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Bill Klaproth: IVF is the most effective fertility treatment, but sometimes the cost can be prohibitive. So is there such a thing as a low-cost strategy? Well, let's find out what Dr. Mary Ramie Hinckley a physician at Reproductive Science Center of the San Francisco Bay Area. This is the Fertile Edge, a podcast by Reproductive Science Center of the San Francisco Bay Area. I'm Bill Klaproth, Dr. Hinckley, thank you for your time. So when we talk about a low-cost IVF strategy, is there really such a thing?

Dr. Mary Ramie Hinckley: Well, I'm glad you asked because yes, there is, there are low cost ways to do fertility treatment and even low-cost IVF. So there's different ways to begin to think about this. And when you start your fertility journey, one of the things that I want to encourage patients to do in order to lower their costs is to be very thoughtful at the outset. And that includes doing the simple things, which maybe aren't so simple, but of optimizing your health. Being on your vitamin, get your weight in the ideal space, take care of all those bad habits like smoking or drinking, or, any of the other things that you do that are maybe not optimal for your health. That's going to put your body in the most optimal situation to get pregnant easier which ultimately translates to lower cost. I also think it's really important to get the right data early. Some people try to save on costs by not seeing the doctor or not doing the tests. And what ends up happening is, for many people that strategy backfires and they end up doing tests later and getting a workup later that tells them about a problem that could have been fixed from the beginning to optimize things again and making it less expensive to get pregnant. So one of the other strategies I have for people to really lower their costs is to do things right at home. And that includes even trying to conceive naturally to not use a lubricant that's unfriendly to sperm, to check your ovulation kits with over the counter kits to know when you're ovulating to have sex appropriately, there's even some at-home sperm tests, and while they're nowhere near as good as doing a sperm test in a fertility clinic, it's a good one way to know early on at a lower cost that you are making sperm and that it is reasonable before you then go through lengthy treatments and then check the sperm many months later. And then lastly, in terms of low-cost treatment, in case you don't have a fertility specialist nearby, it's not unreasonable to consider three cycles with Clomid and insemination or artificial insemination before moving on to something more aggressive that simple three months of treatment will get a good percentage of patients pregnant, maybe 30 to 40% so that they never then have to go on to do a more aggressive expensive treatment. However, if you're doing Clomid and insemination with your OB-GYN, who doesn't do ultrasounds and doesn't do monitoring and doesn't even do insemination, then that's a waste of your time and money, and you might as well move to the fertility clinic to get the best advice early because that will ultimately save you time and money.

Host: Right. So then when it comes to a low-cost strategy, if you will, job one is to optimize your health first, then make sure you get the right data from your physician. And when trying to conceive at home, make sure you're doing the right things and then consider three cycles with artificial insemination. So that's kind of the low-cost strategy if you will. So then are there studies to prove that a low-cost strategy like this is effective?

Dr. Hinckley: Absolutely. There are studies out there that show starting low tech is the best way to be if you're in certain populations and those populations include someone who doesn't ovulate. If you're not an ovulator, then for you just getting you to ovulate is the problem, it's usually the only problem. And so doing something like low tech at home that helps you ovulate can be much more cost-effective. There are also some studies looking at people who are, who have unexplained infertility and for those populations moving forward quickly with the IUI cycles and then moving on to IVF after only three of those all shows also show that that is a statistically significant, better strategy. And lastly, there's some studies out there looking at women over 38, and this is a unique population where moving to IVF sooner actually becomes the better option in order to ultimately lower your cost per baby born.

Host: So generally, if I heard you correctly, it sounds like the three cycles of artificial insemination or IUI, that is the right strategy before moving to IVF. Did I hear you right on that?

Dr. Hinckley: You did. You did hear that, right. And that is really based upon some studies that show a certain percentage of patients will get pregnant in those three cycles and therefore they never have to go through the more expensive IVF. But if you spend more time than those three cycles, or you don't do those three cycles very effectively, for example, you don't do it insemination with them, then you've wasted the time and the money spent on those three cycles and then have to do IVF ultimately to have your baby. So it would have been better to just go to IVF if you didn't do those three cycles well.

