Mild vs Natural Modified at Create

[Jo99999]

I just finished my 2nd round of 3-cycle package with Create. I am on mild IVF protocol. 1st round, 6 eggs, 4 fertilised, 1 day-3 and 1 blast 4aa frozen. 2nd round, 3 eggs all fertilised, 1 blast 5bb frozen.

I had a previously failed cycle with CRGH FET with a 2-3bb blast.

With 1 cycle left with Create, I wonder if I should switch to natural modified since I only get 1 blast per cycle. I did discuss with Create previously about natural modified but they said natural modified only aims to get 1 egg per cycle and the stimulation is just to counteract the effect of Cetrotide and not to stimulate any extra eggs. Will lowering the drugs help the egg quality further? Mild is 150iu bemfola daily from day 2.

I am also due to have a fresh transfer in the 3rd cycle. So I am thinking that lower drug is also better for fresh transfer? I read many research papers and there are different results and it is not clear if fresh or FET is better.

Is there anything you recommend before the transfer? Having had a failed transfer, I would like to maximise the chance of this one. I had anti-coagulant in the last FET.

Thanks!

Hi so I actually did 2 individual cycles of mild IVF with Create and then after 3 failed transfers did a 3 cycle package of natural modified with Create. I'm now 20 weeks with twins

For me I was getting good egg numbers with mild IVF with ICSI - 14 each time so a total
Of 28 over the 2 cycles (I was on 225 of Bemfola) but my egg quality was awful - less than 30% fertilised and I got 2 average quality blastocysts from each cycle - 2x 3AB, 1x5BB and 1x5BC

Natural modified was the best decision I made - in 2 cycles I got 9 eggs 100% fertilised with ICSI and I got 4 top quality blastocysts. The 3rd cycle was a bust as I ended up having to go back to a mild cycle protocol as my lining tends to get too thick on tamoxifen and I wanted to do a fresh transfer. Surprise surprise ended up with rubbish quality eggs again and no blastocysts!

Anyway point is my Create clinic (Birmingham) said natural modified ISNT about only getting one follicle. If they wanted that then they would have suggested natural IVF and saved you the money on the drugs. Natural modified was about giving what you had in your antral follicle count that month a gentle push; not trying to force your ovaries to produce more than it would normally do. First cycle I got 2 follicles 2 blastocysts, second cycle 7 follicles 2 blastocysts

My friend who also did natural modified got 7 follicles and 4 blastocysts!

For Create in terms of procedure it's exactly the same scans etc so shouldnt make difference to them if you took less drugs - but it's not just about lower dose stims you take tamoxifen tablets (similar effect to clomid).

You've got 3 in the freezer so if you get 1-2 more from this next one I'd be happy with that? You've got good quality so far with the aa blastocyst and I know Create only freeze the top quality one on day 3 (one of my twins is the day 3 frozen one) so also in with a good chance with that one?

I'd transfer what you have first and then decide then whether you can financially afford to again with a natural modified cycle but hopefully you won't need to 🤞🤞

(Which branch of Create are you with?)

My experience was different - no tamoxifen (despite asking) and they were insistent on only getting one egg so I think it depends on the doctor you get...

@ivfbeenbusy, @Weswoo, thanks. My clinic is St Paul's. Is it slightly different per clinic? I don't know why they say natural modified only aims for 1 egg at St Paul's. I guess it is really down to the drug level. My drug level is 150 iu per day which is relatively low? If this is reduced to every other day, I suppose it is quite likely I will get 1 egg only or they may not stimulate for as many days. The last two cycles it was 150 iu x 9 days. They gave 1-2 days extra for the smaller follicles to grow. I was not keen on tamoxifen and they did not insist on it either.

At CRGH I had 225 iu meriofert + 225 fostimon x 7 days.

What are your drug regimes?

I was with Create Birmingham

My natural modified protocol was tamoxifen tablets from cycle day 3 and 150ml bemfola every other day also from cycle day 3

Cycle 2 we tweaked it a bit to get more than one follicle as that's when they said otherwise why bother with natural modified save the money on the drugs and just so natural IVF. So instead of 150ml bemfola i did 75ml bemfola and 75ml luveris daily with the tamoxifen

It's frustrating there is so much variance between the same clinic

Thanks. I will book a call with the doctor to ask the questions and how it differs from one branch to another.

