So in the last post we discussed the development of stimulated IVF and how it made the entire process more efficient resulting in improvements every year in the IVF success rates. Yet patient interest in Natural Cycle IVF persisted. Why? Well I am not a patient so I offer these opinions based upon 14 years of practice and thousands of patients that I have had the privilege to treat for infertility.
Reason #1: Fear of fertility drugs The drugs that we use for stimulated IVF have become much more "patient-friendly" over the years. Back in the dark ages, patients had to crack open little glass ampules of saline and then try to avoid slicing open their fingers as they mixed individual doses of fertility drugs. The injections had to be in the gluteus maximus (your backside) and the poor p artners ended up having to dart their loved ones for over a week. Yikes. Eventually we moved to subcutaneous (under the skin) medications and now many patients use multi-dose pens. We are not to the level of the hypospray used by Dr. McCoy on Star Trek, but we are moving in the right direction.
However, some patients really have a great fear of injections and how they may feel on the drugs. It doesn't matter to them that the data suggests no increased risk of cancer for infertility patients that use these medications. They have no desire to go down that treatment path. Even if the drugs are free (with a co-pay), they really don't want to use them.
Reason #2: Fear of OHSS Let's be honest here. OHSS is no fun. The patients feel terrible and as physicians we feel awful that they feel terrible. Although we can tap off the excess fluid and give the patients prompt relief, it is no fun to have OHSS. Of the nearly 200 blog posts that I have written, the one that gets the most hits is the OHSS Woes post that has nearly 80 comments attached to it. Although the risk of OHSS can be reduced by judicious drug dosing, the reality is that we can never eliminate this complication....we can manage it better perhaps but never reduce its incidence to zero...except with Natural Cycle IVF.
For the Hollywood version of OHSS, I refer you to the movie Malice which shows how OHSS can be used in a rather unique fashion....
Reason #3: Fear of multiples So many patients come into our office asking for twins. I understand the mentality of "buy one baby, get one free" but the risks of twins are significant. Prematurity is a huge issue for babies and there can be life-long issues associated with preterm delivery. Although many patients are recommended to undergo elective single embryo transfer (eSET) in stimulated IVF the reality is that a minority of patients choose this option because the temptation to transfer 2 embryos simply becomes too great after going through the entire IVF cycle. In Natural Cycle IVF there is almost always only a single egg and therefore a single embryo. If you get twins in this situation then they must be identical twins which cannot be prevented!
Clearly, the extreme examples of fertility treatment gone wrong make the headlines much more frequently than do the news about twins. However, the NY Times did run a special series of articles last summer about complications associated with twin pregnancies. It was pretty scary stuff and yet most patients are still willing to roll the dice that their pregnancy will not run into such complications.
Reason #4: Fear of extra embryos I really don't know when life begins. Clearly many embryos fail to grow, fail to implant and fail to develop into healthy pregnancies. However, the concept of extra embryos cryopreserved for future use is not always a welcome possibility to some couples. The decision to destroy the extra embryos is very difficult for many patients to handle...and yet if they are not interested in having more children and are not willing to donate their embryos to another couple then their options are limited. Some couples elect to undergo stimulated IVF but decline to freeze extra embryos for this reason. Others ask that only as many eggs get fertilized as they are interested in using. Freezing unfertilized eggs is becoming more effective, so that option may become more common in such cases. However, for many patients Natural Cycle IVF seems like a better way to handle their ambivalence.
Our Conclusions None of these reasons are Natural Cycle IVF works better than stimulated IVF. For those patients who respond well to fertility drugs it is clear that stimulated IVF is more effective on a cycle by cycle analysis. However, I often use the analogy of driving to Leesburg from Arlington. You can take the Dulles Toll Road or you can take Route 7. Both will get you to Leesburg but usually the Toll Road is faster.
Opponents of Natural Cycle IVF seem to forget that patient preference does indeed matter. For some patients, stimulated IVF is just not an attractive option (usually for the reasons listed above). It really doesn't matter to these patients if they get seven cycles for the price of two....or a free toaster....or massage/aromatherapy....they really are not interested in stimulated IVF.
And we think that it is fine for patients to vote with their feet if they are interested in the Natural Cycle approach to IVF.