The incidence of "poor responder" patients is estimated to be about 10%. Poor response is often related to patient age, where the low response to hmg reflects a decline in ovarian reserve. This occurs more frequently in patients over 35 although it may occur in younger women too. in general poor responder patients are refractory to any stimulation protocol, and although many strategies have been suggested, the results remain poor despite high doses of hmg. In such patients, NC-IVF may be a valid alternative. Indeed, the authors had previously demonstrated that NC-IVF is at least as effective as hmg-IUI in terms of pregnancy rates, and that NC-IVF should be preferred because of its favorable cost-benefit ratio.

The authors of this study commented, "in light of our results, minimal stimulation does not seem to have any advantage over natural cycles in terms of pregnancy rate improvement. Minimal stimulation is also expensive...even in low doeses, are additional costs as well as stressful for the woman, without adding any improvement to the expected outcome.

Finally the authors concluded by saying, "NC-IVF is a suitable, feasible alternative to ovarian hyperstimulation in poor responder patients, and it should be suggested by physicians as an alternative to expensive ovarian stimulation with gonadotropins or before proposing egg donation, especially in women younger than 40 years." They suggested that 4 treatments of NC-IVF were reasonable, as the pregnancy rate per cycle remained the same for each consecutive attempt. In my experience, most of our patients who have achieved a successful pregnancy with NC-IVF did so usually within their first or second treatment cycle. A few required 3 treatments and rarely did anyone require 4.

Let's just hope that the good news for our "poor responder" patients continues!

-Dr. Michael DiMattina

She Never Gave Up- Finally, Her Successful IVF Pregnancy With a Surrogate 4/1/09

This case took me to my knees. None of us ever gave up. I strongly believed that sooner or later, we would fine a cure. Now, she and her husband will have their own biological child with the help of a surrogate.

S.R. is a wonderful, delightful, intelligent 28-year-old lady, who came to me in August 2004. She and her husband had been trying to conceive for one year and she had unexplained infertility (UI). In general, UI is best treated with IVF and ICSI. She first tried to conceive by simply trying Clomid with IUI, but this was unsuccessful. In December 2005, she underwent IVF with 2 Grade 1 embryos transferred, but no pregnancy occurred. A second IVF procedure with transfer of 2 Grade 1 embryos was again performed, but still no success. This was followed by an unsuccessful frozen embryo transfer. Three embryo transfers and no baby. What gives? At Dominion Fertility it is rare for us to perform more than 2 IVF procedures on any women who is less than 34 years old and not have a successful pregnancy.

In her IVF treatments, I observed that her endometrium was always 7 to 8 mm thick, so I performed an endometrial biopsy. Sure enough, it showed a luteal phase defect of 6 - 7 days which is not compatible with implantation. By prolonging her follicular phase with estrogen, I was able to normalize her endometrium and so we thought that her problem was solved. Indeed, in November 2006, I performed another frozen embryo transfer and this resulted in pregnancy, but, unfortunately, she miscarried at 12 weeks. This was clearly a bummer for us all. The couple took a break in 2007. In 2008, I strongly recommended that she consider using a surrogate with her eggs and her husband's sperm. S.R. was not ready for that, so she underwent another fresh IVF with 2 blastocyst embryos transferred in February 2008 and this resulted in a biochemical pregnancy. Finally, after a total of 5 embryo transfers and no baby, she agreed to use a surrogate.

Incidentally, I noticed that S.R. was progressively making fewer eggs with each successive IVF treatment and her ovarian reserve diminishing. She never produced a large number of eggs before, but now she was producing even fewer eggs at her young reproductive age. So, time seemed to be of the essence. In October 2008, we performed another fresh IVF but S.R. only produced 3 ova. Two embryos were transferred into her surrogate but no pregnancy occurred. Yes, her ovarian reserve was definitely diminishing. I recommended that they try one more time and FINALLY, in February 2009, we established a successful pregnancy after ET of 2 blastocysts into her surrogate! Wow! I was walking on cloud 9 that day, but so was everyone else.

So, what do we learn from S.R.'s story? Perhaps her infertility is now explainable. A uterine factor seems to be the etiology of this couples' infertility, which only became apparent after many failed embryo transfers of high quality embryos in a young reproductive age female. It was most difficult for the couple to finally agree to use a surrogate, but they are most pleased that they did. They have formed a close, strong relationship with their surrogate during the course of their treatments and delivery is expected later this year.