Host: Okay. So then is that when it makes more sense to pay for the higher cost procedures to get a higher success rate?

Dr. Hinckley: Absolutely. So there are certain situations when doing low tech low cost doesn't make sense. And I think if, if you're someone that looks at your timeline and you really see that your time is limited, you are older to start, or you just have less time. This is the window which you guys have decided would be ideal to conceive. And that window is more limited for jobs from where you're living and your situation travel, et cetera. Then those are times where it doesn't make sense to do low cost, low tech treatment. In addition, if you really want more than one child and you're starting in your mid-thirties, many times, it makes more sense to be aggressive early, because what you can do is bank extra embryos to use for the future. And then those frozen embryos come at a much lower cost than say doing repeat cycles again and again, in the future. So those are situations where time is an issue. If you're someone who can make a lot of eggs. So say, for example, you have a very good ovarian reserve, that is a situation where sometimes moving straight to IVF because it has such a high success rate in the first cycle and then the potential for extra embryos and hopefully extra children. It may make more sense and save you money over the long haul. So not on the first baby, it's not going to save you more money, but it might save you more money for the whole of your family creation to move to IVF sooner. And then, of course, the obvious, which is when insurance covers it. So many women and couples are finding themselves in a situation now where insurances are starting to cover IVF and they're covering it for a variety of reasons. Some because it's become more successful and that's the better medical treatment for your disease, but some, because that is part of the lure of coming and taking a job at that company, many high-tech companies that are really trying to recruit the best employees are offering better insurance benefits. And sometimes that includes fertility treatment. And so if you're someone that has really good insurance benefits, it might make more sense to lean towards IVF sooner because it is more successful and ultimately the cost is less significant for you. There are side effects of taking longer to get pregnant. So if you're on a low tech, low-cost track, you have to recognize that some of those side effects just include the moodiness and the emotional changes that come from the medicine, some depression that comes from repeated failed cycles, marital issues that come up, work demands that add to it. So there, isn't an easy answer to these things. It really takes looking at your situation and saying, is this the right time? And how much time do I have? Where is my value? Would I rather stay low tech, low cost? Or would I rather get more aggressive sooner to try to avoid some of the side effects from a lower-tech approach?

Host: Yeah. There's a lot of factors when making these decisions. It's not as easy as it sounds. I also wanted to ask you about minimal stim IVF or mini stim IVF. I've been hearing about that lately. Can you explain to us what that is?

Dr. Hinckley: Oh, I'm glad you asked that because it is sort of a catchphrase out there now, and I have patients often coming into my office to ask me, can I do mini-stim IVF, or IVF light or minimal IVF? It goes by different names. And basically, this is a less aggressive stimulation. Yielding lower egg numbers. That's what it is in essence. And you can achieve that through a variety of ways, but the most common way to achieve that is to use oral pills, medicines to start your IVF cycle, and then usually finish with some shots that allow you to spend less money on the shots. Typically a medicine for IVF can cost four or $5,000. So if you can use less medicine, you can cut your costs significantly for IVF. It also means less injections, less monitoring, less exposure to drugs, which many people would appreciate. Of course, they only appreciate it if it's going to give them a reasonable success rate because you're getting less eggs, that means you're also getting less embryos, which means you have less choice. And so there are really, benefits and risks with this process in terms of deciding if it's right for you.

Host: So I'm thinking who this might be better suited for. It sounds like it might be better for a younger person with a higher quality egg versus an older person, now that may be an oversimplification, but who should consider mini IVF?

