Search

What IVF protocol is the best for poor responders?

Category:
5 fertility expert(s) answered this question

Answer from: Raúl Olivares, MD

Gynaecologist, Medical Director & Owner
Barcelona IVF
play-video-icon-yt

Unfortunately, there is not a perfect protocol for patients who are low responders. We should individualize each case, as has been done before, and try to change those protocols to see if we can achieve better outcomes. In some cases, we may decide to change from a short to a long protocol, increase the doses of the gonadotropin, or switch to different drugs, adding LH or Elonva. Additionally, we may decide to add testosterone to increase the pool of primary follicles that can be recruited later. It’s crucial to individualize each case and consider which protocol can improve the prognosis of the patient.

 

 

 

Answer from: Halyna Strelko, MD

Gynaecologist, Co-founder& Leading Reproduction Specialist
IVMED Fertility Center
play-video-icon-yt

It is not an easy question because there are more types of “poor responders” patients. There are different types of poor responders, for example, POSEIDON which divides responders into four categories but in real life, it is even more. So, if we have a poor responder because there are very very few follicles in the ovary (like one or two), in this case, for sure there is no need to use a big dosage of medications and standard protocol because we will not receive more than one egg. In such cases, we proceed with protocols like anti-estrogens like those with clomid, letrozole adding antagonists and FSH to receive 1-2 eggs and this way we also save money. Sometimes it is working even better than standard protocol because of the mechanism of action of anti-estrogen: higher your estrogen at the beginning, the more anti-estrogen will produce the FSH the more internal FSH increase.

So, for real poor responders sometimes it is working better. If we can see several waves of follicular growth in women, for example, at the beginning of the cycle we can see five or eight little follicles but two of them have 12 millimeters, one of them 9 millimeters and other are very very little so, we start our standard stimulation. Only three follicles growing – this is also a poor responder but theoretically we can receive more eggs so, we can stimulate these three follicles, extract them, receive 2-3 eggs and in one day start another stimulation. It will take this another wave, a second wave of follicle growing – it will be double stimulation in one cycle. If, for example, we have the same five-six little follicles but they are not growing well with the standard dosage so, in this case, a good idea to increase the dosage to 400 even 600 sometimes – especially if the woman has a mutation of their FSH receptors (they don’t see medication which we give her) so, we will increase the dosage, add LH and it will be the best protocol for her.

Depending on the situation, it is necessary to see exactly what the woman has, her AMH level, her antral follicle count, information about previous stimulation and in this case will be able to choose the best protocol. Also an important thing to mention is that after the age of 35-36 is good to add LH because it may improve the quality of eggs and the requirement of LH from the body is higher in late reproductive age than in young age. It also may be helpful to use growth hormones as it improves sensitivity and improves the quality of eggs.

Answer from: Valentina Denisova, MD PhD Obstetrician Gynaecologist

Gynaecologist, Fertility Specialist
Next Generation Clinic
play-video-icon-yt

So, a poor response is a problem of contemporary assisted reproduction and it comes from a high percentage of advanced age patients whose ovarian reserves have decreased physiologically. Also, there is another wide cohort of patients with premature ovarian insufficiency and this insufficiency can be due to different reasons. All over the world doctors and researchers try to find the best solution for such patients and during these last few years, the term poor response is replacing the term low prognosis. Thus, we can divide our patients into four groups and follow the individual plan for each patient regarding their age, their ovarian reserve markers, and the results of their previous simulations in order to achieve a euploid embryo with maximal implantation potential. Thus, for some patients, we can try to use an ovarian stimulation protocol with higher FSH dosages, and additional LH from the first day of stimulation. For other patients, we can use minimal or mild stimulation, natural cycle IVF, or double stimulation. And of course, we can use PGT; genetic testing on the embryos especially for advanced age patients whose problems are high aneuploidy rate, higher rate of abnormal embryos, and their implantation failure occurs due to genetic reasons, except poor response itself. Right now, there is not enough evidence on the usage of any supplements to improve ovarian response in low prognosis patients but methods we can use show better results so many patients have good chances for success.

Answer from: Guillermo Quea Campos

Gynaecologist, Specialist in Reproductive Medicine
Pronatal Fertility Clinics
play-video-icon-yt

As in patients with PCO Syndrome, we don’t have a definite protocol for those patients with poor response to simulation. The protocol to choose will depend on whether the patient has an ovarian reserve that allows estimating a sufficient response to reach the end of the cycle, including the embryo replacement or if the ovarian reserve is greatly diminished and the intention is to accumulate oocytes or embryos in several cycles. In this case the protocols with probably fancy triads are and gonadotropins are recommended.

Answer from: Evangelos Sakkas, MD, MsC

Gynaecologist, Head of Gyncare IVF Clinic
Gyncare IVF Clinic
play-video-icon-yt

Contrary what we have said regarding PCOS patients for the “poor responders” we should always be very careful which protocol we are going to select but specifically we need to be careful, we need to do the maximum, the maximum for that patient and we should also try to take a small risk with these patients known that this patient will never have OHSS syndrome. The best solution is usually the “flare-up protocol”, the short flare-up protocols, modified and adapted to every patient and every doctor has its own protocols.
Double stimulation is a very good option which means stimulating the patient twice in her cycle: early and the second phase so double stimulation in the same month, same cycle or in some cases we could also do the antagonist protocol but in that case to give FSH and LH together. For example, we go with puregon and menopur – two medications together to make maximum for this patient.
I am not much of a fan of <1.37>in these patients, even if at the beginning it was adapted for these patients. I think that the best treatment for these patients is to know what she has done before and try for the flare-up short protocol or double stimulation. In the case we cannot do these two protocols and we have done and didn’t work, we go for the antagonist with the FSH and LH.

About this question:

Is there any standard medical approach for all poor responders?

Stimulation protocols are selected depending on several factors including how they responded in the past on certain medication. As “poor responders” are described patients who failed to respond to standard protocol which means that there were none or few matured eggs to pick up. What is the way of treatment of such patients?

Find similar questions:

Related questions