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 “ageing” of the ovaries and low ovarian reserve. The good news is that IVF can work for these patients too if the cause is found and treated with the most appropriate treatment.

Definition of poor ovarian deviant

Poor ovarian response (POR) is the medical term used for women who are “poor responders” to IVF cycles. To consider a patient to be a poor responder, we will look at 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 usually 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 ongoing emotional support during the IVF cycle (which we can provide) as the chances of their cycle being cancelled are higher for them. In these cases, they have no alternative but to restart a new stimulation cycle with a personalized protocol. It should also be stressed that ovarian age does not always match biological age.

Prognostic criteria

There are several tests that can help determine whether a woman has a low response before starting in order to tailor the stimulation protocol to the specific needs of the patient. 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 the ovarian reserve. The older the woman, the more difficult it is to conceive due to reduced quantity/quality of eggs.
• Reduced ovarian size after surgery or endometriosis treatment

Negative effects

The ultimate goal of any 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 the results of IVF. An insufficient number of eggs available for fertilisation reduces the chances of pregnancy and increases the likelihood of embryo transfer cancellation. In addition, POR often results in poor quality eggs.

Management & protocols

Women with a poor response to IVF have several 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 start a preparation with androgens in order to induce the production of multiple eggs. This 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 optimise the chances of success for these patients. The aim 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 egg retrieval takes place (i.e. before gonadotropin administration 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 in the first three days of agonist administration.

Embryo collection & vitrification

In order to maximise the number of embryos, several cycles of embryo accumulation can be performed. Embryo banking means that the embryos recovered with each cycle are frozen. They are then thawed and transported.

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 cancelled 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 fertilised using the husband’s sperm in the laboratory. When the patient is of advanced reproductive age, egg donation is the first-line treatment. It should be remembered that the quality of the eggs decreases as the woman grows older. So, for this reason, for a woman aged 43-44 years and older, 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 relates to the economic impact of multiple IVF cycles. This is why choosing the right treatment option is crucial to make it as affordable as possible.

Treatment costs for women with low response rates (PORs)

Another issue that arises in cases of poor ovarian response relates to the economic impact of multiple IVF cycles. This is why choosing the right treatment option is crucial to make it as affordable as possible.