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Poor Responders

Patients With Low Ovarian Reserve

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).

  • Antral follicle count – number of eggs seen on transvaginal ultrasound on the 2nd day of your period.

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.

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

  • Use of DHEA 75 mg daily

  • Use of Testosterone gel 1% - for 20 days pre-IVF.

  • Use of Growth hormone during stimulation.

  • Use of antioxidants.

  • Use of regenerative agents.

  • Natural cycle IVF.

Unfortunately, the evidence in favour of most of these measures is quite inadequate. As per the guidelines of the European Society of Human Reproduction and Embryology, most of the above do not seem to benefit poor responder patients.

Other strategies for treatment include:

  • Ovulation induction with high dose FSH.

  • IVF using mild stimulation with clomiphene citrate and small doses of HMG injections. 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 22% chance of pregnancy with this approach even with a very low ovarian reserve.

  • IVF using high dose hMG stimulation with a GnRH antagonist.

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

If all fails, then egg donation is usually recommended.

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