MINI IVF? Things You Should Know About

MINI IVF? Things You Should Know About

Things You Should Know About MINI IVF

Transcription:

Dr. Marc Sklar:

Welcome to another episode of Fertility TV, I’m Dr. Marc Sklar, the fertility expert, and this channel is your resource for everything having to do with fertility and reproductive health. And today I’ve got a special guest with me to talk about mini IVF. I did this because I get so many questions from all of you about what is mini IVF? What is it good for? And how do I find someone who does it? So I brought someone Dr. Chang from Hanabusa IVF right here to interview so that you can hear it straight from him, what the benefits are and how you should start thinking about a mini IVF in terms of your IVF process. So if you want more information on what mini IVF can do for your fertility journey, keep watching.

Dr. Marc Sklar:

So I’m excited to have Dr. Chang from Hanabusa IVF here with me today. And one of the reasons why I’m excited to have him here, and there are many, but one of the top reasons is because of the type of IVF that you specialize in and do at Hanabusa, which is mini IVF. And we get so many questions on this topic and you know, what is mini IVF? How does it work? Why is it different, those sorts of things. So that’s why I wanted to bring you on to interview you and allow you to share your knowledge about this special type of IVF with the world. So thanks for being here.

Dr. Chang:

No, Dr. Sklar, thank you for having me. It’s a topic that’s obviously very dear to my heart. I think a lot of people have, I guess there’s a confusion out there, and I want to try to clear it up. The primary confusion I think is people are thinking of mini IVF as a replacement for conventional IVF, for traditional high stimulation. And people look at it and they’re thinking, “Hey, look, some of the studies and the data suggests that it’s not as efficient as conventional IVF.” But at the same time that’s not how they really should be looking at. They should be really looking at it. Here’s another option. Does this work for me? And now there’s other confusions here, but let me try to clarify one thing. This term mini IVF is it applies to one particular what we call low stimulation minimal stimulation protocol.

Dr. Chang:

It’s a protocol that was created in the Kato Clinic, in Tokyo, Japan, and it involves two medicines, one an oral medicine, typically it was Clomid originally, but we’ve also been using Letrozole. And then what you do is some injections, FSH, HMG, what we call Follistim, Gonal-F, Menopur. And the idea of the oral medicines is to stimulate your natural FSH that your body produces to stimulate the eggs. And this reduces the amount of injections that you need to take. Now, as opposed to where minimal stimulation is just less medicine than what you would normally use in a traditional IVF cycle. So that’s one clarification. So I’m going to get away from the term. When I say mini IVF, I’m probably applying to just minimal stimulation, not the actual Clomid minimal stimulation protocol. So that’s one thing to clarify. Now with the minimal stimulation, as I said, there is this thought that minimal stimulation is a replacement, but that’s not how you really should be looking at it.

Dr. Chang:

There are some situations where minimal stimulation is ideal. So we take a situation where a woman is older. We know that she has fewer eggs, each cycle that are going to be recruited, that are going to be ideal for potential pregnancy. Or we have a woman with a very low ovarian reserve, fewer eggs. In a situation like this high stimulation protocols, the data shows that they work very, very poorly. And the primary reason for this is the fact that you’re giving so much medicine. You have medicine that’s designed for someone with an ovarian reserve of 20 to 30 at that point, for that recruitment, but there’s not 20 to 30 eggs in these situations. There’s usually half a dozen to a dozen at most. So what you have is number one, a lot of extra medicine that goes to waste.

Dr. Chang:

But the second thing, you have a lot of extra medicine that is raising your hormone levels that actually can harm egg development. Why does it harm the egg development? Because there’s a window of FSH that allows the eggs to grow in an optimal fashion. It’s almost like watering or fertilizing your crops, your fruit garden, your vegetable garden. If you give the appropriate number of amount of water and fertilizer things grow well. But if you give too much, thinking, “Oh, it’s going to grow better.” It’s actually very harmful to your crop. So this is where in this situation, fewer follicles, older women, the lower stimulation tends to work better. Now there’s obviously another situation where you have a woman who has decent reserve. You know, she has an excellent reserve. Conventional stimulation will work really, really well. If anything, it works better than minimal stimulation.