Uterine factors, when the uterus is thought to be normal, is fortunately rare and usually diagnosed only after multiple failed IVF cycles when everything seems to have gone well, but no pregnancy occurs. This couple proves to me that the single most important factor to establishing a successful pregnancy is persistence. Kudos to this wonderful couple!

-Dr. Michael DiMattina

They told her it was a sham. Now she's pregnant! 3/31/09

That's what N.F.'s infertility specialist told her in Columbia, S.C. when she asked if she could try Natural Cycle IVF. She proved them to be wrong.

N.F. is a wonderful, intelligent 30-year-old lady who teaches at her local university. She has been trying unsuccessfully to have a baby for the past 3 years. Her husband has a severe male factor with only 2 million sperm/ml and only 1% normal sperm morphology. Their only hope to have their own biological baby was to use IVF with ICSI, but she did not wish to use ovarian stimulating drugs. She found Dominion Fertility on the internet and came to Arlington, Virginia to see me for a consult in early January 2009.

One month later, on February 19, I transferred a single 8-cell embryo. On March 19, I sent her back to her local Ob/Gyn for routine obstetrical care. She only traveled to Arlington for 3 separate visits: her initial consultation, her egg retrieval and finally, 3 days later, her embryo transfer. She is currently about 7 1/2 weeks pregnant and doing very well. It seems NC-IVF wasn't such a sham after all!

N.F. is thrilled that her NC-IVF treatment at Dominion Fertility worked on her very first cycle. However, she feels that she was not given good advice by her former dcotor and is now on a mission to tell her story. She recently informed me that National Public Radio is interviewing her so that she can get the word out that NC-IVF is no "sham". N.F. believes that many women feel the same as she does, i.e. they want simpler, less expensive infertility treatments that offer good pregnancy rates with few or no risks- without using ovarian stimulation drugs.

NC-IVF is a logical treatment of choice for many patients who have male factor infertility. IUI, with or without fertility drugs, most likely would not have resulted in pregnancy for this couple as they had a severe male factor causing their infertility. But there was no reason to subject this patient to expensive ovarian stimulating drugs and produce many eggs/embryos. We only transfer one embryo in such patients, thereby almost eliminating the possibility of a twin pregnancy. So, no "sham" here, just another baby on the way!

-Dr. Michael DiMattina

Dominion Fertility Announces: "Another First That's a Second" 3/27/09

Dominion Fertility has great news today! A 32-year-old patient who last year delivered a successful pregnancy conceived by our Natural Cycle IVF program is again pregnant using NCIVF. Her pregnancy represents the first successful sibling NCIVF pregnancy in the Washington, D.C. area.

Here's her story: When we met, M.M. was a 30-year-old female who had never been pregnant. She is married to a local anesthesiologist and they had been trying to conceive for about 2 years. Their infertility was related to a male factor with low sperm count, motility and morphology. At another infertility clinic, she underwent treatment using clomid/gonadotropins with IUI for 3 cycles. This did not result in pregnancy, so her doctor recommended IVF. Sound familiar to anyone out there?

M.M. came to me in April 2007 to see if she could try NCIVF. Two months later, we performed her first NCIVF and she became pregnant. She delivered a healthy son in February 2008. In August 2008 she returned to our clinic to try for her second child. In November 2008 we performed NCIVF, but there was no egg in her follicle. Of course this was disappointing, but fortunately this rarely happens as most follicles contain a healthy egg. So, she tried again.

On February 18th, I transferred a single 8-cell embryo. Today M.M. has a healthy 7-week pregnancy and has been referred back to her OB/GYN for continued obstetrical care. One egg, one embryo, no fertility drugs. Natural Cycle IVF is far less expensive than stimulated IVF, and has virtually no risks. What's not to like? The patient is almost speechless since she had been told by the other IVF clinic that she would require drugs for IVF. We are very happy for M.M.'s success!!!

Dominion Fertility is currently in the process of writing up and submitting for publication our 2+ year experience with NCIVF. Many doctors from around the country are now asking us about our program and seem most interested in NCIVF. We believe that patients are intelligent, have a great interest in their healthcare, and are interested in technologies that are effective, less expensive and simpler. Although NCIVF is not a cure all, we believe that it has a definite place in the treatment of many couple's infertility.

