these cases, I would say it’s probably best if you contact us directly. You can send us a copy of your medical file, we could examine it in detail first before giving some advice. The information you’ve provided is just too general. Obviously, 11 fertilized eggs and then to get poor quality embryos in one cycle itself is not an absolute indication for IVM, but it would be an option. It will depend on your age, other factors, the partner’s DNA fragmentation, whether any other factors are important to consider first, whether PGT-A is considered or can be done in your country, and so on.

Can egg quality be improved with DHEA and CoQ10 alone? Is there anything else I can do to improve egg quality? If IVM isn’t an option for me?

There are many different ancillary treatments, which can so-called improve egg quality. DHEA, CoQ10 is widely known, there’s Myo-inositol that you can try, there’s MACA from South America that you can try, some people have taken baby aspirin, and so on, but none of these methods are guaranteed to work. We ourselves do give, in some cases, growth hormone to improve egg quality as well. Regarding this method, you should probably discuss it with your own doctor because I would never like to give patients advice that is overruling the patient’s own doctor.

Is there any age limit for IVM?

The age limit for IVM is the same as it is for IVF. Some doctors will stop doing IVF for women who are 41-43. They will not do IVM as well in such a case. The law here in Quebec says that it’s not possible to treat a woman with her own eggs if she’s more than 46 years old. Obviously, for IVM, it’s the same, we have to stop it if a woman is 46, but in Ontario, there’s no age limit, so long as the patient has a chance and she understands the chances are small, the treatment can be done.

What is your opinion about Duo Stimulations- is it a similar method to IVM?

It’s not the same. Duo-stim is a method of stimulation for IVF. In Duo-stim, what they do is that they will stimulate ovaries by the antagonist protocol, collect all the eggs above about 10 or 12 diameters, and about two days later, after the egg collection, start stimulation again and then do a second egg collection. In our center, we even did the triple stim, and you do get some successes. However, medication cost is expensive because we’re talking about 2 or 3 rounds of egg collections in one cycle. The cost of distribution methods is quite different from IVM, where we are trying to give little medications and collecting eggs when they are immature to be collected. So, no, Duo-Stimulations is not similar to IVM.

Authors
Seang Lin Tan, MBBS, FRCOG, FRCSC, FACOG, MMed(O&G), MBA

Seang Lin Tan, MBBS, FRCOG, FRCSC, FACOG, MMed(O&G), MBA

Dr. Seang Lin Tan is an internationally recognized IVF specialist. He was awarded the Howard Eddey Gold Medal by the Royal Australasian College of Surgeons and the MRCOG Gold Medal by the Royal College of Obstetricians and Gynaecologists in London, UK. He undertook a fellowship in REI with Prof. Howard Jacobs at Middlesex Hospital in London and another fellowship with Prof. Robert Edwards, (Nobel Laureate in Medicine 2010 and inventor of IVF) and Prof. Stuart Campbell at King’s College Hospital in London. He was the Founding Medical Director of the London Women’s Clinic, UK. He was appointed James Edmund Dodds Professor and Chairman of the Department of ObGyn at McGill University and served 3 terms from 1994 to 2010. He founded the McGill Reproductive Centre and led it for 16 years, establishing it as one of the premier IVF centres in the world. His team achieved one of the highest pregnancy rates in the world and had many national and world firsts, including the first IVM (IVF without hormonal stimulation), the first babies born after PGD and the first egg freezing baby born in Canada. He reported the world’s first 4 children born from combined IVM and egg freezing and have had over 40 babies born from women who froze their own eggs and then used them to conceive. He has referred patients from around the world for fertility treatment, including from the major centres across North America and Europe and has trained doctors who have gone on to lead major programs in Canada, USA, Oxford, Turkey, Middle East and New Zealand. A review for the Canadian Institute of Health Research (CIHR) by John Collins showed that he had the highest number of papers published of any IVF doctor in Canada and his work has been published in leading medical journals, including The Lancet, New England Journal of Medicine and Nature. Most recently, his research won the 2016 best basic science research award at the ESHRE scientific conference. I was founding President of the International Society of IVM, founding President of the Global Chinese Association of Reproductive Medicine and Vice-President of the International Society of IVF. In 2018, he was invited by the American Society of Reproductive Medicine as one of the top 40 IVF specialists in the field to contribute to a special volume commemorating the 40th anniversary of the birth of Louise Brown, the first IVF baby born in the world. He receives patients from around the world for egg freezing, IVM, egg donation and surrogacy. He is regularly invited to speak at international medical conferences and has published almost 300 peer-reviewed articles, 15 books and hundreds of presentations and book chapters.
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Caroline Kulczycka

Caroline Kulczycka is an International Patient Coordinator who has been supporting IVF patients for over 2 years. Always eager to help and provide comprehensive information based on her thorough knowledge and experience whether you are just starting or are in the middle of your IVF journey. She’s a customer care specialist with +10 years of experience, worked also in the tourism industry and dealt with international customers on a daily basis, including working abroad. When she’s not taking care of her customers and patients, you’ll find her travelling, biking, learning new things or spending time outdoors.

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