Low ovarian response can make the IVF journey especially challenging — but understanding why it happens and how treatment can be tailored is key. In this live session, Dr Estefanía Rodríguez from Vida Fertility Institute (Spain) explains what truly defines a “low responder,” why some patients respond poorly even with good ovarian reserve, and what strategies specialists use to optimise results.
Hosted by Jessica Bourke, “The Fertility Detective,” this event dives deep into one of IVF’s most frustrating scenarios with clarity and compassion.
In simple terms, a low responder is a woman whom we stimulate and who, despite treatment, does not produce a sufficient number of eggs. This can happen for different reasons. Some women have a low ovarian reserve, which explains the low response. Others appear to have a normal ovarian reserve based on tests such as AMH levels and ultrasound, but after stimulation they still produce fewer eggs than expected. That discrepancy is where the problem lies.
That depends on the individual case and on several factors, especially egg quality. For younger women, even with a lower number of eggs, we may still achieve embryos. In older women, or in women with reduced egg quality, we often need more eggs to reach a reasonable chance of pregnancy.
Age is a major factor. For women over 35, and particularly over 38 or 40, we usually need a higher number of eggs. The same applies when egg quality is compromised. Ultimately, both quality and quantity matter.
In general, we say that retrieving around eight eggs gives more than a 50% chance of a live birth in women under 35. However, this also depends on male factor fertility.
If this is a first stimulation cycle and ultrasound monitoring shows fewer than eight follicles, we usually discuss the situation with the patient. We explain that the response is lower than expected and consider whether to continue the cycle or stop and modify the protocol to improve the response in a future attempt.
Yes, it can happen. Sometimes we see a good number of growing follicles, but at retrieval the number of eggs is lower. Some follicles may not contain an egg, or the egg may not be mature. Unfortunately, the final number of eggs can only be confirmed on the day of retrieval.
Yes. Family history is important. We always ask about the mother and other female relatives. If ovarian reserve is low, the first factor we investigate is genetics.
We check the karyotype and test for Fragile X premutation. If there is a genetic issue, this may affect treatment strategy and, in some cases, lead us to recommend specific types of preimplantation genetic testing.
We use genetic testing to obtain as much information as possible about embryos. In some cases, we recommend PGT-A, which screens embryos for chromosomal abnormalities. In other cases, such as known genetic diseases, we may recommend PGT-M or PGT-SR. The type of testing depends on the patient’s medical and genetic background.
We see young women under 35 with normal hormone tests and ultrasounds who still respond poorly to stimulation. In these cases, we review the stimulation protocol and may adjust the type or dose of hormones, such as increasing FSH or adding LH, to try to improve the response.
We also see young women with genuinely low ovarian reserve. In these cases, genetic factors must be evaluated. Other contributing factors include endometriosis, previous ovarian surgery, or other conditions that affect the ovaries.
Yes, in selected cases. When egg numbers are low, DuoStim allows us to retrieve eggs twice within the same menstrual cycle. After the first retrieval, we wait about five days and then start a second stimulation. This can help accumulate more eggs in a shorter time.
Studies show that egg and embryo quality is comparable between the two stimulations, although embryos must be frozen and cannot be transferred in the same cycle.
We generally recommend stimulating and retrieving eggs before surgery whenever possible. Ovarian surgery almost always reduces ovarian reserve, even when performed very carefully.
If an endometrioma is smaller than 6 cm and not causing significant symptoms, we usually avoid surgery. If it is larger than 6 cm or causes pain or complications, surgery may be necessary, but this decision is always individualised.
We always discuss egg donation openly and honestly. Patients should feel confident that they have tried all reasonable options before moving on.
In some cases, we may consider treatments still under investigation, such as ovarian PRP. This involves injecting platelet-rich plasma derived from the patient’s own blood into the ovaries before stimulation. PRP may improve ovarian responsiveness in some patients, but it does not improve egg quality. Results vary, and it is not suitable for all cases.
Effectiveness depends greatly on the individual case. In younger women with low response, PRP may be more beneficial. In women with very low ovarian reserve and advanced age, the benefits are limited. Ovarian size and baseline reserve also play a role.