Dr. Chang:

But let’s just say that this woman is very fearful of getting very sick from the high stimulation. She’s worried about something called ovarian hyperstimulation syndrome. If she’s fearful of that, she may say, “Look, I don’t want to maximize my efficiency if I could get sick in a situation like that, let me use lower medicines.” Knowing that the success rate will be lower, but at the same time you’re not going to get so sick. And also you’re not going to spend as much money in the process either from a medication standpoint.

Dr. Chang:

Another situation that comes up is let’s just say there’s someone who has, a couple has ethical or religious or moral issues with creating too many embryos. This is a situation where they may want to take the risk of using a lower stimulation protocol. So they don’t have extra embryos that are going to go to waste that they’re not going to use. This would be also another situation. So we don’t think of minimal stimulation versus conventional stimulation. We’re thinking of this as another tool that we can use to apply in particular situations.

Dr. Marc Sklar:

Yeah. I mean, one of the reasons I liked that approach and what you’re saying is because, I often get asked by couples, “What’s the right type of IVF for me?” And I think that’s really the appropriate question because it’s about what’s the best suited approach for that individual versus one type of IVF versus another type, like they’re competing with each other. And one of the things I’ve always appreciated about the way you approach it is that you’ve been very forthright with couples who come to consult with you to say, “Well, you might be better off with a more conventional approach depending on what your desired outcome is and what your hormones are telling us and so forth.”

Dr. Marc Sklar:

So I always appreciate that because it is this difficult choice for couples to make as they’re trying to make these decisions about what’s the right path and what choices are going to yield the best results for them as an individual. If someone is concerned about egg quality, do you find that there is a specific approach that you tend to see better results with, or that you prefer when you’re looking at these different options?

Dr. Chang:

Yeah. And you know, ultimately it comes down to the level of FSH you’re going to maintain. Ideally what you want is a level of FSH somewhere in the 10 to 20 range, you know. Hopefully, I think most of the viewers are pretty educated on all this. And what you need to do is you have to think, “Well, what protocol is going to allow me to achieve that?” Sometimes what I’ll do is I’ll start out thinking I’m going to do a low stimulation protocol, a very minimal stimulation. And I realize that this patient, the body’s metabolism for some reason uses up the medicine very quickly. So the FSH levels never get very high. And I ended up escalating the medicines very quickly and it turns out into a moderate, almost like conventional IVF cycle. So even ahead of time, even though you have a preconceived idea, it may not happen once the treatment takes place.

Dr. Chang:

And we have to understand that everybody’s completely different. So this is a learning experience for many of these patients, and for the doctors themselves, if it’s the first time. So I think the important point, just a general point is that patients can’t go into this whole process thinking this is going to work the very first time. They can’t think of it as a sprint. They have to think of it as a marathon that this may take quite a long time. They could get lucky, the trip could get … They could get to their destination faster. It’s kind of like the airplane. If you get the right tailwinds, I used to fly between New York and San Diego quite a bit at the beginning of this. I was living in New York, I’m flying to San Diego weekly to start up the center here.

Dr. Chang:

And sometimes it would take me six hours of flying. Sometimes it would take me four and a half, you just have to get lucky sometimes.

Dr. Marc Sklar:

Right.

Dr. Chang:

But it’s a matter of adjusting for the situations. Unfortunately a lot of doctors aren’t trained that way, and they’re really trained in one method. And you know, this is where the patient … The patient really shouldn’t be forcing the physician to try something that they’re not really comfortable with. Because if they’re going to try something that they’re not comfortable with, they’re not going to be successful and their efficiency’s going to be much lower. And what’s going to happen, I see this quite a bit. Traditional IVF doctor patients asking, “Do minimal stimulation.” Minimal stimulation does very poorly, it’s because the doctor really doesn’t know the nuances of minimal stimulation. It’s a lot of work.

Dr. Marc Sklar:

Yeah. That piece I think is really important for everyone listening to grasp and to understand. Most IVF doctors are very comfortable with certain protocols. And when we ask them to go outside of that comfort level, many of them are like you mentioned, are going to say, “Yes, I can accommodate that for you.” But if they’re not used to doing that regularly, then those outcomes might not be as ideal as what you’ve read or heard when someone’s doing that sort of protocol. And that has so much to do with the experience and the nuance that you mention, which is one of the things that I really wanted to bring up and have you speak about, because I hear this specific piece all the time that, “My doctor said that we were doing mini IVF.” And then when I ask a little bit of questions to inquire what that really means, I realize that it’s really just, not just, but it’s low stimulation IVF versus mini.

