Melanie Cole (Host):  It’s understandable to be anxious when you start looking into IVF. You have a busy life and you’re maybe looking for the easiest or least expensive approach to conceiving. Today, we’re talking about minimal stimulation IVF or mini stim IVF. My guest is Dr. William Zeigler. He’s a specialist in reproductive endocrinology and infertility and he’s the Medical Director of the Reproductive Science Center of New Jersey. Dr. Zeigler, always a pleasure to have you on. What is mini stim IVF and how is it different than conventional?

Dr. William Zeigler (Guest):  Well with minimal stim in vitro fertilization, it’s kind of like a bridge between natural cycle in vitro fertilization and the conventional cycles which people know about. In natural IVF; you have no ovarian stimulation at all. There are no medications given, however, you only get only one or two eggs which may not be sufficient to get good quality embryos. And then you have conventional in vitro fertilization which has risks of ovarian hyperstimulation, and it requires more medication and more cost for the patient.

So, what minimal stimulation protocols do for us, is it helps give more eggs but not overstimulate the patient. And on the average, we get anywhere between three to six eggs which can produce anywhere between one to four good quality embryos. And therefore it does increase the chances for a healthy viable pregnancy. The main goals for minimal stimulation IVF is to again, minimize exposure to medication during the ovarian stimulation period. Another one is to reduce the risks for ovarian hyperstimulation syndrome. And it can also reduce the time between cycles. With minimal stimulation, we can kind of batch cycles so we can possibly get more eggs and more embryos and possibly even have extra embryos for a person to use later on down the reproductive life.

Host:  Well that was great explanation. So, is the concept of mini IVF aimed at producing quality eggs while conventional is going for quantity? Or is that not the case?

Dr. Zeigler:  With minimal stim IVF; its main benefits compared to conventional is like I mentioned, that it reduces the amount of medication a patient takes so therefore it reduces the out of pocket costs and just due to the increased amount of fertility medication. It is a gentler treatment cycle so therefore; the ovaries are not going to be markedly enlarged. It does produce high quality eggs. We’re just not getting the 15 to 20 eggs that we sometimes get with conventional in vitro fertilization. And this type of stimulation is not for everybody. The patients who benefit from this approach are those that are high responders, those who have a marked increase for ovarian hyperstimulation syndrome like those patients who are polycystic ovarian syndrome patients in particular. Also for those that are low responders, those that despite giving them a lot of medication; we still only get one or two eggs.

So, to bombard a patient with a lot of medication may not be in their best interest and we get the same result by using lower amounts of medication. And it’s also designed for patients who are not interested in freezing embryos. We do have patients that don’t want to freeze embryos for either a personal or a religious reason and they want to limit the number of eggs to be fertilized. So, this kind of targets those three populations.

Host:  Wow. So, tell us a little bit about the success rates based on everything you’ve told us here today. How well does it work? What have you seen?

Dr. Zeigler:  Well, in women who are under the age of 39; we see with minimal stimulation; we see a cumulative live birth rate of around 49% which is lower than conventional in vitro fertilization which is around 63%. But it also, we saw now incidence of ovarian hyperstimulation syndrome, as with conventional, you can see it up to around 6% of patients can have enlargement of their ovaries. And a small number of them may require a hospital visit. So, when we take a look at all these factors; we do counsel our patients that yes, with minimal stimulation the success rate is going to be a little bit lower. We are not going to get a large number of eggs. However, the flip side of that is that it does help curtail cost, it does reduce the risk for, and which are associated with conventional in vitro fertilization.

And depending on the way the patient feels, this may be an appropriate treatment option for them.

Host:  Dr. Zeigler, as we are talking about benefits and possible downsides; when you mentioned the medications that are used for mini stim IVF versus conventional; is there a difference in how they are injected? Is there a difference for the patient? If someone is like afraid of needles or if there’s any of those issues present, is the mini stim better in that regard? Or easier on the patient?

Dr. Zeigler:  Yes. And yes, it is. Depending on the patient, we may just use a medication like clomiphene citrate or just letrozole which are oral medications and therefore, we can avoid the injections of gonadotropins. The downside is using an oral medication, again, you may only get one or two eggs. It’s very similar to natural cycle and just IVF. And there’s also that possibility of a cancellation that if they do start to begin their ovulation or having their LH surge naturally before the follicle is mature to be retrieved; that is a disadvantage. So, there is a higher per cycle cancellation rate.

And also, if we use lower dose – like if we do use an oral medication or lower dose gonadotropins just along with the Clomid; that a patient may require multiple stimulated cycles to achieve a pregnancy. Because again, we’re not going to get the large number of embryos in which we get with conventional in vitro fertilization. And again, we always tell our patients that if we have any extra good quality embryos to freeze of course in which we can freeze those. But in these types of cycles; it’s very unlikely we are going to have extra embryos to freeze if we go for a transfer.

Host:  So, if the cost is lower and it’s basically a more gentle approach; if it does not work; can you then always try the conventional approach if you need to? Or do you sort of have to choose?

Dr. Zeigler:  No, you can go for the conventional approach and like I mentioned before, that this is for specific individuals who may want that gentler stimulation and even though the pregnancy rates are a little bit lower; the cumulative pregnancy rates if we take the cost of what a conventional in vitro fertilization cycle cost a patient, they could do three or four minimal stimulation cycles and get a good number of eggs so the cumulative pregnancy rates are very close to what the conventional in vitro fertilization rates are for a single cycle.

So, when you start looking at the cost and benefit analysis; in many cases, doing a minimal stimulation protocol is better for a patient because it still gives them a decent pregnancy rate at a lower cost and if they need to do another cycle, whether it is another minimal stimulation cycle, they have money that they would have put towards a conventional IVF cycle to use for another minimal stim cycle and still be less even with two minimal stim cycles being less than what one conventional cycle is.

Host:  That is so interesting. So, what’s the bottom line Dr. Zeigler? What would you like patients to know about the minimal stimulation IVF versus conventional and what you want them to think about or questions you want them to ask, things to consider when they are looking at their options?

Dr. Zeigler:  Well patients need to be aware that there is no one treatment protocol for every patient. Every patient is different and what their goals are, are different. And they have to be taken into account. And that minimal stimulation in vitro fertilization, which is another option, especially for those that again, are paying out of pocket for in vitro fertilization in which they don’t have the luxury of having insurance coverage for these procedures and they need to do the cost benefit analysis. But to ask questions of their provider. What about a minimal stimulation protocol for myself? And like I mentioned, this is beneficial for those that are low responders that only get a few eggs, those are high responders such as polycystic ovarian syndrome patients and for those that are not interested in embryo cryopreservation or they don’t want a lot of embryos in the bank because what is a patient going to do with 15 frozen embryos?

So, it will help – basically you are tailoring the treatment for the patient. The patient needs to be aware there are other options for them. They just need to ask.

Host:  Great information. What an interesting topic and something that I’m sure that not many people know about. Thank you so much Dr. Zeigler for educating us today. And that is another episode of Fertility Talk with RSCNJ, the Reproductive Science Center of New Jersey. Please visit our website at www.fertilitynj.com for more information and to get connected with one of our providers. If you found this podcast as educational and interesting as I did, please share with other couples that you know, share with your friends and family on social media and that way we can all learn from the experts together. Thanks for listening. This is Melanie Cole.