NATURAL CYCLE IVF
Dr. Markus Nitzschke
DEFINITION
WHY NATURAL CYCLE IVF?
HOW IS IT DONE?
WHAT IS THE SUCCESS RATE? : Efficiency
PATIENT SATISFACTION
WHEN? : Indi...
WHY NATURAL CYCLE IVF
OHSS
moderate: 1-7%
severe: 0,5%
OHSS
moderate: 1-7%
severe: 0,5%
Ovarian
Torsion: 0,1%
Ovarian
Torsion: 0,1%
Multiple
Pre...
Egg Quality
Baart et al., 2007, Hum Reprod
Embryo selection
Baart et al., 2007, Hum Reprod
Verproest et al. 2008, Hum Reprod
Rubio et al. 2010, Hum Reprod
Convention...
Endometrium
Ovulation
Horcajadas et al., Mol Hum Reprod, 2005
Gonadotropin free IVF with SET?
ADVANTAGES: INCONVENIENCES:
 High embryo quality
 Better endometrial receptivity
 Reduc...
 Conventional-IVF
 Low dose-IVF
 Mild-IVF
 Minimal-Stimulation-IVF
 Late Start Minimal Stimulation-IVF
 Natural Cycl...
A clinically understandable definition
IVF with gonadotropins
IVF without gonadotropins
Conventional IVF: High dosages of ...
IVF WITHOUT GONADOTROPINS
Modified Natural Cycle IVF
= IVF Naturelle
The problem: premature ovulation
1) Plan egg retrieval according to the natural hormonal pattern?
2) Premature ovulation i...
Concept:
- The anti-estrogenic effect of CC can be used to control LH instead of
GnRH Antagonists
(Teramoto and Kato, 2007...
Clomifen citrate to control LH rise + ovulation induction :
⇒ 50mg Clomid from D7-8 until ovulation induction
⇒ Hormonal b...
IVF Naturelle -
the basic concept
Less controls
Monthly egg retrievals without anaesthesia
Low risk of complications
Low c...
Aanesen et al., RBMonline, 2010
Modified NC-IVF - Sweden
Less controls
1 2 3 4 5 6 7 8 9 10 11 12 ........36h-OR........ET….......OR+14
OR=oocyte retrieval LH-surge/GnRha/HCG HCG-Test
IVF Natur...
Easy egg retrieval without complications
• > 1000 egg retrievals: without complications
• No cancellation because of pain
...
IVF Naturelle - Efficiency
Premature ovulation
(Control of ovulation)
Premature ovulation
(Control of ovulation)
Immature ...
Premature ovulation/immature oocytes
Nº Cycles ER
Premature
ovulation
ER with
oocyte
Immature
oocytes
Fahy, 1995 79 65 17%...
Natural Cycle IVF – Pregnancy rate
Cycles ER ET/cycle
Implantation
rate
Clinical
PR/cycle
Multiple
pregnancy
rate
Fahy, 19...
Natural Cycle IVF – Cumulative pregnancy rate
Nargund et al., Hum Reprod 2001
3,49 cycles per patient
Mean age : 34
Regula...
COSTS
Nargund et al., 2001, Hum Reprod; Berna
Conventional IVF Modified Natural Cycle
Time of treatment 1-2 months 3-4 mon...
Study in Bern, Switzerland:
How painful was the egg retrieval compared with drawing blood?
Much
less
A bit
less
The
same
A...
Study in Bern, Switzerland:
Which of the following interventions was less stressful during Conventional
IVF or during Natu...
WHEN
Indications (our opinion):
 Patients who do not want or tolerate
hormonal stimulation
 Moral or religious reasons (...
CONCLUSIONS
Natural Cycle IVF offers pregnancy rates up to 15%/cycle
Nevertheless, this technique requires:
Low cost Less ...
THANK YOU FOR YOUR INTEREST
Natural cycle ivf aveya
of 29

Natural cycle ivf aveya

Dr Nisha Bhatnagar - Dr Marcus Nitzschke
Published on: Mar 3, 2016
Published in: Health & Medicine      
Source: www.slideshare.net


