It describes several mutations that decrease the sensitivity to stimulation. By the routine way, we don’t do that because it does not happen often and it cost quite a lot but from time to time, we can send the blood sample of patient to specific laboratory, molecular genetic laboratory and do this test but it is not something which we are doing in routine normally if we have done 3-4 stimulation, we have a strange response, we use huge dosage and patients has normal body mass index, we can see follicles but they are not growing so, something like that should be done.
So the low prognosis patient or patients with poor ovarian responses are classified into four groups according to the results of the ovarian reserve markers. So like AMH level, Antral follicle count, their age, number of oocytes retrieved in previous cycles of conventional stimulation. And note that not all embryos are carrying the normal set of chromosomes and this aneuploidy is the most frequent reason for implantation failures. When these are undetected and unemployed may increase the risk of first-trimester pregnancy loss so it can lead to failures during our procedures. But I have to say that the accumulative level rate in patients with poor ovarian response and patients with low prognosis is not so bad. It’s about 56% of 18 months of treatment. So we can use different types of protocols, we can perform something like banking of oocytes or embryos before performing an embryo transfer. So in more than one-half of patients, we can achieve a low birth rate in 18 months, even in patients with poor ovarian response. And for some patients we can try to use ovarian stimulation particularly with high FSH dosages, for another we will use another protocol for stimulation and of course, for advanced age, genetic testing on the embryos, which will permit us to achieve pregnancy much more sooner.
A patient is considered a poor responder or having poor response to ovarian stimulation after a complete cycle or picking up fewer than 4 oocytes during the ovarian puncture in response to 150 daily units of gonadotropins. The protocol to choose will depend on whether the patient has an ovarian reserve and to a low estimating of sufficient response to reach to the end of the cycle or if the ovarian reserve is diminished and the intention is accumulated oocytes embracing several cycles.
According to Bologna criteria, an oocyte recruitment of less than 7 follicles already categorize patient as “poor responder” of course that should be always correlated with the age of the patient – I mean today we have the 4 Poseidon group where we know that the patient 42 years old produces 5 oocytes – yes she is poor responder and this is expected and this is another thing and another thing is patient of 33 years old that produces only 5 eggs so every patient is treated differently. Of course how to deal with it – choice of the protocol is the most important thing to do as we said before: double stimulation, flare protocol, antagonist, FSH, LH are all solutions for these patients.
How to enhance, how to improve poor ovarian response? Unfortunately after the last ESHRE congress it seems that the only one thing that can give maybe one oocyte more will be the androgenes taking before beginning the IVF cycle. The androgens can be DHEA-S or lots of the testosterones that could be also orally or transdermally in any case accordingly for protocol doctor uses. One month of androgens before beginning the IVF is the only worldwide method that could give you something more or the other solutions proposed in the past years: growth hormone, whatever not given us significant results.