Dr. Marc Sklar:

And I know there’s variations when it comes to that mini piece, but one of the beautiful things that you do with your patients is the way you monitor their blood work and their hormone levels throughout. You know, one of the things that I’ve observed is that you’re really engaged as a clinic in the progression of their hormone levels, not just before they start, but throughout the cycle itself. And you tend to, or at least I’ve observed, you tend to be running lab work much more frequently than other clinics I’ve observed. And to me, that’s the nuance that comes into play when we’re talking about this sort of management of patients and the IVF medication and so forth. Can you talk a little bit about that?

Dr. Chang:

There’s actually a couple of things I wanted to comment on what you just said. When you hear mini IVF. As I mentioned before, this protocol design in Kato’s Ladies Clinic was based on Clomid 50 milligram tablets daily, and then anywhere from three to five injections of what they used was Menopur equivalent to Menopur, about 150 units. What a lot of physicians latched on to was mini IVF meant a Clomid stimulation cycle. So many times what you’ll see from doctors, when they say mini IVF, they’re giving Clomid along with their stimulation. And that’s what they call mini IVF, which is not true, you know? What is minimal stimulation? I guess it’s lower than what typical stimulation is, but there’s really no set guideline what minimal is. It’s just, you don’t give 300 units of stimulation a day.

Dr. Chang:

So that’s one thing. Another thing that I wanted to comment is about patients and their doctor comfort level. You know, if the doctor is not comfortable with a certain protocol and you know that there’s another doctor who’s comfortable with those protocols, maybe just don’t stay without a physician, no matter how much you like that physician, how friendly you think the staff is. If it’s not what you want, and if you’ve failed multiple times in that one manner, it might be time to switch. I mean, I hear these stories. I have patients coming in, eventually having failed like three, four or five cycles of IVF with the same physician, doing basically the same thing. And I’m thinking to myself, “Why didn’t you just leave earlier? You could have saved yourself a lot of grief and heartache.” Coming back to your question about monitoring minimal stimulation.

Dr. Chang:

To be honest, I actually don’t really do that much more than what most physicians do. There’s one test that totally differentiates me from everybody else who’s doing it conventionally. And it separates the minimal, I guess, the minimal stimulation doctors from the normal stimulation and it’s FSH levels. You know, there was this focus on FSH. FSH is important. It is what makes the eggs grow. If you don’t have enough of it, the eggs won’t grow well. If you have too much of it, the eggs won’t grow well, if you have too much of it, naturally it’s your body struggling to make your eggs grow. But at a certain point it becomes too much medicine for the eggs. So that’s really the only difference. In some ways I hear centers, they’re testing every other day or every day. You don’t do that, you know?

Dr. Chang:

Yes, some centers are only testing maybe two or three times, maybe I’ll do like four or five. But one thing is that I’m testing FSH. I’m always doing FSH testing. And that allows me to adjust the hormones to what I think is more ideal when you’re dealing with a low stimulation protocol. With a high stimulation protocol, if you find the right patient, lots of eggs, young person, 90% of the time you apply that protocol they should be fine. But when it fails, and if you haven’t done the testing, you don’t know why they fail. And sometimes there are rare cases. Some of these patients need actually more medicines, not less medicines.

Dr. Marc Sklar:

Yeah. And I think that FSH piece is the one that I was thinking about because I’ve observed that to be something a bit more unique or different than what I see at many clinics. So I’m glad you mention that, because that’s something that I have observed and speak to couples about when we’re seeing joint patients together. So that’s often come up in conversation. Something that I’ve observed that does make a difference, or can I should say make a difference in the outcomes.

Dr. Chang:

Yeah. And there’s an important point about FSH. I think a lot of people have been, let me see, falsely comforted by day three FSH. Day three FSH is supposed to be the FSH represents what your reserve is. If it’s low, it’s supposed to be better. If it’s high, it’s supposed to be worse, but there’s more to it. There’s an important point that a lot of people don’t realize. For that FSH to be accurate on day three, your estradiol level has to be relatively low. You can’t have an estradiol of over 50 because that will artificially suppress your FSH. So you really want an estradiol at that point somewhere between 30 and 50, might be 30 and 60, and that will give you an accurate FHS. Otherwise, you have an estrogen of a 100 and an FSH of six, and that is not a good situation. And I believe a lot of patients don’t understand that.