@Jo99999 I was on 150 bemfola from day 5, nothing else (St Pauls).

Hi all, I have a consult with create lined up for natural modified ivf. I’ve done 3 rounds and never get more than 4 eggs regardless of dose of Stims so thinking if I did natural modified I could maybe aim for those 4 but they would be better quality and could also do back to back collections too.

However my issue is I’m in Ireland and with covid and Quarantine I’m not sure how it will work. I was wondering if you think that I would need to be in create or if I could ask my clinic here to give me a low dose of Stims and do the round with them to see if the more natural version would work for me.

What do you guys who have done it think of that? Do create monitor you closely or same as short protocol (baseline scan, scan day 7 then every two days until egg collection) - do they do anything else different aside from lower dose of Stims? I see someone mention tamoxifen?

We both work from home so technically we could move over for each round but we would need to be there for probably 2 weeks each month for 3 month and then quarantining back home for 2 weeks each time and then there the risk the U.K. might shut down.

@Racinglikeapronow Create scan you every other day from the start and there are also blood tests at every visit as they look at the whole picture, not just scans. I suppose it depends on how knowledgeable your clinic are with natural modified and how much monitoring you will get

Unfortunately there are no clinics doing natural modified here! I think we’re quite behind as obviously a conservative country so the clinics have only been open around 20 years!! Thanks for your reply. I guess I might need to just chance travelling over winter and hope it goes ok. As if we didn’t all have enough going on without covid too!

Hi all are there any Create stats for natural modified ? Also on standard ivf there seems a big variance between create clinics , with St. Paul’s being under the national average for 40 plus and Wimbledon over national average . I wonder are Wimbledon better generally .

I always look at live births per embryo transferred

@Sunshinelove8

I could be wrong but I'm sure I read somewhere that natural Modified IVF results aren't reported the same way because they would be comparing 2 completely different protocols with each other? (But might have dreamt that up!)

I do know that St Pauls was voted best IVF clinic in London this year and on the HFEA website they are consistent with the national average I believe?

Wimbledon is a much smaller clinic and they probably transfer more complex cases to St Paul's which skews the statistics (that's pretty common amongst clinic groups)

@ivfbeenbusy thanks for replying 💜
on HFEA website for standard ivf 38 and over they are both under the national average , although it says ‘consistent’ both are a percentage or two under . Compared to some other clinics say crgh which are quite above national average . I think the stats are important.
I do think they should show something for natural modified if it’s being offered otherwise how can success be judged . I wish this was all clearer !

The HFEA website is really difficult to understand I think! And completely different to what is on Create St. Paul's website but I think it's down to the specific parameters on the HFEA website as there are so many options it fries my brain 🤣

The screen shot is what I've seen published several times so don't think clinics would be able to publish data which wasn't in accordance with HFEA data

I still would vouch for natural modified. I know the stats and that's why I went to CRGH first. But after that I realise stats are just aggregated numbers. They don't tell what the number is in my specific case. I did one cycle at CRGH and 3 cycles at Create. All my cycles were pretty consistent. I got 3-4 eggs fertilised in each cycle and 1 blastocyst. My blastocyst quality was better at Create. I also think lower drugs and cost matter. My last cycle at Create was natural modified and two prior were mild. The last cycle had 4 fertilised eggs which was better than the 2nd cycle which was mild so I think natural modified has similar outcome as mild in my case. Obviously there are variations from cycle to cycle even with the same protocol.

Hey thanks for looking , I’m 40 so in that bracket and looking at live births per embryo transferred it’s pretty low . I think pregnancy without a baby at an end doesn’t count - at least from my perspective

@Jo99999 yes you are right , I know stats at my current clinic are great for 40 plus but they gave me and individual stat which was about half the published one . I guess I’m just trying to narrow things down because it’s a minefield otherwise 😖
Can I ask some questions if you don’t mind ? You say you get 3/4 retrieved- I keep reading mixed things saying they only go for one or two follicles so max you can get is one or two eggs retrieved ? What was your experience and was it at Paul’s ?
Also what are your stats ? I’m 40 , 7 AF , fsh 9 last month and amh not sure was 5.8 a year ago x thanks

@Sunshinelove8, Each cycle I had 4 -7 eggs retrieved but 3-4 eggs fertilised. The thing is regardless of which protocol, my outcome is similar so I am glad that I switched to the lower drug route. I don't think it is for everyone but for me it is the right choice.

