The term poor responder is a term used to define women who require large doses of stimulation medications and who make less than an optimal number of eggs. There is no uniform definition of poor responders, but many authors have used a cutoff of less than four mature oocytes at the time of hCG or a peak estradiol of less than 500.
Diagnosis
This can be determined by through an IVF cycle and achieving poor stimulation outcome. However, it is preferable to determine this problem ahead of time through ovarian reserve testing including basal FSH levels, and the clomiphene challenge test. In addition, the ultrasound assessment of the ovaries and the resting or antral follicle numbers allows for the prediction of a poor response to stimulation. Cycle day 3 blood levels of Inhibin B levels add little to the information gained from the above testing, and variability is problematic.
Management of poor response
The major challenge facing patients who are poor responders is whether or not they should attempt IVF. Several studies have illustrated that women with substantially high day 3 FSH levels during a clomiphene challenge test, have a poor prognosis for a successful IVF cycle. Furthermore, if there are fewer than four resting follicles available on a baseline ultrasound for recruitment, similar poor outcomes are seen. It is critical that women considering IVF have proper ovarian reserve testing to be sure that they are not wasting their time, money, or emotions by pursuing IVF when it has little or no hope of success.
Increase the dose of gonadotropins: there may be a limited benefit to increasing FSH dose to a maximum of 6 ampules or 450 IU per day.
The use of baby aspirin and luteal phase support further augment pregnancy rates.
In conclusion, patients who are labeled as poor responders certainly face a formidable challenge in achieving a pregnancy. It is critical to determine through ovarian reserve testing using FSH levels and the clomiphene challenge test as well as ultrasound assessment of the resting follicle numbers whether a patient is indeed a candidate for IVF treatment. Once this has been verified, it is critical to seek out a clinic where experience exists in the stimulation of poor responders so that an optimal protocol can be tailored to the patient’s needs.
The laboratory is also critical for success, particularly with regard to the use of an excellent culture system and the application of assisted hatching. There may be some marginal benefit as well to the adjunctive use of baby aspirin started prior to stimulation and luteal progesterone and estradiol support following oocyte retrieval. Nevertheless, there is a portion of patients who may continue to fail due to depleted oocyte quality and may well benefit from consideration of oocyte (egg) donation treatment.
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