Home : Mini-stim IVF™
Mini-stim™ IVF at Infertility Solutions, P. C.
Mini-IVF or Mini-stim™ IVF or Micro-IVF is an advanced reproductive technology that uses a gentler/milder ovulation induction to produce mature eggs than does conventional IVF. The objective of the ovulation induction with Mini-IVF is to produce two good embryos. Most physicians believe that an ovulation induction that uses less medications and produces fewer embryos, provides better quality embryos than an ovulation induction that uses significantly higher doses of medications. Such an approach can result in significant savings in terms of both medications and monitoring. It can also be an easier process for a patient to undertake because of fewer doctor visits and blood tests.
For Mini-stim IVF, we use a mild ovulation induction similar to what we have used over the years for IUI. This approach is significantly more powerful than IUI, but less effective than traditional IVF. The trade-off of possibly having to do more cycles to achieve pregnancy is compensated for by a lower cost and an easier patient experience. Our program is also based on the research of two groups: Fauser from the Netherlands and Teramoto from Japan. Fauser has published several well designed studies on good prognosis patients which can be used to scientifically justify the use of Mini-IVF. Teramoto has published details of over 40,000 cycles of Mini-IVF which enables us to estimate its effectiveness for different age groups.
We usually have our patients take oral contraceptives for two to four weeks. They then have a baseline ultrasound and start an oral medication called letrozole (Femera) or clomiphene citrate (Clomid) for five days. Letrozole shares some mechanisms of action with clomiphene citrate but has fewer side effects on the reproductive system. Patients are also started on a small amount of gonadotropins. They are usually on these injectable medications for 5 to 8 days before receiving HCG to complete maturation of the eggs. Egg recovery is done under conscious sedation anesthesia, because we don't want our patients to experience pain and we want to be able to flush follicles if needed to enhance egg recovery. We utilize a nurse anesthetist for conscious sedation so that patients don't feel or remember the egg retrieval. ISCI is performed on all mature eggs as needed to optimize the fertilization rate. (It is included in the price of a cycle for self pay patients.) Embryos are usually replaced about three days after fertilization.
Our objectives are to create two good embryos and also to make the procedure as simple as possible for the patient. Monitoring is primarily by ultrasound exams with minimal blood tests. The entire process takes place over about two weeks and is easy to fit into the life of someone with a busy schedule.
How much does Mini-stim IVF cost?
The total cost is about half that of a traditional IVF cycle. Costs include medications, office monitoring visits, anesthesia costs, and IVF specific procedure and laboratory costs. Some patients without IVF coverage will have some of these costs covered by their insurance. The cost of the IVF specific procedures and IVF laboratory costs is about $5000 (more cost information). Medication, laboratory and ultrasound monitoring and anesthesia total about $2000 additionally
Potentially anyone could do Mini-IVF and the choice to use this technique depends in part on patient preferences. A typical patient will have failed a trial of getting pregnant using clomiphene with IUI for two to 4 cycles. Mini-IVF is a much better choice than gonadotropin-IUI therapy which is commonly used in this situation. Mini-IVF is a reasonable choice prior to undertaking the more aggressive conventional IVF. We think the informed patient can make better choices and this is an objective of this web site. The patients with the highest pregncy rates are the younger good prognosis patients. ICSI compensates almost completely for male factor and IVF compensates for tubal factor which makes Mini-IVF a good choice if these are the primary problems present or suspected. A patient planning Mini-IVF may need to do more cycles prior to getting pregnant than if she did conventional IVF however, each cycle costs less than 1/2 as much). The success rate of a given patient very much depends on her intrinsic fertility. IVF provides more information to the treating physician than does Mini-IVF (since with Mini-IVF we will often have only one or two embryos) and anyone with a complex history may find that it is disadvantage of Mini-IVF compared to conventional IVF. IVM, performed on good prognosis patients for IVM, will generally result in more embryos than with Mini- IVF since embryos may be created from both mature and immature eggs. For patients with high numbers of eggs in their follicles, we prepeer IVM over Mini-stim IVF.
Women under age 35 with good intrinsic fertility (good ovarian reserve) have done very well in our program. It seems that women who are fertile except for a severe male factor or damaged tubes really don't need a large number of eggs to produce a good embryo with the ability to become a baby. Mini-IVF is adequate to achieve pregnancy and on a per cycle basis costs less than1/2 as much. The literature suggests that this group of patients would have a pregnancy rate about 2/3rds of conventional IVF and this is consistent with our findings.
We think that patients with certain ovarian problems are likely to better with conventional IVF. Women between the ages of 35 and 40 who are almost always in a period of decreasing, but adequate, ovarian reserve are likely to do better with traditional IVF. However, we are not aware of any published study that has undertaken a randomized objective comparison. The patients we have treated in this age range have done well, but our number are too low to make a quality assessment.
The group for whom we most strongly recommend Mini-IVF is the group of women above age 40. For these women, with conventional IVF, we push as hard as we can to maximize the number of eggs we have to work with. Traditionally, we maximize the medication dose, but usually only get fewer than five eggs. Teramoto's work shows the pregnancy rate with minimal stimulation is in the same range as with traditional IVF for this age group. (Both therapies have high cancellation rates for this age group.) We have found the same thing. It is also our impression that the embryos appear to be of better quality after Mini-stim IVF than after a full stimulation conventional IVF cycle.
