Post on 14-Dec-2015
… an intractable problem in infertility treatment….
… with no clear definition/consensus….
… has managed to dodge the advances in infertility treatment….
POOR RESPONDERS
IN INFERTILITY TREATMENT
Jisha Rajendran
Poor responders – it is not uncommon!
Keay SD et al. BJOG. 1997
Poor responders – how to diagnose
FOLLICLES E2
HMG
OOCYTES
D2 FSH
AFC AMH
Poor responders – BOLOGNA criteria from ESHRE
ADVANCED AGE>40/OTHER RISK FACTORS
FOR POR
ABNORMALORT
PREVIOUS POR
Poor responders – BEHIND THE SCENES
1470
FSH
7014
True reserve – only after stimulation
Poor responders – Why should you know them?
Individualise the protocol
Early initiation of treatment
Counsel against stimulation
Poor responders – how to sight them?
hormones
Dynamic tests
ultrasound
FSHMost commonly used Easily availableD2 or D3higher values –predictive
False positive rate 5%
SCREENING TEST!
AMHCostly testNot widely availableCycle independentBetter predictive value
Current role - controversial
ultrasound AMHCostly testNot widely availableCycle independentBetter predictive value
Current role - controversial
AFCSimple testGood inter- & intra- observer
reproducibilityBefore starting stimulationBetter correlation with retrieval number
Current role – widely practised
Poor responders – how to manage them?
Modify Stimulation
Protocol
Adjuvant therapy
Conventional Agonists protocol- Dampening of ovarian response to gonadotropin stimulation
Mini dose protocol
“Stop”protocol
Short/Ultra-short/Flare
protocol
Micro dose flareprotocol
Poor responders – how to manage them?
Modify Stimulation
Protocol
Antagonist protocol-decreases stimulation duration-fewer cancellations-lesser Gonadotropins
Poor responders – how to manage them?
Adjuvant therapy
Growth Hormone
Androgens
Soft Protocols
r- LH
L-arginine, steroids, aspirin
COC pill
Estradiol
Poor responders – how to manage them?
Growth Hormone1. Potentiates effect of FSH2. Previous poor responders have
proven benefit3. Costly 4. Not widely available5. No consensus on dose / route
Case – Control design128 – 81
2U s/c Growth HormoneMore M-II oocytes, higher E2 levels, pregnancy rates
Poor responders – how to manage them?
AndrogensDHES
1. Essential prohormone in follicular steroidogenesis
2. Improves the ovarian micromilieu3. Micronised DHES – 25mg TID X
4months 4. Improves pregnancy rates and
reduces miscarriage rates
Poor responders – how to manage them?
r- LH
1. LH plays a role in follicular development
2. From D8, 75-150 IU 3. Beneficial in a subset of
a. age >35, b. previous PORc. Antagonist cycles
4. Improves pregnancy rates
Poor responders – what to remember?
1. Not uncommon2. Bologna criteria – Age, risk factors, ORT,
previous cycle response3. Hormones + USG – better prediction4. Modified protocols 5. Adjuvants