Fertility Show

Come and visit Create Health at the Fertility Show Olympia 5-6th November 2010

http://www.fertilityshow.co.uk/index.html

Natural Cycle IVF/M – A New Alternative approach to Conventional IVF Treatment

There is an increasing interest in Natural cycle IVF among patients because it relies on natural selection, does not involve ovarian stimulating drugs, results in fewer side effects, and is therefore safer and more comfortable.

During each menstrual cycle, usually only a single follicle (egg sac) grows to the ovulation stage to release an egg for potential fertilisation. However there are several small follicles called antral follicles in the ovary which contain immature eggs.

In natural cycle IVF, a single, naturally selected egg is collected for fertilization and a single embryo is transferred. In natural cycle IVF with IVM, we would aim to collect one mature egg together with several immature eggs. Immature eggs are matured in the laboratory using special and advanced culture conditions (IVM) to create several embryos. This could be an exciting and new alternative for infertility treatment. Normally, 70-80% of these immature eggs collected from the ovaries will mature 24-48 hours after culture in the laboratory. In comparison with current IVF treatment, the major advantages of natural cycle IVF combined with IVM include avoidance of stimulation drugs and associated side effects including ovarian hyperstimulation syndrome.It is carried out in a woman’s own menstrual cycle with no suppression with drugs which cause menopausal symptoms. There is no artificial cycle and women feel that they are in control. It costs less and simplifies treatment.

Recently, it has been demonstrated that immature egg collection followed by IVM is a successful alternative to conventional IVF for women with polycystic ovaries (PCO) or polycystic ovarian syndrome (PCOS) – related infertility (Chian et al, 1999). In general, the clinical pregnancy rates are 30-35% in infertile women with PCO or PCOS, based on approximately 1,000 cycles of IVM-treatment. So far, there are more than 250 healthy infants born worldwide following the collection of immature eggs which were matured with IVM. (Data from Canada, Denmark, France, Korea, Japan, Taiwan and China).

Studies have also demonstrated that immature eggs collected from small follicles can be successfully matured and fertilized in vitro, resulting in pregnancies and healthy live births even from women with normal ovaries and in older women. Therefore, one very attractive possibility for enhancing the successful outcome of natural cycle IVF treatment is its combination with immature egg collection and subsequent maturation with IVM. If both the mature egg from the dominant follicle and the immature eggs from the small follicles were collected, the chance of achieving a pregnancy would be greatly increased with IVM and result in several viable embryos some of which could be frozen and transferred in a subsequent cycle. IVM, once considered a challenge, is now a reality. However, it will continue to be important to individualise natural cycle IVF treatment with or without IVM treatment for different patients in order to optimise the success rates.

Frequently asked Questions & Answers

What is Natural cycle IVF?

In Natural cycle IVF, we collect a naturally selected, single mature egg from the ovary for fertilization and a single embryo is transferred.

What is IVM?

IVM means “In Vitro Maturation of eggs”. In this method, we are able to collect immature eggs from smaller follicles in the ovary and mature them in the laboratory with the use of specially designed and sophisticated culture conditions. Several embryos could be created without exposing women to high doses of stimulating injections and their side-effects.

What are the advantages of IVM?

Women are usually not given stimulating injections.Therefore,they are not exposed to harmful side-effects and risks of ovarian hyper stimulation syndrome (OHSS).The cost of treatment cycle is lower than conventional stimulated cycle.

What is Natural cycle IVF/M?

This is a new and exciting development in infertility treatment. Recent scientific publications have shown that this could be an alternative approach to conventional IVF.

Women with normal ovaries, reduced egg reserve and older women can also try this treatment if they have small (antral) follicles in their ovaries. Essentially, we can potentially create more embryos from a Natural Cycle usually without stimulating drugs. This can be a “win-win” situation for the woman. There are no side-effects or risks of drugs, it costs less and can potentially have the same advantages of stimulated cycles (i.e.: more eggs and embryos from one natural cycle).

How is Natural cycle IVF/M different from Natural cycle IVF?

It is a type of natural cycle IVF with additional benefit of potentially producing more than one embryo for transfer or freezing. In Natural cycle IVF withIVM, smaller follicles are also emptied to find immature eggs which could be matured in the laboratory to more create embryos. This increases the success rate per cycle.

How is it different from Conventional stimulated IVF?

It is fundamentally different to conventional stimulated cycle. Natural cycle IVF /M treatment is carried out in a woman’s own natural cycle usually with no stimulation hormones. It is aimed at producing more than one embryo from a natural cycle. It has all the advantages of a natural cycle as regards to cost, safety and natural selection with additional benefit of producing more than one embryo without high or no ovarian stimulation.

