Poor Responders

Patients with a poor ovarian reserve constitute almost 50% of our patients (as is the case in most IVF centres). Delayed child-bearing and advanced maternal age are the commonest causes of women having a reduced egg reserve by the time they opt for IVF.

There are several tests to estimate the "time on hand" by assessing the ovarian (egg) reserve. These are:

• Serum FSH level on 2nd or 3rd day of your periods.

• Serum Anti Mullerian Hormone (AMH) is the most accurate and reliable test for egg reserve. It is a walk-in test which can be done on any day of the menstrual cycle and does not require any fasting.

• Antral follicle count – number of eggs seen on transvaginal ultrasound

The egg reserve is considered to be decreased after the age of 37 and in patients who show elevated FSH levels ( > 8 miu/ml) or greatly reduced AMH levels ( < 2).

The most accurate test which can be done by patients of all age groups and at any time during the menstrual cycle is the serum AMH level. Levels of 2-6 are ideal. More than 6 is usually seen in patients with mild-severe Polycystic ovarian disease. Levels of < 2 are usually seen in patients with reduced egg reserve.

Irrespective of age, a reduced AMH level indicates that the egg reserve is depleted and the patient needs aggressive treatment. Artificially lowered AMH levels might be seen if the woman has been on any kind of hormonal medication or birth control pills.

Several therapeutic measures have been suggested for these patients such as:

• Use of Testosterone gel 1% - for 20 days pre-IVF OR DHEA for 2-3 months

• Use of antioxidants such as coenzyme Q, L-arginine, etc

• Use of regenerative agents such as resveratrol

• Long agonist protocol with hMG (for better synchronization and more top quality embryos)

• Short antagonist protocol with combination of rFSH and HP-hMG

Other strategies for treatment include:

• Ovulation induction with high dose FSH.

• IVF using embryo accumulation. With this approach, our clinic recommends 2- cycles of stimulation with egg retrieval, IVF and freezing of all embryos. Once we have a stock of 3 grade I embryos we would plan the embryo transfer with optimal endometrial preparation to increase the chances of pregnancy. You can expect a decent chance of pregnancy with this approach even with a very low ovarian reserve.

• IVF using high dose hMG stimulation with a GnRH antagonist. Here, pre-treatment with estradiol, norethisterone, birth control pill or the antagonist is mandatory to ensure a uniform cohort of follicles and to get maximum number of mature eggs.

• IVF using down regulation with a GnRH agonist and hMG stimulation.

• Dual stimulation, once popular, is no longer recommended for patients with a poor egg reserve. It is to be reserved for cancer patients who are going in for chemotherapy and need their fertility to be preserved urgently.

If all fails, then egg donation is usually recommended.