Evaluating strategies for improving ovarian response of the poor responder undergoing assisted reproductive techniques

Objective: To assess the efficacy of various controlled ovarian hyperstimulation (COH) regimens in the prior poor-responder patient preparing for assisted reproductive techniques. Design: English-language literature review. Patient(s): Candidates for assisted reproductive techniques who had been defined as having a prior suboptimal response to standard COH regimens. Intervention(s): A variety of regimes are reviewed, including increased gonadotropin doses, change of gonadotropins, adjunctive growth hormone (GH), luteal phase (long) GnRH agonist (GnRH-a) initiation, early follicular phase (flare) GnRH-a initiation, low-dose luteal phase (ultrashort) GnRH-a initiation, progestin pretreatment, and microdose flare GnRH-a initiation. Main Outcome Measure(s): Maximal serum E-2 levels, follicular development, dose, and duration of gonadotropin therapy, cycle cancellation rates, oocytes retrieved, embryos: transferred, and clinical and ongoing pregnancy rates. Result(s): A lack of uniformity in definition of the poor responder and of prospective randomized trials make data interpretation somewhat difficult. Of the varied strategies proposed, those that seem to be more uniformly beneficial are microdose GnRH-a flare and late luteal phase initiation of a short course of low-dose GnRH-a discontinued before COH. Conclusion(s): No single regimen will benefit all poor responders. General acceptance of uniform definitions and performance of large-scale prospective randomized trials an critical. Development of a reliable precycle screen will allow effective differentiation among normal responders, poor responders, and those who will not conceive with their own oocytes.