-Dr.DiMattina

Natural Cycle IVF- "Thinking Outside the Box" 2/24/09

"Albert Einstein's 1905 burst of creativity was astonishing. He had devised a revolutionary quantum theory of light, helped prove the existence of atoms, explained Brownian motion, upended the concept of space and time , and produced what would become science's best known equation e = mc2." Einstein, His Life and Universe by Walter Isaacson, 2007.

Without doubt Einstein thought "outside of the box". He was not afraid to challenge existing theories and try something new. And his theories proved to be so right in so many scientific areas. Einstein humbly stated, "I have no special talents, I am only passionately curious".

And that is how our Natural Cycle IVF program began, thinking "outside of the box" and with much curiosity. But I do believe that at Dominion Fertility, we have a very special staff who have very special talent. Because of our high success rates with our Natural Cycle IVF program (44% per embryo transfer in 2008), we decided to extend the program to allow patients who were told that there was no hope to achieve pregnancy with their own eggs, another chance.

Since beginning in November, 2008, we have already established a 12 week pregnancy in a 39 year old patient, with a Day 3 FSH level of 20, and who had failed stimulated IVF at another local IVF center. That center told her to adopt or use donor egg IVF. And recently, we had 2 other patients experience "biochemical" pregnancies following treatment with Natural Cycle IVF. One was a 39 year old local dermatologist, who has been infertile for the past 4 years. We performed one cycle of NC- IVF, transferring an 8 cell embryo, but this did not result in pregnancy. She immediately repeated NC-IVF, and this time we transferred a blastocyst embryo which resulted in her biochemical pregnancy. She plans to try again. The third patient was a 38 year old, with a 5 year history of infertility and a Day 3 FSH level of 15.8. She failed treatment with gonadotropins and IUI with a very poor response to the ovarian stimulating drugs. We transferred a blastocyst embryo in our NC-IVF program and she had a biochemical pregnancy in her first attempt. She also plans to try again.

All of these patients had less than a 5% chance for pregnancy, but we are getting results that seem to be "outside of the box". It is too early for us to truly know how many patients will ultimately achieve a successful pregnancy in our extended Natural Cycle IVF program but we know, so far, that at least one patient has and at least 2 others were very close.

Let me take a moment to briefly describe our extended Natural Cycle IVF program. Simply stated, it is an extension of our existing Natural Cycle IVF program for patients who were told that there is no hope for pregnancy with their own eggs. Such patients traditionally would be best treated using Ova Donor IVF or adoption. Now, patients are offered a last chance for pregnancy with their own ova before using donor egg IVF or adoption. We recently transferred two 47 year old patients using NC-IVF but unfortunately, neither achieved pregnancy. Clearly, their chances for pregnancy were less than 1 % but the embryos were astoundingly high quality 8 cell embryos upon embryo transfer. Both patients plan to try again.

Candidates for the Dominion Fertility Natural Cycle IVF Program:

Age: Less than 60 years old and in good health
Menses: Must have regular menstrual cycles
Day 3 FSH: Not restricted
Previous IVF: Patients may have previously failed IVF or have been told that they are not now a candidate for stimulated IVF with their own eggs.

The cost for Dominion Fertility's Natural Cycle IVF or for is $4,000 total. And it is prorated if the cycle is not completed in the following ways:
If the cycle is cancelled prior to egg collection with no IUI: Cost to the patient is $1,000.
If the cycle is cancelled prior to egg collection with IUI: Cost to the patient is $1,900.
If no egg is obtained, then the cost to the patient is $2,500.
If no embryo transfer is performed, then the cost to the patient is $3,500.
The credits can be used for another attempt or simply refunded but the total cost for a completed treatment cycle is $4,000. Preliminary testing is required prior to treatment and such testing is not included in the the above costs.  (Please call for updated costs as prices are subject to change.)