Transcripts - Natural cycle ivf aveya

  • 1. NATURAL CYCLE IVF Dr. Markus Nitzschke
  • 2. DEFINITION WHY NATURAL CYCLE IVF? HOW IS IT DONE? WHAT IS THE SUCCESS RATE? : Efficiency PATIENT SATISFACTION WHEN? : Indications COSTS
  • 3. WHY NATURAL CYCLE IVF
  • 4. OHSS moderate: 1-7% severe: 0,5% OHSS moderate: 1-7% severe: 0,5% Ovarian Torsion: 0,1% Ovarian Torsion: 0,1% Multiple Pregnancy Multiple Pregnancy Risks of conventional IVF: Kjellberg et al., 2006, Hum Reprod Delvigne et al. 2002, Hum Reprod. Update
  • 5. Egg Quality Baart et al., 2007, Hum Reprod
  • 6. Embryo selection Baart et al., 2007, Hum Reprod Verproest et al. 2008, Hum Reprod Rubio et al. 2010, Hum Reprod Conventional Minimal Type of cycle Aneuploid Embryos Convencional IVF 63% Baart et al Mini - IVF 45% Baart et al No stimulation 36% Verpoest et al
  • 7. Endometrium Ovulation Horcajadas et al., Mol Hum Reprod, 2005
  • 8. Gonadotropin free IVF with SET? ADVANTAGES: INCONVENIENCES:  High embryo quality  Better endometrial receptivity  Reduced risk of OHSS  Less multiple pregnancies  More “patient friendly”(?)  Lower costs (?)  Long learning curve  Team has to be flexible  Higher % of cancellation/cycle  Less benefit(?)
  • 9.  Conventional-IVF  Low dose-IVF  Mild-IVF  Minimal-Stimulation-IVF  Late Start Minimal Stimulation-IVF  Natural Cycle-IVF  Modified Natural Cycle-IVF  IVF-NAT  …………………….. DEFINITION
  • 10. A clinically understandable definition IVF with gonadotropins IVF without gonadotropins Conventional IVF: High dosages of gonadotropins Mini-IVF: less dosage of gonadotropins +/- aromatase inhibitors or SERM Natural Cycle IVF: IVF without medication Modified Natural Cycle IVF: Similar to Natural Cycle IVF, but using medication to control LH
  • 11. IVF WITHOUT GONADOTROPINS Modified Natural Cycle IVF = IVF Naturelle
  • 12. The problem: premature ovulation 1) Plan egg retrieval according to the natural hormonal pattern? 2) Premature ovulation induction (HCG o GnRHa)? 3) GnRH-Antagonists? 4) Prostaglandin inhibitors (NSAIDs) ? 5) Clomifen Citrate (CC) ? Possible solutions: 5) Clomifen Citrate (CC) ?5) Clomifen Citrate (CC) ?
  • 13. Concept: - The anti-estrogenic effect of CC can be used to control LH instead of GnRH Antagonists (Teramoto and Kato, 2007, RBMOnline) CLOMIFEN CITRATE (CC)CLOMIFEN CITRATE (CC) How does it work? - In healthy women with normal ovarian reserve, LH is triggered on the hypothalamus level when the blood E2 concentration stays 2 – 3 days over 200 pg/mL. - CC is blocking the E2 receptors on the hypothalamus and is able to delay LH surge in this way.
  • 14. Clomifen citrate to control LH rise + ovulation induction : ⇒ 50mg Clomid from D7-8 until ovulation induction ⇒ Hormonal blood test D10: E2 + LH ⇒ If E2 < 300 pg/mL D10, repeat E2 + LH until E2 > 300 pg/mL ⇒ Alternative: TVS D10 => Monitor follicle until 19 - 21 mm ⇒ Ovulation induction HCG or GnRH Agonist ⇒ Program ER 36h after trigger ⇒ Embryo transfer 2 – 3 days after egg retrieval ⇒ Luteal phase support: 200 mg progesteron vaginally every 12h Protocol
  • 15. IVF Naturelle - the basic concept Less controls Monthly egg retrievals without anaesthesia Low risk of complications Low cost Efficient
  • 16. Aanesen et al., RBMonline, 2010 Modified NC-IVF - Sweden Less controls
