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Insights from clinical experience in treating IVF poor responders
‘Poor responders’ is a term used to describe a subpopulation of IVF patients who do not respond well to ovarian stimulation with gonadotrophins. While there is no standard definition of a poor responder, these patients tend to be of advanced maternal age (≥40 years), have a history of poor ovarian response with conventional stimulation protocols, and/or have low ovarian reserve. Despite the heterogeneity of this patient group, there are characteristics and needs common to many poor responders that can be addressed through a holistic approach.To pill or not to pill in GnRH-antagonist cycles: the answer is in the data already!
The planning of IVF treatment by scheduling menstruation and hence initiation of ovarian stimulation using sex-steroid pre-treatment is commonly used. Pooling data from six randomized-controlled trials encompassing 1343 patients, with and without combined oral contraceptive pill pre-treatment, suggests that the ongoing pregnancy rate per randomized woman is significantly lower in patients with oral contraceptive pill pre-treatment (relative risk [RR]: 0.80, 95% confidence interval [CI]: 0.66–0.97; rate difference [RD]: −5%, 95% CI: −10% to −1%; fixed effects model).Dual ovarian stimulation is a new viable option for enhancing the oocyte yield when the time for assisted reproductive technnology is limited
Ovarian stimulation improves assisted reproductive technology outcome by increasing the number of oocytes available for insemination and in-vitro handling. A recent Duplex protocol features a dual stimulation, with the second stimulation started immediately after the first oocyte retrieval. Remarkably, the Duplex protocol is unexpectadly well tolerated by women and provides twice as many oocytes and embryos as a regular antagonist protocol in less than 30 days.Androgen receptor CAG repeat length is associated with ovarian reserve but not with ovarian response
The human androgen receptor (AR) gene contains a highly polymorphic CAG repeat sequence within exon 1. In-vitro studies have shown a relationship between CAG repeats in the AR gene and its transactivation potential. This variation in length may play a role in anovulatory infertility. The objective of this study was to investigate whether CAG polymorphism of the AR gene has a predictive value for ovarian reserve, response and cycle outcome in an egg donor programme. CAG length of the AR gene was determined in 147 oocyte donors.Impact of high serum progesterone during the late follicular phase on IVF outcome
With ovarian stimulation for IVF, serum progesterone concentration may increase during the last few days of stimulation. Several factors, mainly the intensity of the ovarian response to gonadotrophins, have been identified to explain progesterone elevation but many other issues remain uncertain. The aim of this narrative, nonsystematic review is to address the nonconsensual issues of the reasons and consequences of premature progesterone elevation during ovarian stimulation. The determination of the optimal threshold above which progesterone elevation may have an impact on IVF outcome is still a matter of debate because it is likely related to the patient's profile.Can anti-Müllerian hormone concentrations be used to determine gonadotrophin dose and treatment protocol for ovarian stimulation?
The ability to predict the response potential of women to ovarian stimulation may allow the development of individualized ovarian stimulation protocols. This tailored approach to ovarian stimulation could reduce the incidence of ovarian hyperstimulation syndrome in women predicted to have an excessive response to stimulation or could improve pregnancy outcomes in women classed as poor responders. Namely, variation of the type of gonadotrophin-releasing hormone (GnRH) analogue or the form and dosage of gonadotrophin used for stimulation could be adjusted according to an individual’s response potential.Can oestradiol pretreatment be used to reliably avoid weekend oocyte retrievals?
Scheduling the initiation of ovarian stimulation in a gonadotrophin-releasing hormone (GnRH)-antagonist protocol by sex steroid pretreatment has been suggested as a means to reduce the incidence of oocyte retrievals during weekends. The rationale is that by manipulating the initiation of gonadotrophin stimulation, Thursday or Friday will be avoided as days on which triggering of final oocyte maturation will be performed and thus weekend oocyte retrievals will not occur. Apparently, the assumption behind such an approach is that duration of stimulation is homogenous enough to serve this purpose reliably.Elevated progesterone during ovarian stimulation for IVF
There is an ongoing debate regarding the impact of premature progesterone rise on the IVF outcome. The objective of this review is to assess evidence of poorer ongoing pregnancy rate in IVF cycles with elevated serum progesterone at the end of follicular phase in ovarian stimulation. It also explores the origin of the progesterone rise, potential modifying factors and possible methods to prevent its rise during ovarian stimulation. This review draws on information already published from monitoring progesterone concentrations at the end of follicular phase in ovarian stimulation.