I hope that this post gives everyone a good understanding of our extended Natural Cycle program. Dominion Fertility takes pride for "thinking outside of the box". In 1986, we produced the first Gift baby in the Washington DC area, immediately followed by the first Zift babies. We developed Gift and Zift because the IVF pregnancy rates at that time were horrendously low and Gift and Zift resulted in better pregnancy rates for our patients, again, thinking "outside of the box". But with increasing knowledge and technology, the pregnancy rates for IVF boomed and Gift and Zift became obsolete. Because of the high success rates with Dominion Fertility's stimulated IVF program, we decided to embark on Natural Cycle IVF in January, 2007, and because of its success, we are now offering this treatment to more patients.

We invite you to learn more about our Natural Cycle IVF programs on our web site, dominionfertility.com and to continue with your own curiosity. I encourage you to think "outside of your box". All best wishes, Dr. DiMattina

Natural Cycle IVF for the "Poor Responders"

What can be done for the IVF patient who poorly responds to her ovarian stimulating drugs and now is told to adopt or use ova donor IVF as her only options? And what can be done for the patient who is not a candidate for IVF because of her advanced reproductive age or because her day 3 FSH level is too high and abnormal?

Now comes a recent study in Reproductive Biology online (2008, vol 17, no 2, p 207-212) reporting a 20% pregnancy rate in patients treated with Natural Cycle IVF (NC-IVF) who had previously responded poorly to gonadotropins in a stimulated IVF cycle. In fact, those patients who underwent stimulated IVF had a 5-15% pregnancy rate compared with those who had NC-IVF. The authors concluded that NC-IVF may be a reasonable treatment choice for patients who respond poorly to gonadotropins and who don't make many eggs or embryos. They also pointed out that the patients who used NC-IVF did not incur the expenses of fertility drugs or the pain of multiple daily injections. What I find to be particularly interesting is that this clinic only used NC-IVF as a "last resort" in women with high FSH levels and prior IVF cycle cancellations due to poor response to conventional stimulation protocols. Yet, the pregnancy rates were higher in those patients who underwent NC-IVF compared with those treated with stimulated IVF.

Last week at Dominion Fertility, we treated two 47 year old patients using NC-IVF and both underwent a successful embryo transfer in their first treatment cycle. At this time, they are the oldest patients that we have treated with NC-IVF. Both of these patients were advised that their best chances for pregnancy were with Ova Donor IVF, but both had wanted a chance to try IVF with their own eggs knowing that their chances for success were less than 1% at their age. Amazingly, one patient had a Grade 1, 8 cell embryo for transfer and the other, an early morula. We are firmly convinced that mother nature selects the best egg each month in the natural menstrual cycle as most of the eggs and embryos that we get from NC-IVF patients appear to be of very high quality even in those patients of advanced reproductive age. The above recent report further supports these beliefs.

Also last week, we are pleased to announce that we have referred back to her obstetrician for OB care, our previously reported 39 year old patient who was successful in our NC-IVF program. Her day 3 FSH level was 20 and she was a "poor responder" in her stimulated IVF cycle performed at another local infertility clinic which was unsuccessful. They told the patient to either adopt or do Ova Donor IVF. She then came to Dominion Fertility and underwent one NC-IVF treatment with us and was successful in her first attempt. This patient had three serious infertility factors, her advanced age, diminished ovarian reserve (day 3 FSH 20), and a poor response to ovarian fertility drugs, yet she became pregnant in her first treatment with NC-IVF. Congrats to her for "hanging in there"!!!!!

-Dr.DiMattina

Natural Cycle Success

Patient J.M.
J.M. is a healthy 36 year old lady with primary infertility (previously never been pregnant) who came to me in June, 2008. Her HSG showed a right hydrosalpingx (a blocked tube full of embryo toxic fluid), that was clearly preventing her from conceiving. In July, a laparoscopy confirmed the hydrosalpingx and the tube was removed as it was irreparably damaged.

Because J.M. was 36 years old, she also had an age factor and was showing some diminished ovarian reserve on both her sonogram, and with her serum antimullerian hormone level (AMH) which was only 0.7. She wanted to be aggressive in treating her infertility, but she did not wish to immediately go through IVF because of the stress, costs and fertility drugs.So, I suggested Natural Cycle IVF as a less stressful, less costly alternative which does not use any ovarian stimulating drugs either.

On November 26, we obtained a single egg produced in her normal, natural menstrual cycle, in our office with minimal conscious sedation. The egg collection took less than 3 minutes once the needle was placed into her follicle.During her monitoring, she had only 4 total office visits.