My first cycle at CRGH generated one 2-3BB day 5 blasto but it did not stick. They also made a mistake on the instructions of drugs and I had to change to FET in the last minute which was a point of contention.

Create's mild is basically short protocol but Create prescribes lower drugs than CRGH. CRGH doctor was fine to lower my drug after my first cycle when I asked. But to be honest, I already decided that I was only able to get 1-2 blasto per cycle so the clinic did not matter much in my case. The result turned out to be as I predicted. I suppose you know your body best. I also read a research about low AMF and higher age group benefit from lower stimulation. And Create is doing exactly the amount and type of medications as that paper.

Create's natural modified aims for one egg per cycle. But in most cases I hear more eggs were retrieved. I got 7 eggs retrieved in the natural modified cycle (3 fertilised), more than the mild one. I know most of them are not going to make it so I am not too focused on the quantity either way. I am in late 39. AMH 6.3 FSH 8.6 which was from a while back. Still have to wait and see the result of my first transfer at Create so I cannot say much about the further stages. My overall experience with Create is positive so far and due to the problem I had with CRGH I made sure to double check things anyway.

@Jo99999 thanks so much for the detailed information. Will you do pgs ? I want to do pgs on whatever blasts I get because I’ve had recurrent mc . It’s hard because really for any chance you need to be putting forward 7-10 blasts , which is pretty impossible with low amh etc

@Sunshinelove8

I had 5 previous miscarriages so decided to try PGS

I did PGS on one cycle with Create. Age 36 I didn't get any normal embryos - legally in the U.K. you can't transfer abnormal embryos and they have to be destroyed so you could end up with nothing to transfer. I did have one mosaic which was allowed to transfer but it was a BFN

I decided not to test again but changed protocol to natural modified - quality of embryos improved hugely and am now pregnant with twins from 2 untested embryos

I'm a bit sceptical of PGS now

@Sunshinelove8, I don't plan PGS. I read on HFEA site that it might damage the embryo as it takes some cells off it to test. With only a few blastos, it is not worth the risk of damage. Without repeated miscarriages, I don't think the doctor would recommend it either.

Hi both , I understand that doing pgs I may get no blasts put back but that’s preferable over the mental and physical pain of late first trimester mc for me . I can get pg without ivf and the only reason I’m doing ivf is to try and find the normal embryo.
@ivfbeenbusy at some point , especially at 36 normal embryos will likely appear , is it 50/50 at that age or something like that . Perhaps your final round was when these appeared and assume they would have shown as pgs normals . Congrats twins is a dream 💜
At 40 I can probably go on getting pregnant and miscarrying , wasting 5 months at a time , impacting my work, life, relationship etc and I’d rather just avoid that and if i can’t find any normal I’ll look at donor next.
@Jo99999 I spoke to embryologist and there’s a very slim margin of error as little as 3% with current next generation tech . So that’s 3% it’s normal and it’s actually not and vice versa . 97% plus abnormals will either have a definite chromosome issue and will lead to mc or disability or will be extremely mosaic and the same. For low level mosaic , there is a small chance the embryo can correct itself and counselling is had and these can be put back . Through pgs , if I get that far , they will be able to tell me if the embryo is viable or not and that will save me a lot of the heartache I’ve suffered x

Risk of damage is almost nil at my clinic from their stats x

Hi Sunshinelove8, how are you?

Did you go onto have enough good grade embryos to PGS Test?

Hi @PGSTesting123 it’s me nc. I got one pgs normal on ice (out of 2 blasts) and that’s on ice. My next ivf cycle was converted to iui at the last minute and I just had a baby on the back of that ! Not pgs tested. I did immunes though , this may have been my issue all along