How is it different from Mild IVF?

There are usually no stimulating drugs involved.

It has the advantages of potentially having more than one embryo in a natural cycle .It costs less than a mild IVF cycle.

What are the disadvantages?

The success of Natural cycle IVF/M depends on the availability of smaller follicles in the ovary. There is a possibility that immature eggs are not collected or matured in the laboratory. Not every woman is suitable for this treatment.

Is IVM safe?

The scientific papers and the data from birth of hundreds of IVM babies across the world have shown it is safe for the mother and child.

Is it licensed by the HFEA?

Yes, it is licensed treatment in the UK.

It is successfully practiced in Canada, Japan, Korea and China.

How do I know if I am eligible to have Natural cycle IVF/M?

If you are ovulating and have smaller follicles (usually 7 or more) in your ovaries, you will be able to have this treatment. You will need an advanced ultrasound scan to assess your suitability for this treatment.

Can I have IVM if I am not ovulating?

Yes, as long as you have smaller follicles in your ovaries as described above.

If you have PCO, you can also have IVM treatment cycle.

What is its success rate?

The success rates of Natural cycle IVF/M are encouraging. The pregnancy rates will of course, depend on your age, egg reserve, hormone profile and other factors affecting implantation. Recent scientific paper on Natural cycle IVF/M has shown the following results (Lim et al, Fertility & Sterility Vol 91, 4, 2009).

A total of 417 cycles were started, and 410 cycles (98.3%) were completed. Of 410 cycles, 151 (36.8%) were treated by natural cycle IVF/M, 63 (15.4%) underwent IVM alone, and 196 (47.8%) underwent COH. With increasing age fewer cycles can be treated by natural cycle IVF/M or IVM. Clinical pregnancy rates were 40.4% (61 of 151) for natural cycle IVF/M, 41.3% (26 of 63) for IVM alone, and 37.8% (74 of 196) for COH. There were no differences in implantation rate in the three groups (17.8% [82 of 462], 16.7% [35 of 210], and 20.1% [103 of 513]).

Natural cycle IVF/M together with IVM-alone treatment can offer more than 50% of infertile

women with an acceptable pregnancy and implantations rates.

Initial results of Natural IVF/M in our clinic are encouraging .

For further information, please e mail info@createhealth.org .You can also attend Free Patient open day conducted on Saturdays once a month. Please see www.createhealth.org for details.

IVM - In vitro maturation

Geeta has been liaising with Professor Chian from McGill University in Canada who has pioneered a technique called IVM.

IVM is a treatment that benefits couples trying natural cycle IVF and has particular benefits for women with PCOS or PCO, but which may also benefit those women who might not normally consider natural cycle IVF due to the reduced likelihood of achieving a pregnancy.

In natural cycle IVF, no medication is used to induce follicular growth. This means however that only one egg is usually harvested which means that the likelihood of successful pregnancy is lower than stimulated IVF where many eggs can be harvested and a number of embryos created. Geeta's published studies have shown that the success rate of natural cycle IVF is 46% over four IVF cycles.

In natural cycle IVF with IVM, in addition to the mature egg, up to 20 immature eggs are also harvested (women usually develop these immature eggs during their cycle). The IVM technique then comes into play as these immature eggs are brought to maturity through culture in vitro between 24-48 hours after harvesting. This then means that the possibility of creating viable embryos is far greater than in simple natural cycle IVF as there are more eggs to fertilise. The success rate of natural cycle IVF with IVM in women with PCOS or PCO has been 36% per cycle in Prof Chian's studies in Canada.

The technique has been pioneered in Canada, and there have now been over 250 successful, healthy pregnancies. Professor Chian will be carrying out the first UK trial of this technique with Geeta. Create will be the first clinic to offer IVM in Natural cycle in the UK

Open Days

We are committed to raising public awareness about fertility and assisted conception and hold regular Patient Open days. We are setting up a Patient Support Group locally. Please ask the Centre Manager for details of our next patient information evening and details of how to join the support group.

Open days at our West Wimbledon Clinic...

Saturday 4 September

Saturday 16 October

Session One starts at 12pm and
Session Two starts at 2pm

• These are an opportunity to view our facilities, speak to our staff and book a first appointment.

• Please arrive on time as the session starts with a presentation followed by a question and answer session.

• You will be given a welcome pack with information and price lists

• You will be given an opportunity to have a personal 5 minute chat with Mrs Nargund which is very helpful when you are trying to make a decision.