The egg fertilized, but on day 3 after the aspiration, the embryo was developing slowly with only a 4-5 cell embryo. Typically, on day 3 a normal embryo would be 8 to 10 cells. Therefore, we continued to culture her embryo to see if the embryo was healthy or whether it had arrested in its growth. Fortunately for J.M., the embryo continued to grow and a healthy blastocyst embryo was easily transferred back to the patient's uterus. On December 30th, a transvaginal ultrasound exam confirmed a 7 week normal appearing pregnancy. The patient could not believe how simple the entire process was.

J.M. was my last obstetrical sonogram for 2008, and I am most pleased for her. The lesson we learn here is that "what you see may not be what you get." On day 3 her embryo was clearly lagging behind in its development, but this does not necessarily mean that all is bad. By allowing the embryo to continue to culture in our lab, it was later evident that there was hope and J.M.'s hope is quickly becoming her reality.

- Dr. DiMattina

Natural Cycle IVF at Dominion Fertility

We just had a 36 year old patient who had failed IVF at another local major center become pregnant after only one treatment with Natural Cycle IVF. What's amazing is that her day 3 FSH level was 20 (normal is less than 10)! The other center refused to do IVF again with her own eggs, instead recommending ova donor IVF as her only option.

Now, Natural Cycle IVF is clearly no "cure all" for one's infertility, but it is so very different from conventional IVF because there are no ovarian stimulating drugs. This allows the body to select out the "best egg" for that cycle and this may offer an advantage compared with conventional IVF.

Dominion Fertility has just started offering Natural Cycle IVF to patients who have failed to achieve pregnancy using other methods or whose day 3 FSH level is elevated. This patient is the first in our extended program to become pregnant!

- Dr. DiMattina

Male Factor Infertility

Patient N.L
Patient N.L is, a young 32 year old woman who had tried unsuccessfully to become pregnant for four years. She went to a local fertility clinic that diagnosed a male factor with her husband's sperm morphology diminished.

That fertility clinic treated her with clomid and IUI for two treatment cycles, but no pregnancy occurred. They then recommended stimulated IVF as the next step. Before beginning the intensive treatment program, N.L. decided to seek a second opinion.

She came to Dominion Fertility and underwent one treatment with NCIVF. Not only did N.L. achieve a successful clinical pregnancy right away, she spent $4,000 as compared to the $10,000- $20,000 she would have spent on stimulated IVF.

Patient M.M.
M.M. is a 30 year old healthy female whose husband also had male factor infertility. The couple had been trying to achieve pregnancy unsuccessfully for two years. They, too, had been treated with clomid, and Gonal F with IUI for three cycles over a six month period at another local fertility clinic. These treatments did not result in pregnancy and again, that clinic recommended stimulated IVF.

M.M. came to Dominion Fertility in April 2007. Here she underwent one treatment of NCIVF, and promptly achieved a successful clinical pregnancy within two months. The patient remarked at how much easier and less stressful the entire process was compared with IUI.

Comments:
We believe that NCIVF offers distinct advantages compared with IUI in patients whose infertility is male factor related.

Tubal Factor Infertility

Patient Y.S.
Y.S. is a 34 year old patient who experienced infertility for four years and was unable to achieve pregnancy because of both tubal and male factors. She needed treatment with IVF but did not wish to use ovarian stimulation drugs. With this in mind, she set out to search for an alternative treatment option.

At Dominion Fertility Y.S. underwent one treatment with NCIVF and achieved a successful pregnancy. By avoiding the use of ovarian stimulation drugs she not only incurred less expense, but avoided health risks such as ovarian hyperstimulation syndrome.

Comments:
In general, tubal factor infertility is best treated with IVF. Natural Cycle IVF avoids the use and risks of ovarian stimulation drugs.

Endometriosis

Patient D.W.
D.W. is a 34 year old female who had severe endometriosis and was trying to become pregnant for four years. She was treated with several cycles of IUI and one cycle of stimulated IVF with no success.

At Dominion Fertility she underwent two treatments with NCIVF and achieved a successful clinical pregnancy in her second embryo transfer. With less stress and much less cost, D.W. was able to achieve with Natural Cycle what conventional treatment never had.

Comments:
Natural Cycle IVF can be used to treat patients whose infertility is related to endometriosis, and in this patient's case, severe endometriosis.