What is new in the management of poor ovarian response in IVF?

PURPOSE OF REVIEW: The management and treatment of patients with poor ovarian response is still a controversial issue in IVF. Increasing evidences demonstrate that the number of oocytes retrieved after a controlled ovarian stimulation (COS) greatly influences the clinical outcome in terms of cumulative live birth per started cycle. For this reason, any COS should aim to optimize the number of oocytes according to the ovarian reserve of the patient. The aim of this review is to provide an overview of new strategies proposed to manage poor responders according to the novel POSEIDON classification. RECENT FINDINGS: Gonadotrophins cannot compensate for the absence of follicles in the ovary, therefore, COS in poor responders may benefit from the exploitation of multiple follicular waves within a single ovarian cycle, for instance, through luteal phase stimulation or double stimulation (follicular plus luteal) in the same ovarian cycle (DuoStim) protocols. SUMMARY: Many strategies have been proposed to manage poor responder patients, however, a consensus upon which is the most beneficial has not been yet reached. DuoStim is the most promising approach to increase the number of oocytes collected in a single ovarian cycle; however, more embryological and clinical data is required, as well as an analysis of its cost-effectiveness.

Protocolo weekend-free con cetrorelix y lutropina alfa en inseminaciones intrauterinas / A weekend-free protocol with cetrorelix and recombinant luteinizing hormone in intrauterine inseminations

Objetivo. Evaluar la eficacia de un nuevo protocolo de supresión hipofisaria con cetrorelix y lutropina alfa (LH recombinante) en la estimulación ovárica con FSH recombinante para evitar las inseminaciones intrauterinas en fin de semana por razones logísticas. Sujetos y métodos. Estudio prospectivo, abierto y comparativo que incluye 182 parejas que realizaron su primer ciclo de estimulación ovárica para inseminación intrauterina de febrero de 2006 a diciembre de 2009. Se establecieron 2 grupos de estudio en función de la respuesta ovárica y el desarrollo folicular que conducía a una inseminación en fin de semana (grupo A: 91 pacientes) y las primeras 91 parejas cuyo ciclo se completó con la inseminación en días laborables. Los criterios de inclusión fueron: edad de la mujer < 39 años, FSH basal < 10 UI/l, estradiol basal < 80 pg/ml o PRL< 40 ng/ml, índice de masa corporal < 32 kg/m2, permeabilidad tubárica bilateral y parámetros seminales con morfología espermática normal > 4% y recuento total de espermatozoides móviles (REM) igual o superior a 10 millones/ml. Resultados. El total de gestaciones conseguidas en el grupo A fue de 30 (32,9%), mientras que en el grupo B fue de 19 (20,9%), diferencias que no alcanzaron la significación estadística (Chi cuadrado; p = 0,066). Conclusión. La supresión hipofisaria con cetrorelix y LH recombinante, administrados en forma de dosis múltiple en un protocolo de estimulación ovárica controlada con FSH recombinante para inseminación intrauterina, es seguro para evitar las inseminaciones en fin de semana por razones logísticas (AU)

Objective. To evaluate the efficacy of a new protocol for pituitary suppression with cetrorelix and recombinant luteinizing hormone (LH) for ovarian stimulation with recombinant follicle-stimulating hormone (FSH) to avoid weekend intrauterine inseminations for logistical reasons. Subjects and methods. This prospective, open, comparative study included 182 couples who underwent their first cycle of ovarian stimulation for intrauterine insemination between February 2006 and December 2009. Two study groups were established based on ovarian response and follicular development: one group that required weekend insemination (Group A: 91 patients) and another consisting of the first 91 couples whose cycles were completed with insemination on weekdays (Group B: 91 patients). The following inclusion criteria were applied: women aged < 39 years, baseline FSH < 10 IU/L, baseline estradiol < 80 pg/ml or prolactin (PRL) < 40 ng/ml, body mass index < 32 kg/m2, bilateral tubal permeability and seminal parameters with normal sperm morphology > 4%, and total motile sperm count (MSC) equal to or greater than 10 million/ml. Results. The total number of pregnancies achieved in group A was 30 (32.9%), while 19 (20.9%) were achieved in group B. This difference was not significant (X2 P = .066). Conclusion. Pituitary suppression with cetrorelix, administered in multiple doses with recombinant LH and recombinant FSH during a protocol of controlled ovarian stimulation for intrauterine insemination, allows weekend inseminations to be safely avoided for logistical reasons (AU)

Variation in antimüllerian hormone concentration during the menstrual cycle may change the clinical classification of the ovarian response.

OBJECTIVE: To assess the variability of antimüllerian hormone (AMH) concentrations in women with "adequate ovarian reserve" during unstimulated menstrual cycles and to determine the impact on clinical classifications. DESIGN: Pilot cohort study. SETTING: Private fertility clinic. PATIENT(S): Twelve consecutive women (aged 29 to 43 years) referred to a fertility service, with AMH measurements repeated throughout unstimulated cycle, and who had at least one AMH measurement indicating "adequate ovarian reserve." INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): AMH concentrations assessed in 82 serum samples from 12 women compared against the published cutoffs for reduced ovarian reserve and for risk of excessive response to ovarian stimulation. RESULT(S): Over half the women (7 of 12) were reclassified as a result of testing AMH concentrations at different phases of the menstrual cycle. Over one-third (4 or 5 of 12) crossed a cutoff for reduced ovarian reserve; 2 of 12 crossed cutoffs predicting hyperstimulation. There was a statistically significant change in AMH concentration according to the day of the cycle, with a negative trend of the median AMH concentration from the follicular to luteal phase. The maximum change in median AMH concentration over cycle was 7.9 pmol/L, and the mean difference between the maximum and minimum AMH was 6.7 pmol/L. CONCLUSION(S): In this pilot study, the AMH concentration varied during menstrual cycle, and the clinical classification of the ovarian response was altered.