Strategies for pituitary down-regulation to optimize IVF/ICSI outcome in poor ovarian responders

The ovarian stimulation of poor responders still remains a challenging task for clinicians. There are numerous strategies that have been suggested to improve the outcome in poor responders but there is still no one pituitary down-regulation protocol that best suits all women with such condition. Traditional GnRH agonist flare and long luteal phase protocols do not appear to be advantageous. Reduction of GnRH agonist doses, "stop" protocols, and microdose GnRH agonist flare regimes all appear to improve outcomes, although the proportional benefit of one approach over another has not been convincingly established. GnRH antagonists improve outcomes in this patient population, although, in general, pregnancy rates appear to be lower in comparison to microdose GnRH agonist flare regimes

Prediction and diagnosis of poor ovarian response: the dilemma

Failure to respond adequately to standard protocols and to recruit adequate follicles is called 'poor response'. This results in decreased oocyte production, cycle cancellation and, overall, is associated with a significantly diminished probability of pregnancy. It has been shown that ovarian reserve tests, such as basal FSH, antimullarian hormone [AMH], inhibin B, basal estradiol, antral follicular count [AFC], ovarian volume, ovarian vascular ?ow, ovarian biopsy and multivariate prediction models, have little clinical value in the prediction of a poor response. Although recent evidence points that AMH and AFC may be better than other testsbut they still continue to be used and form the basis for the exclusion of women from fertility treatments. Despite the rigorous efforts made in this regard, a test that could reliably predict poor ovarian response in all clients that undergo IVF is currently lacking