Minimal Stimulation and Natural Cycle In Vitro Fertilization

114 Pages·2015·3.372 MB·English

by  Gautam N. Allahbadia, Markus Nitzschke (eds.)

Minimal Stimulation
and Natural Cycle
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Gautam N. Allahbadia
Markus Nitzschke
Editors
123
Minimal Stimulation and Natural Cycle
In Vitro Fertilization

Gautam N. Allahbadia
Markus Nitzschke
Editors
Minimal Stimulation
and Natural Cycle
In Vitro Fertilization
Editors
Gautam N. Allahbadia Markus Nitzschke
Rotunda - Blue Fertility Clinic Department of Assisted Reproduction,
& Keyhole Surgery Center Obstetrics and Gynecology
Medical Director, Rotunda - ICI – Instituto Canario de Infertilidad –
The Center for Human Reproduction Las Palmas de Gran Canaria
Mumbai Spain
India
ISBN 978-81-322-1117-4 ISBN 978-81-322-1118-1 (eBook)
DOI 10.1007/978-81-322-1118-1
Library of Congress Control Number: 2015952830
Springer New Delhi Heidelberg New York Dordrecht London
© Springer India 2015
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This book is dedicated to all sincere health professionals,
who are interested in learning more about the fascinating
fi eld of minimal stimulation and natural cycle IVF.

Foreword
S ince the birth of the fi rst baby conceived by in vitro fertilization (IVF) in
1978, reproductive medicine has progressed rapidly. Gonadotropins have
been introduced and the laboratory technologies have improved signifi cantly,
especially in the 1980s and in 1990s. In recent years, however, improvements
besides the introduction of new cryopreservation techniques have been only
marginal. In an attempt to nevertheless further increase the effi ciency of IVF,
two approaches are now predominant.
The fi rst consists in the introduction of new laboratory techniques to
increase the quality of the embryos or to identify the highest quality embryos.
These approaches include the preimplantation screening where, as far as pos-
sible, the genetically intact and thus supposedly best embryos are selected.
However, no increase in the live birth rate has so far been obtained with this
technique.
T he second approach is based on an opposite philosophy. It is believed
that the conventional stimulation regimen using exogenous gonadotropins
leads to signifi cant alterations in the folliculogenesis and results in a reduced
implantation potential of the corresponding oocytes. Indeed, implantation
rates of embryos generated under the natural cycle IVF procedure were
indeed found to be higher than those generated by conventional IVF with
high dosages of gonadotropins. This impressively demonstrates that the natu-
ral follicle selection process creates the best oocytes.
T herefore, why should we not follow nature and use these naturally
selected best oocytes?
Some people might argue that the introduction of exogenous gonadotro-
pins in the 1980s have substantially improved the IVF outcome by inducing
a polyfollicular response and thereby allowing us to generate a high number
of follicles and oocytes and thereby overcompensating the lower oocyte qual-
ity. Yes, this argument is absolutely correct. The introduction of gonadotro-
pins was a milestone in IVF and gonadotropins will always be an essential
part in many IVF therapies.
H owever, time has changed since the fi rst IVF birth. Our IVF biologists
and technicians have done a great job and have substantially improved the
laboratory procedures. Nowadays, even a single oocyte has a high potential to
be fertilized and to implant successfully. Furthermore, the age of the women
requiring IVF has substantially increased. We are nowadays confronted with
many women who develop only very few follicles even under high dosage
gonadotropin stimulation due to their low ovarian reserve. And fi nally, many
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viii Foreword
women do not want to be treated with high dosages of hormones anymore,
and they do not accept the side effects, costs, and risks of conventional IVF
therapies.
Therefore, I think it is time to rethink our IVF strategy. Natural cycle IVF
with all its modifi cations is on the way to become an acceptable IVF alterna-
tive under certain circumstances. It has been shown that in many women, this
technique is less stressful, less expensive, and better accepted by women.
Under defi ned conditions, such as young women with tubal and andrological
factors, or women with a low gonadotropin response, it presents so many
advantages that one wonders why it is not offered more frequently.
So what can we do to change the IVF strategies for the sake of women?
First, we have to further distribute our knowledge about the advantages of this
IVF technique. Second, we need to improve the effi cacy of this technique
even further, and third, the technique needs to be modifi ed to reduce the num-
ber of required consultations and to introduce more protocols, which can eas-
ily be copied by physicians. In conclusion, the technique needs to become
smarter.
This book provides a fi rst and important step on our way to widely intro-
duce this smart technique. It gives us a brilliant overview about the state of
the art in natural cycle IVF. It not only provides basic information to better
understand the physiological basics of natural cycle IVF, it also presents
some modifi cations and protocols, which can easily be introduced in the clin-
ical routine in IVF centers.
Therefore, this book is an important contribution to IVF therapies and is
worth reading from the fi rst to the last page.
Berne, Switzerland Michael von Wolff
Pref ace
Natural cycle IVF is the oldest IVF treatment approach we have. The fi rst IVF
babies were born with this technique more than 30 years ago. The main prob-
lem back in pioneer times of IVF was the control of the LH surge and ovula-
tion. If the female menstrual cycle is left alone, LH surge and ovulation may
occur at any time, and in the majority of the cases, it does not occur during
the working hours of the IVF clinic. Often enough, the egg retrieval had to be
done in the middle of the night. In these times, many researchers started to
look for possibilities to control ovulation and the LH surge, in order to make
IVF treatments more convenient for doctors and patients. The early reproduc-
tive endocrinologists had a deep understanding of the hormonal patterns of
the female menstrual cycle. Some of them were experimenting with drugs
like Clomiphene citrate, using its antiestrogenic effect to control the LH
surge. Subsequently, many reproductive endocrinologists started using ovar-
ian hyperstimulation with Clomiphene citrate and human menopausal gonad-
otropin (hMG), in order to get more than only one egg per treatment cycle.
More eggs allowed compensating for the loss of eggs and embryos during the
IVF process. We should not forget that back in these early days, IVF labora-
tories were also quite ineffi cient, as modern embryo culture techniques did
not exist. The breakthrough came in the early 1980s with the application of
GnRH analogs in IVF treatments. In order to control the LH surge and ovula-
tion, GnRH agonists can be used to put the patient into a “temporary artifi cial
menopause,” blocking her natural FSH and LH production while supplement-
ing the missing FSH for follicle growth from outside. This allows multiple
follicle growth without the risk of premature ovulation. With the possibility
of hCG triggering, egg retrievals could be programmed within the opening
hours of IVF clinics, which made IVF treatments much more convenient for
medical staff and patients. Furthermore, transferring more than one embryo
allowed raising the pregnancy rate per IVF treatment. Thus, IVF became a
mainstream treatment and more and more IVF clinics opened around the
world.
O ver the following decades, research focused mainly on improving the
IVF laboratory, developing better embryo culture systems and new fertiliza-
tion techniques, such as ICSI. On the clinical side, there have not been a lot
of changes over many years. Only recently has the introduction of GnRH
antagonists brought some alternative stimulation protocols into the main-
stream IVF treatment. Nevertheless, the long agonist protocol is still the most
widely used stimulation protocol for IVF in the world. The main reason for
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