Managing poor responder

Managing poor responder

DR G A RAMA RAJU

Krishnaivf clinic,

Krishnaivf.com

Eshre consensus :Poor responder

Poor responder eshre definition

Two of the following three

features must be present:

Advanced maternal age (≥40 years)

or any other risk factor for POR;

A previous POR (≤3 oocytes with a

conventional stimulation protocol);

An abnormal ovarian reserve test (i.e.

AFC <5–7 follicles or AMH <0.5–1.1

ng/ml).

Predicting poor responder

AFC

AMH

Ovarian volume

Testosterone

PRIOR POOR RESPONSE

AGE

Precycle adjuvants

DHEA Simple

cyst

drainage

Precycle

OCP

DHEA

Simple cyst drainage prior to stimulation

Precycle oral contraception or antagonist

suppression combined estrogen priming

Adjuvants at initiation of cycle

Gnrh analog

flare

GRH

AGONIST

MICRODOSE

FLARE

PROTOCL

AGONIST

VERSUS

ANTAGONIST.

CLOMIPHENE

FLARE

LETRIZOLE

FLARE

Gnrh analog flare protocol

Antagonist versus Agonist protocols

Natural ,clomiphene letrizole ivf

Letrizole flare

protocol

Clomiphene

flare

protocol

Poor Responder management in stimulation phase

DOSEHMG VERUS

REC FSH

LH IN POOR

RESPONDER

MINIMAL

STIMULATIO

NATURAL

CYCLE IVF

DOSING

INTERVAL

Starting dose

600

units

450

units

Once

daily

Twice

daily

Role of HMG in intial poor response with rec fsh

Role of lh in poor responder

LABARATORY OPTION

LABARATORY OPTION

ICSI FOR LOW

OOCYTE NUMBER

PREIMPLANTATION

ENETIC DIAGNOSIS

IDEAL DAY OF

TRANSFER

NUMBER OF

EMBRYOSDONOR OOCYTE

Icsi for all ?

Preimplantaion genetic screen for poor responder

Ideal day of transfer

• The role of day 5 embryo transfer for poor responders is less clear

• Randomized controlled trial demonstrating increased clinical pregnancy rates for poor responders undergoing day 2 embryo transfer compared with day 3 embryo transfer

Number of embryos for transfer

Optimizing the number of cleavage stage embryos to

transfer on day 3 in women 38 years of age and older

Donor oocyte

Next 5 years poor responder

Genomic proteomic metabolomics will play a major

role in stimulation protocol.