Dr. Marc Sklar:

Yeah. I mentioned that quite a bit to them because I do think that estradiol is not either observed or discussed in enough detail when they’re trying to make these decisions and understand what all their hormones mean. So if we were going to pick two or three types of women or couples who should consider this lower stimulation method of IVF, what are the top two, three, four, diagnosis or issues that you would say, “If you are struggling with these issues, you should consider or think about low stimulation.”

Dr. Chang:

Number one, diminished ovarian reserve. Now the question is, at what point diminished ovarian reserve? Typically I see that once the ovarian are … AMH, that’s a number which a lot of women are aware of. Once you see that AMH below one, this is where high stimulation protocols don’t work really well. This is where it’s just too much medicine. When it comes to the antral follicle counts, once you see that antral follicle count below probably six to eight, that’s where these, you really have to go to low stimulation. Sometimes you will be able to get away with eight to 10, but you have to be cautious. There’s actually different levels of conventional high stimulation protocols. When I came here from the Northeast and I came here, I noticed that Southern California uses a lot more medicine than they use in the Northeast. And in these diminished ovarian reserves where you have follicles like eight to 12, a Northeast protocol might work pretty well, but a Southern California super high stimulation doesn’t work very well in a situation like that.

Dr. Chang:

But for mini IVF, for minimal stimulation, diminished ovarian reserve, I would say AMH below one, antral follicle count below eight. You really should think about going to a minimal stimulation specialist. A second person to consider is a person who’s just failed multiple times in traditional IVF cycles. Why do the same thing? When you go to conventional center, conventional center the stimulation is basically the same. You’re hoping that the laboratories are a little bit different, but in all honesty, most centers, embryology labs were very, very good, you know? It really makes a very small difference in that case. But if you failed multiple times doing a traditional high stimulation protocol, think minimal stimulation, go that route.

Dr. Chang:

A third person to consider is just from a financial standpoint, it’s just an older woman over 40, you know? The problem is women over 40, she’s only going to make one or two perfect eggs in a cycle if she’s lucky and that’s maybe 20% of the time or less. So why waste all your money on all that medicine? The general anesthesia, suffer through all that when you only really need the first couple eggs in every cycle to optimize your chances. And then the last, well, not the last, but then other couples, the younger couples to think about is like I said, people who have maybe moral issues about having extraneous embryos and tubal factor, someone with blocked tubes that there’s no other way for them to get pregnant. A low stimulation protocol will be able to get them pregnant without having to suffer through all that.

Dr. Marc Sklar:

Yeah. I mean, I think those groups, those categories are really valuable for everyone listening to understand kind of how you can start to manage your own process as you’re making those decisions and decide which path might be a better option. But I think it’s at least worthwhile to have that consultation, to have that discussion, and then can always make that decision when you’re going back and forth between those different types.

Dr. Chang:

There is one particular group of patients that minimal stimulation is actually not so easy. And it’s a condition called polycystic ovarian syndrome. We have many, many, many eggs and the eggs, none of the eggs really want to, they’re unable to get to a dominant. They all fight each other and no one wins. And minimal stimulation, in theory it’s great, because these women, if you do traditional stimulation, you worry about something called ovarian hyperstimulation, they can get really sick. But minimal stimulation, this situation is really, really difficult because you’re not really getting enough stimulation to get the extra grow because they don’t want to grow. They’re fighting with each other. So it’s very, very hard. And it’s taking me, you know, I think I have a protocol that works for it, but even I’m not a 100% comfortable with my minimal stimulation protocol in these situations.

Dr. Marc Sklar:

Yeah. I mean, I think that’s also great for those who are listening who have PCOS to understand where the limitations are and how to also make those decisions. Now, I know there are variations within that spectrum of minimal stimulation, and I’ve seen you do no medication whatsoever, more like a natural IVF cycle to more medication. How many different variations, two, three and I know it’s going to vary quite a bit from patient to patient, but if we had to isolate them into maybe specific categories, are there two or three or four different types when we’re starting to group them all together?

