I-27: Management of Poor Responders:Current and Past Recommended Strategy

The management of poor responders in IVF cycles is extremely controversial due to their inadequate response to controlled ovarian hyperstimulation.. A low ovarian response may be idiopathic or may be associated with many different factors including age, diminished ovarian reserve, endometriosis and prior ovarian surgery, and a reported incidence 9-24% of IVF patients. Several strategies have been proposed for the treatment of poor responders. The most commonly used strategies to improve oocyte yield in poor responders include an increased daily dose of gonadotropins (300-450 IU per day) with GnRH agonist (long, stop or microdose flare protocols) or GnRH antagonist protocols. There are a number of newer procedures in assisted reproduction that may find a role in the management of poor responders. These include in vitro maturation (IVM), cryopreservation of oocytes or embryos from multiple retrieval cycles, as well as cryopreservation of donor oocytes allowing for commercial egg banking as well as in sperm banking. Despite these recommended strategies, managing poor response cycles, however, continues to present challenges for the reproductive endocrinologist. In this review, we will review the available options, including adjuvants prior to cycle starts, those used at the initiation of gonadotropin therapy, GnRH analog flare protocols, GnRH agonist microdose flare protocols, agonist versus antagonist protocols,clomiphene flare protocols, hMG versus recombinant FSH, the role of LH in stimulation protocols for poor responders, minimal stimulation, natural, clomiphene or letrozole only IVF, the available gonadotropin regimens and doses, as well as IVF laboratory options, in handling low oocyte yield cases. We will also discuss that over the next coming years, some of the above options will become standard care in assisted reproduction, while others will no doubt be discarded when efficacy cannot be established.