Women with low response to IVF cycles
Management & better protocols
The incidence rate of poor responders (PORs) to stimulation in IVF cycles currently ranges from 7 to 24%. This rate is even higher in patients aged 38 years and older. The main causes are ovarian “aging” and low ovarian reserve.
The good news is that IVF can also work for these patients if the cause is found and treated with the most appropriate treatment.
Contents
- Definition of poor ovarian response
- Diagnosis
- Prognostic criteria
- Causes of poor ovarian response
- Negative effects
- Management & protocols
- Cost of treatment selection for women with poor response rates (PORs)
- Frequently asked questions
- Can I have sex as a low response to ovulation induction?
- Is the natural cycle a good option for women with low response?
- What if the number of eggs I produce is insufficient for IVF?
- Can women with poor response use supplements to improve IVF results?
- Growth hormone for women with poor response to IVF, yes or no?
- What is the best IVF protocol for women with poor response?
Definition of poor ovarian deviant
Poor ovarian response (POR) is the medical term used for women who respond “poorly” to IVF cycles.
To consider a patient to be a poor responder, we will consider the following factors:
- Number of follicles in the ovary
- 7 or fewer follicles are observed via ultrasound in the ovaries.
- Number of oocytes recovered
- If only 3 have been recovered
- Estradiol levels (E2)
- A maximum E2 level of <500 pg/ml after an ovarian stimulation cycle.
Diagnosis
The term poor responder is commonly used to describe a woman who has undergone at least 2 cycles of IVF stimulation that result in 3 or fewer follicles in each.
These patients need continuous emotional support during the IVF cycle (which we can provide), since the chances of their cycle being canceled are higher for them. In these cases, they have no alternative but to start a new stimulation cycle again with a personalized protocol.
We should also emphasize that ovarian age does not always match biological age.
Prognostic criteria
There are several tests that can help determine whether a woman is a low responder before starting in order to tailor the stimulation protocol to the patient’s specific needs.
There are several factors that indicate low ovarian response.
The most important ones are:
- Age
- Fewer than 7 primordial follicles observed in ultrasound
- Anti-slip hormone (AMH) below 1.2 ng/ml
- Basal FSH levels above 10 mIU/ml
- Diagnosis of POR in previous cycles
Causes of poor ovarian response
The following are the most common causes of poor ovarian response:
- Age: It is inversely proportional to ovarian reserve. The older a woman is, the more difficult it is to conceive due to reduced egg quantity/quality.
- Reduced ovarian size after endometriosis surgery or treatment.
Negative effects
The ultimate goal of each IVF cycle is to induce the production of multiple eggs so that a large number can be retrieved and at least one of them is able to result in a viable embryo.
This is precisely why poor response has a negative impact on IVF outcomes. An insufficient number of eggs available for fertilization reduces the chances of pregnancy and increases the likelihood of embryo transfer cancellation.
Furthermore, POR often leads to poor quality eggs.
Management & protocols
Women with a low response to IVF have various options to succeed.
Such as:
- Preparation with androgens
- Converting an IVF cycle to IUI
- IVF spreading protocol
- Oocyte aggregation & vitrification
- Egg donation
Preparation with androgens
After a poor response during an IVF cycle, it is possible for the patient to begin androgen conditioning in order to induce the production of multiple eggs.
It can be done using transdermal testosterone or DHEA (oral dehydroepiandrosterone) replacement therapy.
However, their effectiveness in cases of POR has not yet been proven.
Converting an IVF cycle to IUI
If one or two follicles are observed to develop via ultrasound, we may consider converting an IVF cycle to intrauterine insemination (IUI).
IVF flare protocol
In cases of poor response to IVF, a special treatment is designed to optimize the chances of success for these patients. The goal is, as always, to develop many eggs.
An option widely used in these cases is the so-called flare protocol , also known as microflare , microdose flare , n or short protocol .
In this type of ovarian stimulation, the GnRH agonist is started on day 2 of the same menstrual cycle in which the egg retrieval takes place (i.e. before the administration of gonadotropins begins).
In this way, we can take advantage of the initial secretion of FSH and LH release from the patient’s pituitary gland, which usually occurs within the first three days of agonist administration.
Embryo collection & vitrification
In order to maximize the number of embryos , several embryo collection cycles can be performed.
Embryo pooling means that the embryos retrieved with each cycle are frozen. They are then thawed and transferred.
Vitrification is the extremely rapid cryopreservation of eggs, embryos and sperm, which prevents the formation of intracellular ice crystals
Egg donation
When multiple IVF cycles have been canceled due to poor ovarian response, the best option for the patient is egg donation . Donors are young, healthy women who donate their eggs to another woman (the recipient). The donor’s eggs are fertilized using the husband’s sperm in the laboratory.
When the patient is of advanced reproductive age, egg donation is the first-line treatment. We must not forget that the quality of eggs decreases as the woman ages. So, for this reason, for a woman aged 43-44 and above, the only option to become a mother may be to use eggs from a young donor.
Treatment costs for women with low response rates (PORs)
Another issue that arises in cases of poor ovarian response is related to the financial impact of multiple IVF cycles.
This is why choosing the right treatment option is crucial to making it as affordable as possible.
Treatment costs for women with low response rates (PORs)
Another issue that arises in cases of poor ovarian response is related to the financial impact of multiple IVF cycles.
This is why choosing the right treatment option is crucial to making it as affordable as possible.
Frequently asked questions
Is the natural cycle a good option for poor respondents?
In women with low response, there is medical evidence of similar live birth rates using high-dose ovarian stimulation versus natural cycle. This is probably because low-response women do not produce many eggs and high stimulation cannot deliver the extra. There are also reports that perhaps egg quality is better in a natural cycle.
What if the number of eggs I produce is insufficient for IVF?
In order to be able to fertilise more than one egg in the same IVF cycle, women’s ovaries are stimulated using fertility drugs. Often, due to a variety of reasons, the ovarian response of some patients is insufficient and the number of eggs collected is very low (below 3). In such cases, we can turn to the following strategies:
- cancel the cycle before egg retrieval and start a new stimulation cycle with a different stimulation protocol.
- freeze the eggs using the vitrification technique to collect a larger number of eggs in subsequent cycles.
- freeze the embryos using the embryo vitrification technique to collect a larger number of embryos cumulatively.
Can poor respondents use supplements to improve IVF results?
Many supplements are used in cases of poor ovarian response to increase the chances of pregnancy in these patients, such as DHEA, testosterone, CoQ10, human growth hormone (hGH), etc. However, in some cases they work, while in others they do not. Again, it depends on each woman’s response and the reason behind the POR in each case.
Growth hormone for poor responders to IVF, yes or no?
Some studies have concluded that the use of growth hormone (GH) can increase clinical pregnancy rates in women with a poor response to IVF treatment. It can be added in the month before gonadotropin stimulation or during the stimulation phase, as it can help increase the number of follicles.
The addition of GH depends on each patient and is often applied in cases of women who have experienced previous IVF failure due to poor ovarian response despite maximum doses of gonadotropins.
What is the best IVF protocol for poor respondents?
Several studies have been carried out in an attempt to answer this question. However, no differences in pregnancy rates have been observed between different ovarian stimulation treatments. The truth is that each woman’s response is different, so are their needs. Hence the importance of individualizing each protocol in order to get the most out of it.