Dr. Hinckley: So interestingly, there's really two populations for whom it may be best for. And they're at the two extremes. So if you are a younger patient or at least a patient with great ovarian reserve, but you have a logistical issue, let's say, for example, your tubes are blocked or your husband had a vasectomy. You are someone that the quality of your eggs should be very good, so you don't need as many. So, therefore, you can save money by doing mini stem IVF. Getting less eggs, but those eggs result in a higher rate of embryo development and a higher healthy embryo development so that you can get pregnant. It's also really good for the opposite extreme, and these are called low responders. They don't necessarily have to be older women. They could be young women, but women that just don't respond very well to the medicine that we use, the fertility shots. Sometimes this means they have a low AMH level or a high FSH level. These fertility markers, sometimes it means they've done a cycle before where they just haven't produced many eggs, even with the high dose medicine. And so for these women, it doesn't matter what dose of medicine I give them. They're still gonna only make three or four eggs. And in that situation, it's much more cost-effective to use a lower dose, get the same yield, and then that gives them more money in the bank in case they have to try again because unfortunately minimal stim IVF, especially if you're a low responder, does not have great success rates. And so, therefore, you may have to try it more than once, which is why it's better if you don't spend all your money on the first cycle. So, that cumulative success rate can slowly begin to add up to help you get pregnant.

Host: Okay. So two extremes people that are young you'll have less eggs, but because you're young, you have a higher quality and then people that are poor responders to the treatments, is that correct?

Dr. Hinckley: Correct? Absolutely correct.

Host: Okay. All right. So you talked about success rates briefly. Can you dive into that a little bit more for us? You said the success rates. are potentially lower for mini- IVF, is that because it's less eggs?

Dr. Hinckley: True, again, it depends on the quality of the egg and the quality of the embryo. People who do mini-stim IVF usually are not doing embryo biopsy. So we're not testing the embryo because that's very expensive, and so, therefore, we don't have the same knowledge of the health of the embryo as if we were testing it. So for example, a young woman who has one good blast assist to transfer from a mini STEM IVF and our center would have a success rate between 55 and 65% of getting to a live birth. That's pretty good, but that's about what her success rate would be if she did IVF and it made lots of embryos and we just put one in, so you can see, that it doesn't change that much for the young good quality embryo producer. On the flip side, a woman who's over 38, even a one good quality embryo, it doesn't have a great success rate unless it's been tested and we know that it's chromosomally normal. And so let's say at 38, one good embryo may still only have a success rate of about 30%, and most studies that have looked at mini STEM IVF for low responders, actually show success rates of around five to 10%. So it's not very successful on a per cycle basis. But again, a high dose stimulation may not be successful either. And if they're able to do multiple cycles back in 2016 in a study by Zang, they have shown the cumulative live birth rate can get upwards of 49% from six months of many IVF stimulations. A meta-analysis in 2019 also showed that it is equally successful in high dose stimulation. If you're able to try multiple times and Cochrane reviews, which are kind of the classic reviews that look at all of the studies that have been done, have again, shown no real difference in success rate, but that doesn't mean its great success. It's still pretty low success for people that are poor responders, but it may be their best option if they're not willing to consider egg donation or adoption.

Host: Right. So you have dropped a lot of knowledge on us, and we always appreciate that Dr. Hinckley. So maybe you could bottom line this for us. Last question, how should a woman or a couple decide on going the low-cost route versus the more traditional route.

Dr. Hinckley: Well, I really hope that people will take some time at the front end to really think about their values and where they want to go with this. And they wouldn't just try to, say pinch a penny here to end up costing them in the long run, but would instead try to optimize the variables they can, get the right data to the right place and make a good decision. And I think so much of it has to do with your age and your egg reserve. That would be what your ovaries look like on ultrasound or your AMH level. And so if you're able to get at that data early, if you score well, if you're young and you have a good AMH, you can really use the low-cost strategy to your advantage. And that's who I would encourage to do that. Women who are not in that situation, who are in the middle really should just go with traditional IVF, but that's going to give you your highest success rate and ultimately give you the greatest chance of having a baby.

Host: Well, that's some great advice to follow and a perfect way to wrap this up. Dr. Hinckley as always, thank you so much for your time. We appreciate it.

Dr. Hinckley: Well, thank you. It's so nice to be on and I hope it's helpful to some people out there.

Host: That's Doctor Mary Ramie Hinckley, and to get connected with Dr. Hinckley or another physician, please visit RSCBayArea, com that's RSCBayArea.com. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is the Fertile Edge by Reproductive Science Center of the San Francisco Bay Area. I'm Bill Klaproth. Thanks for listening.