Dr. Chang:

I guess you could probably kind of put them into four categories. One is the most common is this classic mini IVF with Clomid and a few injections. Another one is actually just taking a traditional IVF cycle. Usually what they do, many doctors do something called an antagonist cycle. You give FSH, you give like Gonal-F, Follistim, Menopur, couple of injections. Eventually you have to worry about premature ovulation. And at that point you give a second medicine called an antagonist to stop this from happening. The dosages tend to be very, very high, but you can literally just kind of use those same medicines and just bring everything down so that the goal is not 20,30 eggs. It’s maybe more like an eight to 12 egg situation. Another protocol, what I call low complexity or simple IVF, the Japanese called it ultra mini.

Dr. Chang:

I thought it was kind of, there was a TV show back in the old days when I was a little kid watching called Ultraman and I think of that. But I’d call it a low complexity IVF in the sense that you’re really just taking oral medicines. You’re really producing maybe two to four eggs. And the retrievals become very easy. They can be done under local anesthesia very easily. And in that situation, instead of doing all these things like freezing and testing number, you can just literally just pop the embryo back in. Last, but not least is the natural IVF. There’s, no medicines involved the one egg every month. It’s a very inefficient mode of approaching things because you’re only getting that one egg.

Dr. Chang:

But, if you’re, someone who is defiantly afraid of medicines, who really have very, very firm beliefs that you don’t want to produce anything more than one egg every month, it’s a very simple, straightforward protocol. Another person, if you’re a woman who’s 45, you really don’t need all those extraneous eggs because you’re really going to be lucky enough to make one good egg in a cycle. So I would probably kind of filter this down to like four different protocols out there.

Dr. Marc Sklar:

Yeah. I think that’s really helpful for everyone listening. As we’re wrapping up, is there anything else that you want to add or mention, or just leave the viewers with as it comes to what we’ve been discussing?

Dr. Chang:

Yeah. It’s important. Actually, yes, the most important thing with this whole process is, don’t repeat the same thing over and over again expecting a different result. Try something. There’s so many different approaches. What most centers will give you is that one approach, but there’s many, many, many different ways to succeed. And if one way doesn’t work for you, because everybody’s completely different, try something else, try something different, go to a different center, explore.

Dr. Chang:

You know, if you hear about someone who very intriguing across the country, give them a call, try to talk to them, see, what you think. And, it may be more appropriate for your situation. And now with transportation, it’s very, I get tons of patients who do their monitoring elsewhere, and they’ll just fly in to San Diego for a weekend to get these procedures done. Like it can be done. It doesn’t mean like everything has to be done right and that you’re right by your house.

Dr. Marc Sklar:

Right. Yeah, that’s great. I mean, I think it’s really important for everyone listening to get an understanding for what’s the appropriate protocol for you, have those consultations learn about what the options are, so that you could make the best decision for yourself and your needs. And regardless of where you are, just like Dr. Chang was saying, you can be monitored in one place and then have the procedures done someplace else. So that makes it a lot easier. Well, thank you so much for being with me today and for answering these questions. Hopefully everybody watching found some value there. If you have questions about this topic, please post them in the comments below. We will do our best to get back to you and answer all those for you. And if you want to see or learn more information about Dr. Chang and Hanabusa IVF, you can do so at hanabusaivf.com, or we’ll put the link in the description below. Is there any other way that they can reach out to you or was that accurate?

Dr. Chang:

That sounds good. I mean, there’s probably other ways, but my team knows better than I, so.

Dr. Marc Sklar:

Great.

Dr. Chang:

Thank you very much, Mark for having me on the show.

Dr. Marc Sklar:

Absolutely. Well, thanks for being here. I really appreciate your time.

Dr. Chang:

Thank you.

Dr. Marc Sklar:

Bye everyone. Have a wonderful day. I want to thank you all for being here, for staying through to the end and watching this excellent interview with Dr. Chang from Hanabusa IVF. If you want more information on mini IVF and Hanabusa IVF, just use the link in the description below. If you have questions about this topic, please post them in the comments below. If you liked this video, give me a thumbs up. And if you’re not already a subscriber to my YouTube channel, you need to be, so hit that bell so that you can get notified when I put out a new video for you. Until the next video, I want you all to stay safe, stay healthy, and most of all, stay fertile.

 

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