Please contact the clinic to book a place at one of our open days - please click on the contact me link at http://www.createhealth.org/Events.htm

New website for Create!

Have a look at our new website.


http://www.createhealth.org/

Louise Brown

For those of you who are not familiar with the name Louise Brown, she is the first ever IVF baby. Now many people think that high levels of hormone drugs are the way that IVF has always been carried out, and that Natural cycle IVF is a new approach. It is in fact the reverse of this. Lousie Brown was actually conceived as a result of Natural IVF procedures.

Lesley Brown and her husband, John, had been unable to conceive for nine years. Lesley was diagnosed with bilateral fallopian tube obstruction. In 1976, she was referred to Dr. Patrick Steptoe. He recommended that she try a new experimental procedure that would bypass the fallopian tubes blockage completely.

Lesley underwent a laparoscopy whereby a single mature egg was aspirated from one of her ovaries. John's sperm was added to the egg in the laboratory under the direction of Robert G. Edwards. A few days later a developing embryo was placed into Lesley's uterus.

At 11:47 p.m. July 25, 1978, Louise Joy Brown was delivered by cesarean section. She weighed five pounds 12 ounces and had blonde hair and blue eyes.

Louise has just celebrated her 30th birthday. The world celebrated the 30th anniversary of a new era. The era of extra corporeal assisted reproduction. History will regard that moment 30 years ago with as much awe and importance as the first moon landing.

On December 20th, 2006, Louise gave birth to her own child, Cameron John Mullinder. She conceived without fertility treatment of any kind on the six month that she and her husband tried. The delivery was by cesarean section since the baby was breech.

Natural and Mild IVF in the News!

Have a look at a this recent article detailing the benefits and hope offered to women, for whom natural IVF is the better option.

http://www.telegraph.co.uk/health/women_shealth/7726034/A-softly-softly-approach-to-IVF-offers-women-fresh-hope.html

Open Day Tomorrow!!!

Don't forget - if you are joining us of one of the open day sessions tomorrow,
12-2pm
2-4pm
please arrive on time - as there will be a presentation at the start given by Geeta and Freda.

Car parking is available at the rear of the clinic with access from Worple Road.
To park in the car park drive past St George’s House and stay in the right hand lane. Turn right at Boots into Lambton Road and turn first right again into Worple Road.
The car park entrance is sign posted 100 yards on the right.
Call reception on 020 8947 9600 to lift the barrier.
Please inform centre staff when you are leaving so they can lift the barrier for you.

There is also ample street parking around the surrounding roads.

Alternatively you can of course arrive by public transport - and Raynes Park station is just a couple of minutes walk away.

Create Health Expands Again!

Exciting news!

Create Health Clinic has expanded - the new premises are ready and from Monday 26 April 2010 we will be in our new premises in St Georges House, which is number
3-5 Pepys Road - on the opposite side of the road to Excel House.

If you would like to find out more about us - and see our new premises please come along to our next open day on May 15th.

Please call or e-mail the clinic to book your place, numbers are limited to enable us to give you the best possible attention

Tel: +44 (0)20 8947 9600

samantha@createhealth.org

'One stop' Fertility MOT

Create clinic pioneered the 'One stop' Fertility MOT.

The idea behind it being that before embarking on Fertility treatment, or to find out if there are any issues regarding your fertility, you can have a medical assessment that combines medical history, blood tests and state of the art ultrasound techniques to assess your fertility.

It is carried out in only one hour, with a report given immediately after the test, and is offered to single Women, Men and Couples.

For Women: The test involves the use of expert, advanced scanning, including Doppler and 3D ultrasound. Ultrasound scan to check egg reserve, ovarian blood flow, ovulation, womb lining, blood flow to the womb, and to asses for any abnormalities. Some blood test may also be required.

For Men: A detailed, expert semen analysis. If any problems are detected advice from fertility experts is available.

An interesting article on the use of ultrasound to asses fertility can be found at:

http://humrep.oxfordjournals.org/cgi/reprint/16/12/2481?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=1&author1=nargund%2C+g&andorexacttitle=and&andorexacttitleabs=and&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT

If you would like further information about the MOT - or to book please visit:

http://www.createhealth.org/one-stop.htm

Create Open Days

Create Clinic are committed to raising public awareness about fertility and assisted conception, and conduct regular patient open days.

The next patient open days are on:

Saturday 27th March 12-2pm and 2-4pm
Saturday 17th April 12-2pm and 2-4pm
Saturday 15th May 12-2pm and 2-4pm

If you would like to attend one of the open days, or find out a bit more information about them, please call or email the clinic to book your place. Numbers are limited to give you the best possible attention.

