Clinical significance and management of poor response in IVF

Abstract

Patients with a poor ovarian response in IVF treatment are known to have low pregnancy rates because of the low number of embryos available at transfer and the high cancellation rate. Many strategies have been suggested to improve the IVF outcome in these patients. However, it will probably be more rewarding to identify those poor responders that will have poor pregnancy prospects in subsequent cycles than to continue the search for stimulation protocols that might improve IVF outcome.

To determine the prognosis of a patient with an insufficient response to ovarian hyperstimulation it is clinically useful to discriminate between expected and unexpected poor responders. In expected poor responders the poor response was predicted on the basis of the result of an ovarian reserve test, such as basal FSH and the antral follicle count. As the underlying cause of the poor response in these patients will most likely be a diminished ovarian reserve, alternative stimulation protocols are bound to fail. Continuation of IVF treatment should be discouraged. In contrast, most unexpected poor responders, with normal ovarian reserve tests, will have sufficient ovarian reserve to respond normally in the subsequent cycle. Their cumulative pregnancy rates are not diminished. In the present thesis it is shown that the commonly used strategy of aggressive stimulation with high doses of gonadotrophins does not improve the IVF outcome of poor responders and should therefore be avoided.

Because the ovarian reserve declines with age, women of 41 years and above are normally not treated with IVF in the Netherlands. However, when women between 41 and 44 years of age were treated with IVF in a research setting, the majority of these patients showed five or more antral follicles on ultrasound. This indicates that the ovarian reserve is still sufficient. The pregnancy rate in IVF in this group was comparable to the pregnancy rate of women aged between 38 and 41 with sufficient follicles. The number of antral follicles therefore is a better predictor of IVF outcome in older women than age. It seems no longer justified to simply deny IVF treatment to all older patients now that it is possible to select a subgroup with a favourable prognosis.