How successful is Mini-IVF?
Because of the very large number of cycles reported by Teramoto, his published results provide the best estimate of success with this technique. The potential for pregnancy is age related. Up to age 36, the ongoing pregnancy rate per IVF transfer varies from 15 to 22%. From age 36 through 41, the ongoing pregnancy rate per IVF transfer varies from 5 to 11%. These rates are about half the average US success rates for IVF. However this is likely an unfair comparison. For example, for women under 35 with male factor, Mini-stim IVF has a three to four times higher pregnancy rate than IUI using gonadotropins. The process of Mini-stim IVF is not much more complicated for the patient than IUI (and has much lower risks of multiple births and of ovarian hyperstimulation). Teramoto's pregnancy rates are also lower than what we have seen in our program.
There are three types of patients who utilize Mini-stim IVF in our practice and they have potentially different pregnancy rates with Mini-stim IVF (as they do with conventional IVF). Some patients in the best subgroup are those who used oral medications with IUI first, but then move to Mini-stim IVF because it is a more efficient way to achieve pregnancy than the use of gonadotropins and IUI. The second group includes those patient who are candidates for conventional IVF, but choose Mini-stim IVF because of its benefits (cost, simplicity, less drugs, and fewer embryos created). The third group includes women over 40 and with decreased ovarian reserve. This latter group has a low success rate with conventional IVF and Mini-stim IVF is often the preferred approach in our program. This is because the pregnancy rate appears the same, but it is much cheaper and easier for the patient.
How many cycles of Mini-stim IVF should I do?
This depends in part on your prognosis and your decision making process about traditional IVF or IVM. The Fauser group reports results in terms of three cycles (20% pregnancy rate in good prognosis patient). Teramoto averages more than 10 tries in his oldest subgroup of patients. As with everything in infertility, this is a decision that should be individualized for a particular patient.
We generally recommend three or four cycles of Mini-stim IVF and if pregnancy is not achieved, then conventional IVF is usually recommended.
How does our program differ from the Teramoto/Japanese protocol for Mini-IVF?
Based on our reading of their protocols, our programs differs in the way we use oral medications, the way we prevent the LH surge, the way we trigger egg maturation, our routine use of anesthesia, our routine use of follicle flushing, and our common use of ICSI. We use slightly more medications than some of their protocols, but utilize less monitoring and fewer blood tests. We also don't use cryoreservation (vitrofication) as they do.
Our approach to the ovulation induction is a variation on one we have used for the last twenty years for superovulation and IUI. We found it was less expensive for the patient and more efficacious compared to a more traditional superovulation approach. We expect that this protocol will cost the patient about as much as the Teramoto approach while being somewhat more convenient and about as effective. It also appears to have a lower cancellation rate and takes less time to complete.
How does it differ from the Fauser/Dutch protocol for Mini-IVF?
Our protocol uses oral medications which should decrease the potential for cycle cancellation. Our routine use of conscious sedation anesthesia, follicle flushing and ICSI are also different. The costs are about the same and the monitoring is similar. We don't use GnRH antagonists in our pure Mini-stim IVF cycles, which they routinely do.
How does Mini-stim IVF compare to IVM?
Mini-stim IVF is an established procedure different from IVF as far as the laboratory and patient management are concerned. Mini- IVF should be in the skill set of any practice which provides IVF. IVM requires some additional skills and additional laboratory processes. IVM uses less medications than Mini-IVF and takes less patient time. It could be viewed as a variant of natural cycle IVF. In good prognosis patients for IVM, it provides embryos from both immature and mature eggs, which should translate into a higher pregnancy rate. There are several publications where the pregnancy rate for IVM is the same as conventional IVF in that program. This combined with a lower cancellation rate makes IVM a more successful procedure in the qualified patient. We prefer it for patients who qualify for both.
How does Mini-IVF compare to natural cycle IVF?
Pure natural cycle IVF probably should be replaced by either Mini-IVF or a natural cycle version of IVM. Pure natural cycle IVF is a more complicated procedure in terms of patient management and convenience than either Mini-IVF or IVM. It also has a higher cancellation rate and a lower success rate. The avearge number of mature eggs produced in a Mini-IVF cycle is two; whereas in a natural IVF cycle, it is one.
Mini-stim IVF completely compensates for male factor. IUI only partly compensates for it. (Under age 35, it is 3 to 4 times as effective.) Similarly, Mini-stim IVF similarly completely compensates for tubal factor, but other therapies only compensate in terms of producing extra eggs (and thus extra chances to have an egg picked up). Doing Mini-IVF may save the cost of a diagnostic laparoscopy. The cost differences for a given patient depend on insurance coverage. For gonadotropins with IUI therapy, with the increased cost of medications, the cycle cost is likely to be half of the total cost of Mini-stim IVF.
Almost all cases of high order multiple births occur using gondotropin-IUI therapy. With Mini-stim IVF, the risk of multiple births is at most twins since we almost never transfer more than two embryos. The risk of ovarian hyperstimulation is lower with Mini-stim IVF than gonadotropin IUI therapy (but not as low as with IVM).
Actual patient experiences with Mini-stim IVF (in their own words)
Mini-IVF and IVM are new tools that can be used to help you get pregnant as quickly and cost effectively as possible. Our effectiveness as a program is enhanced by having many different tools rather than just conventional IVF.