Tel: +44 (0) 20 8947 9600
Email: samantha@createhealth.org

Discussion Forum

A new discussion forum for Create Health Clinic - Natural and Mild IVF has been set up at:

http://createhealth.creatingforum.com/forum.htm

This is an area where you can find out more about Natural and Mild IVF - and also discuss treatment, and hopefully receive (and possible give) support to people who might be travelling the same treatment path as you.

Tailored IVF Treatments and the Role of Natural and Mild IVF

There is a renewed scientific interest in a more natural approach to IVF cycles.

More than 50 peer reviewed papers have been published in the last five years addressing natural, modified natural and milder approaches to ovarian stimulation in IVF cycles. Better understanding of ovarian physiology in relation to ovarian follicular growth and maturation, advances in ultrasound technology (eg Doppler) and clinical availability of GnRH antagonist (a hormone used to block spontaneous ovulation), have allowed ovarian stimulation to be started in a natural menstrual cycle (i.e. without forced follicular recruitment) and have given us the opportunity to develop novel, gentler approaches to ovarian stimulation. Advances in embryology, ultrasound technology and endocrinology are making the natural cycle and mild stimulation IVF more successful and increasingly relevant to everyday practice.

This approach is much needed because not only are we entering an era of single embryo transfer but also we are increasingly aware of the need to put the health, safety and welfare of the woman right at the top of the agenda when it comes to Assisted Reproduction Technology (ART).

The conventional approach to ovarian stimulation in IVF treatment is aimed at maximizing the number of oocytes available for fertilisation, in order to generate several embryos for selection and transfer. The potentialclinical problems associated with ovarian stimulation include ovarian hyperstimulation syndrome (OHSS).

The prevalence of severe Ovarian Hyperstimulation Syndrome (OHSS) ranges from 0.5-5% of cycles andcan be associated with severe symptoms requiring hospitalization. Furthermore the impact of such side effects can influence many patients to say “never again”. The long term effects of conventionally stimulated cycles are not conclusive. Most of the long-term studies are based on the effects of clomiphene citrate (clomid) treatment and detailed long term analyses of the effects of gonadotrophins (IVF drugs) related to dosage are not available and are urgently needed. Less well known are the effects of ovarian stimulation and the resultant very high levels of oestrogen concentrations on the quality of eggs and endometrium (lining of womb).

There is a substantial scientific evidence suggesting adverse conditions in the endometrium (lining of womb) for implantation of the embryo and an increase in chromosome abnormalities in eggs following high dosages of ovarian stimulation used in IVF cycles.

Finally the cost of treatment is higher with conventional ovarian stimulation protocols due to higher daily dose and cumulative dose of drugs. The treatment cycle is prolonged by nearly two weeks due to suppression of ovaries leading to unpleasant menopausal symptoms. Natural and Mild IVF are fitted in a woman’s spontaneous cycles. Natural and modified natural cycle IVF have specific applications in women with damaged or blocked tubes, in older women, poor responders, those with failed implantation and in those where stimulating drugs are to be avoided ( in women with cancer).

The success rates (live birth rates) of natural/modified natural cycle IVF can be lower per cycle (10-17% per cycle) but cycles can be repeated in subsequent cycles (up to 3-4 cycles) to achieve success rates similar to stimulated cycles. A recent Lancet paper has shown that cumulative pregnancies resulting in term live birth after one year were 43.4% with mild IVF compared to 44.7% with conventional IVF.In addition, mild IVF might lessen patient discomfort, costs and multiple births and risks associated with multiple births. The role of IVM is limited to young women with PCOS and needs further trials.

Modified natural cycle and Mild stimulation IVF are already popular in many countries and will be widely used globally in the future.

Definitions are described below:

Terminology	Aim	Methodology
Natural cycle IVF	Single oocyte	No medication
Modified Natural cycle IVF	Single oocyte	hCG only Antagonist & FSH add-back
Mild stimulation IVF	2-7 oocytes	Low dose FSH, oral compounds & antagonist
High stimulation IVF (Conventional)	≥8 oocytes	Agonist or antagonist High FSH dose

It is my view that tailored protocols (natural, modified natural, mild) should become standard during IVF treatment cycles in order to make treatments safer, low-risk, more patient-friendly and cost-effective. Women should receive information about all options during consultation. The HFEA must provide information and outcome of natural/mild IVF in Patients’ Guide. It would also help to get more IVF cycles funded on the NHS.What’s more, the scientific evidence supports this.

