… an intractable problem in infertility treatment….

… with no clear definition/consensus….

… has managed to dodge the advances in infertility treatment….

POOR RESPONDERS

IN INFERTILITY TREATMENT

Jisha Rajendran

Poor responders – it is not uncommon!

Keay SD et al. BJOG. 1997

Poor responders – how to diagnose

FOLLICLES E2

HMG

OOCYTES

D2 FSH

AFC AMH

Poor responders – BOLOGNA criteria from ESHRE

ADVANCED AGE>40/OTHER RISK FACTORS

FOR POR

ABNORMALORT

PREVIOUS POR

Poor responders – BEHIND THE SCENES

1470

FSH

7014

True reserve – only after stimulation

Poor responders – Why should you know them?

Individualise the protocol

Early initiation of treatment

Counsel against stimulation

Poor responders – how to sight them?

hormones

Dynamic tests

ultrasound

FSHMost commonly used Easily availableD2 or D3higher values –predictive

False positive rate 5%

SCREENING TEST!

AMHCostly testNot widely availableCycle independentBetter predictive value

Current role - controversial

ultrasound AMHCostly testNot widely availableCycle independentBetter predictive value

Current role - controversial

AFCSimple testGood inter- & intra- observer

reproducibilityBefore starting stimulationBetter correlation with retrieval number

Current role – widely practised

Poor responders – how to manage them?

Modify Stimulation

Protocol

Adjuvant therapy

Conventional Agonists protocol- Dampening of ovarian response to gonadotropin stimulation

Mini dose protocol

“Stop”protocol

Short/Ultra-short/Flare

protocol

Micro dose flareprotocol

Poor responders – how to manage them?

Modify Stimulation

Protocol

Antagonist protocol-decreases stimulation duration-fewer cancellations-lesser Gonadotropins

Poor responders – how to manage them?

Adjuvant therapy

Growth Hormone

Androgens

Soft Protocols

r- LH

L-arginine, steroids, aspirin

COC pill

Estradiol

Poor responders – how to manage them?

Growth Hormone1. Potentiates effect of FSH2. Previous poor responders have

proven benefit3. Costly 4. Not widely available5. No consensus on dose / route

Case – Control design128 – 81

2U s/c Growth HormoneMore M-II oocytes, higher E2 levels, pregnancy rates

Poor responders – how to manage them?

AndrogensDHES

1. Essential prohormone in follicular steroidogenesis

2. Improves the ovarian micromilieu3. Micronised DHES – 25mg TID X

4months 4. Improves pregnancy rates and

reduces miscarriage rates

Poor responders – how to manage them?

r- LH

1. LH plays a role in follicular development

2. From D8, 75-150 IU 3. Beneficial in a subset of

a. age >35, b. previous PORc. Antagonist cycles

4. Improves pregnancy rates

Poor responders – what to remember?

1. Not uncommon2. Bologna criteria – Age, risk factors, ORT,

previous cycle response3. Hormones + USG – better prediction4. Modified protocols 5. Adjuvants