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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.
