Management of poor ovarian responders in IVF

Abstract

Correct controlled ovarian stimulation is of paramount importance in assisted reproductive technologies. Therefore, analysis of the ovarian reserve of the patient is mandatory to tailor the best ovarian stimulation regimen. When the ovarian reserve is reduced, the induction of a multifollicular growth remains a challenge. Several factors could be associated with reduced ovarian response. However, reduced ovarian reserve either in older patients or in young patients represents the most frequent aetiological factor. Whatever is the aetiology, one of the main problems is how to predict a reduced ovarian response, and although several tests have been suggested, no very accurate predictive test is available. A variety of different stimulation protocols have been suggested but the lack of any large-scale, prospective, randomized, controlled trials of the different management strategies and the lack of a uniform definition of the population may result in comparisons of heterogeneous groups of patients, making it difficult to draw any definitive conclusions. Natural cycle IVF may represent an easy and cheap approach in the management of this group of patients. Although no controlled large prospective randomized studies are available to compare the natural IVF procedure with ovarian stimulation IVF in poor responder patients, the efficacy of natural cycle IVF is hampered by high cancellation rates mainly due to untimely LH surge. The use of gonadotrophin-releasing hormone antagonists in the late follicular phase, which reduces the premature LH rise rate, and the improvements in laboratory conditions and fertilization techniques, increase the embryo transfer rates, making this procedure more cost-effective.

A direct action for GH in improvement of oocyte quality in poor-responder patients

“…Unfortunately, w9-24% of all IVF cycles undertaken fail to respond to standard ovarian stimulation regimens, due to poor ovarian response (POR) to hormonal stimulation (Abir et al 2008). Currently, the management of POR patients represents a significant therapeutic challenge (Hazout et al 2009, Yovich & Stanger 2010, such that various alternative forms of clinical intervention have either been ineffective or lack sufficient scientific evidence necessary to support clinical application (Ubaldi et al 2005). Recently, we have demonstrated that the administration of exogenous growth hormone (GH) supplementation, in conjunction with standard ovarian stimulation regimens, resulted in significantly higher embryo implantation and clinical pregnancy rates compared with those not treated with GH (Yovich & Stanger 2010).…”

Dehydroepiandrosterone improves the ovarian reserve of women with diminished ovarian reserve and is a potential regulator of the immune response in the ovaries

“…Among the various causes of DOR, abnormal immune function may be a great contributor to this phenomenon (2). Patients with DOR often become infertile and have a poor response to in vitro fertilization (IVF) (3,4). Researchers have developed different protocols to solve this problem, but none of them has proven to be ideal for such patients (5-7).…”

Accumulation of oocytes from a few modified natural cycles to improve IVF results: a pilot study

“…The aim of controlled ovarian hyperstimulation is to reduce the cycle cancellation rate, increment the number of oocytes and top-quality embryos and ensure better results in terms of pregnancy rates [2][3][4][5]. However, in different clinical situations such as reduced ovarian reserve, previous oncologic or estrogen-dependent disease the natural cycle continue to be considered the method of choice for IVF treatment [6][7][8][9][10][11][12][13][14][15][16].…”