  • 17. 1 2 3 4 5 6 7 8 9 10 11 12 ........36h-OR........ET….......OR+14 OR=oocyte retrieval LH-surge/GnRha/HCG HCG-Test IVF Naturelle - Switzerland Monitoring (E2, LH)/Ultrasound X (X) Von Wolff, 2011-2013 not published data Less controls Cycle day 1,2 controls x cycle
  • 18. Easy egg retrieval without complications • > 1000 egg retrievals: without complications • No cancellation because of pain Bern, Switzerland:  Without anaesthesia  Very thin needle (19G)  Fast procedure (< 5min)
  • 19. IVF Naturelle - Efficiency Premature ovulation (Control of ovulation) Premature ovulation (Control of ovulation) Immature oocytesImmature oocytes Pregnancy rate / transferPregnancy rate / transfer Pregnancy rate / initiated cyclePregnancy rate / initiated cycle
  • 20. Premature ovulation/immature oocytes Nº Cycles ER Premature ovulation ER with oocyte Immature oocytes Fahy, 1995 79 65 17% 83% Nargund, 2001 181 174 82% Ingerslev, 2001 114 74 32,4% 87,8% 11,6% Lenton, 2007 534 495 8,7% 81% Aanesen, 2010 129 89 13,2% 85% Kawachiya, 2011 962 934 3,6% 75,3% 2,6% Von Wolff, 2013* 103 91 6,8% 77,7% 2,9% ER: egg retrieval * < 42 years. Protocol with clomifen citrate
  • 21. Natural Cycle IVF – Pregnancy rate Cycles ER ET/cycle Implantation rate Clinical PR/cycle Multiple pregnancy rate Fahy, 1995 79 65 14% 9% Nargund, 2001. 181 174 68% 24% 13,2% Ingerslev, 2001 114 74 39% 14% 3,5% 0% Lenton, 2007. 495 495 57% 15% 8% Aanesen, 2010 129 89 46,5% 27% 12,4% 0% Kawachiya, 2011 962 934 46,8% 39,1% 14,7% (NV) Von Wolff 2013* 103 91 54% 25% 14% 0% *(Natural Cycle IVF, Bern) (< 42 years, 1.2 follicle controls pre cycle) .
  • 22. Natural Cycle IVF – Cumulative pregnancy rate Nargund et al., Hum Reprod 2001 3,49 cycles per patient Mean age : 34 Regular cycles 46%
  • 23. COSTS Nargund et al., 2001, Hum Reprod; Berna Conventional IVF Modified Natural Cycle Time of treatment 1-2 months 3-4 months Pregnancy rate 30-40% 30-40% Costs/life birth (only treatment costs) ≈$6.000,- 70% less (40% less, Bern) OHSS 2-4% 0% Multiple pregnancy 17% ≈0% The INeS study- Bensdorp 2009
  • 24. Study in Bern, Switzerland: How painful was the egg retrieval compared with drawing blood? Much less A bit less The same A bit more Much more
  • 25. Study in Bern, Switzerland: Which of the following interventions was less stressful during Conventional IVF or during Natural Cycle IVF? Conventional IVF The same Natural IVF Follicle control Egg retrieval Transfer
  • 26. WHEN Indications (our opinion):  Patients who do not want or tolerate hormonal stimulation  Moral or religious reasons (no generation of more than one embryo)  History of OHSS  Low responders to ovarian stimulation  Low ovarian reserve  Patients with low economic resources Relative contraindications (our opinion)  PCOS with dis-ovulation  Irregular menstrual cycles  Anovulation because of GnRH deficit  Difficult access to ovaries
  • 27. CONCLUSIONS Natural Cycle IVF offers pregnancy rates up to 15%/cycle Nevertheless, this technique requires: Low cost Less risks Higher satisfaction A specialization of the clinic A bit more time to achieve the pregnancy Regular menstrual cycles Higher flexibility of patients and staff of the clinic
  • 28. THANK YOU FOR YOUR INTEREST

Related Documents