Poor Ovarian Response(POR)

Patients with poor ovarian response (POR) are both challenging to treat and represent a large proportion of patients presenting with infertility . Patients with POR, who are often of advanced maternal age, have a high cycle cancellation rate, higher miscarriage rate, and significantly reduced live birth rate per cycle.
The term “poor responder” is typically referred to as someone whose ovaries and body does not respond to fertility medications. Usually they will require much higher doses of stimulation medications to produce 4 or less than optimal number of eggs needed to proceed in an IVF treatment.

How do you diagnose someone who may be a poor responder?
In most cases a poor responder diagnosis is discovered after going through an IVF cycle resulting in a poor stimulation outcome. However, it is possible to identify potential issues ahead of time through ovarian reserve testing. This can be done through having a provider ideally a fertility specialist, check the FSH levels and conducting the clomiphene challenge test. An ultrasound assessment can help predict both resting and antral follicle numbers. There is one last test that can help determine if a person will be a poor responder and that is cycle day 3 blood testing of the Inhibin B levels.

It has been recognized that, in order to define the poor response in IVF, at least two of the following three features must be present: (i) advanced maternal age or any other risk factor for POR; (ii) a previous POR; and (iii) an abnormal ovarian reserve test (ORT). Two episodes of POR after maximal stimulation are sufficient to define a patient as poor responder in the absence of advanced maternal age or abnormal ORT. By definition, the term POR refers to the ovarian response, and therefore, one stimulated cycle is considered essential for the diagnosis of POR. However, patients of advanced age with an abnormal ORT may be classified as poor responders since both advanced age and an abnormal ORT may indicate reduced ovarian reserve and act as a surrogate of ovarian stimulation cycle outcome. In this case, the patients should be more properly defined as ‘expected poor responder’. If this definition of POR is uniformly adapted as the ‘minimal’ criteria needed to select patients for future clinical trials, more homogeneous populations will be tested for any new protocols. Finally, by reducing bias caused by spurious POR definitions, it will be possible to compare results and to draw reliable conclusions.

It is important that women who are diagnosed as poor responders talk discuss with their fertility specialist on whether they fall in the spectrum. There are studies that indicate that women with elevated FSH levels during a clomiphene challenge test, may have an unsuccessful IVF cycle. However, everybody’s diagnosis can vary as well treatment protocol.

Here are a few different treatments for a poor response to ovarian stimulation that are commonly recommended:

  • Altering the pituitary down regulation protocols
  • Modifying stimulation cycle medications (e.g., different types and amounts gonadotropins),
  • The use of adjuvant therapy (such as, growth hormone or androgen pretreatment), and
  • advanced laboratory techniques (e.g., assisted hatching, continuing to egg retrieval despite low follicle numbers, or day 2 transfers)

Agonist Protocol or Microdose Lupron Flare Protocol: If patient had a poor response to other protocols or are of advanced maternal age, we can recommend a lower dose of Lupron that stimulates (rather than suppresses) the body’s natural production of follicle stimulating hormone (FSH). This is considered the “flare” period. patient will continue to take the microdose of Lupron during the stimulation phase up until hCG trigger injection. The combination of low-dose Lupron and stimulation drugs maximizes the patient’s ovarian stimulation potential. eggs will be retrieved, fertilized, and transferred back into uterus. This cycle takes approximately 6 weeks, if birth control is not used, until the time of pregnancy test.

Estrogen Priming Protocol: In conjunction with the Antagonist Protocol, estrogen can be supplemented to silence natural hormone production and ovarian stimulation. The estrogen patch is typically prescribed two weeks before day 1 of cycle and is replaced daily until period (cycle day 1) arrives. The stimulation period begins and follows the Antagonist protocol. This is best for poor responders or women diagnosed with Diminished Ovarian Reserve (DOR).


What is a mini IVF cycle?

Mini, also known as minimal stimulation, IVF protocols have one distinct difference from traditional IVF protocols.  Instead of using fertility medication to push the body to produce a large number of eggs, Mini IVF focuses on producing a small number of high quality eggs.  On average, a mini IVF cycle retrieves between two and five high quality eggs.

Why are poor responders and Mini IVFs a good match?

Because minimal stimulation IVF protocols are not concerned with retrieving a large number of eggs, poor responders are often a good fit.  Each woman is prescribed only the specific level of medication she needs to promote ovulation. Throughout the cycle each woman is closely monitored which allows the care team to make adjustments as necessary to provide the best outcome.

What medication is used during Mini IVF cycles?

Each woman’s medication is determined by her specific needs, therefore treatment amounts vary. Generally, women undergoing a Mini IVF protocol can expect to take one dose of Clomid a day as well as up to three injections of Menopur during the course of the cycle.   Additionally, a dose of Synarel – which is administered via nasal spray – is generally used to trigger ovulation.

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