For more information contact: www.createhealth.org

Low-dose HCG is useful in preventing OHSS in high-risk women without adversely affecting the outcome of IVF cycles

Geeta Nargund is Head of Reproductive Medicine at St George’s Hospital and Medical Director of the Centre of Reproduction and Advanced Technology, London, UK. She is also Chief Executive of the Health Education Research Trust (HER Trust) UK and the President of ISMAAR (International Society for Mild Approaches in Assisted Reproduction). She has published extensively on the role of advanced ultrasound technology in reproductive medicine. She is the chief author of the first scientific paper on cumulative live birth rates of natural (unstimulated) cycle IVF and on one-stop fertility diagnosis using ultrasound technology. Her research interests include minimal approaches in assisted reproduction and advanced ultrasound technology.

The following link is to a paper written for RBM online, detailing research into the use of low-dose HCG in the prevention of OHSS:

http://www.stgeorgeshouseclinic.org.uk/RB2843.pdf

What is Natural or Mild IVF?

Natural cycle IVF is suitable for all women who ovulate naturally. Young women who want to avoid stimulating hormone injections can try natural cycle IVF first. It has been particularly effective in older women and in those who have responded poorly to stimulating drugs. It can also be suitable for women who want to avoid ovarian stimulation or fertility drugs as a matter of choice, and indeed for those for whom there may be no other choice, such as women at risk of hormone-related cancers. It is also safer and healthier for women than a fully stimulated cycle. The total cost is significantly less than for stimulated IVF. There is no suppression of the ovaries and associated menopausal symptoms and the treatment cycle is completed within a woman’s own menstrual cycle. The consultants at Create Health Clinic have published extensively in this field and have contributed in making Natural cycle IVF more successful. The centre puts women’s health and safety at the top of the agenda when it comes to assisted conception, physically, emotionally and financially. WHAT IS NATURAL CYCLE IVF? Put simply it is IVF without the use of stimulating drugs. In stimulated IVF/ICSI cycles the patient takes drugs to stimulate her ovaries to produce multiple eggs. With natural cycle IVF the treatment cycle relies on the spontaneous development of one follicle only and therefore the aspiration of only one egg from the follicle (it is possible however that the cycle can have more than one egg or no eggs). There is nothing new about natural cycle IVF, in fact Louise Brown, the world’s first ‘test-tube’ baby was conceived using this method 25 years ago. DOES THIS MEAN NO STIMULATING DRUGS ARE TAKEN WITH NATURAL CYCLE IVF? Yes. But drugs may be given to prevent spontaneous ovulation. This is called a Controlled Natural Cycle. In addition the patient will need to take hCG (as with other less invasive treatments such as Ovulation Monitoring and Intra-Uterine Insemination) to time egg collection as well as progesterone pessaries to supplement the body’s progesterone levels. WHAT ARE THE BENEFITS OF NATURAL CYCLE IVF? There are no side-effects such as ovarian hyperstimulation syndrome (OHSS), bloating, mood changes or other concerns relating to ovarian stimulation. Due to the effect of ovarian stimulation drugs on the body, patients undergoing stimulation cannot pursue consecutive cycles of treatment and need to take 2-3 months break between treatment cycles. In contrast, natural cycle patients can repeat their treatment in consecutive cycles. As only one embryo is transferred in a natural cycle, there is virtually no risk of a multiple pregnancy. Furthermore, ovarian stimulation drugs are expensive and this means that the cost of natural cycles is significantly less compared to the cost of stimulated cycles reducing costs by up to £1500 per cycle. WHAT ARE THE DISADVANTAGES OF NATURAL CYCLE IVF? The success rate per cycle is low compared to stimulated IVF. There is also a small risk of spontaneous ovulation before egg collection. WHO CAN HAVE NATURAL CYCLE IVF? Women under the age of 45 who ovulate regularly can be considered for natural cycle IVF. Natural cycle ICSI is also offered, although patients should be informed that natural cycle ICSI success rates are lower than natural cycle IVF. WHO CAN’T HAVE NATURAL CYCLE IVF? Natural cycle IVF is not suitable for those who do not ovulate spontaneously. Instead they will need a Mild Stimulation option. WHAT IS MILD IVF? It is aimed at producing 2-7 eggs. It does not involve shutting down the hormones for 2 weeks. It is conducted in the woman’s natural menstrual cycle. Smaller dosages of stimulating drugs are given for a shorter period to help ripen the 2-7 eggs. Spontaneous ovulation is blocked with injections so that eggs could be collected. This approach is also called Soft IVF. It is safer, less expensive and avoids side-effects associated with suppression of hormones in a conventional IVF cycle. It also reduces the risk of Ovarian Hyperstimulation Syndrome (OHSS).