Obstetrics Gynecology – MD, MSC, MMSC, Phd – Fertility Specialist

Low ovarian potential – How do we deal with it?

Written by Dr. Athanasios V. Garavelas
Recognizing an existing problem in a woman’s cycle, we proceed step by step to solve it, based on the latest scientific methods in the field of assisted reproduction.
The development and maturation of multiple follicles is crucial for achieving IVF pregnancies.
A significant proportion of women, however, undergo ovarian stimulation as part of assisted reproduction that do not adequately respond to standard ovarian stimulation protocols, with a significantly reduced number of developing follicles.

These women are defined as “poor responders” and usually show reduced oocyte counts, low fertilization rates, poor fetal quality and, consequently, low pregnancy rates. Poor ovarian response occurs in 9-24% of women undergoing ovarian stimulation and requires a special therapeutic approach and treatment.
Until recently, there was no understanding of the definition of “poor ovarian response”, resulting in significant difficulty in assessing the effectiveness of various treatment methods based on relevant published studies. Various criteria have been used to define the “poor ovarian response”, most importantly the number of developing follicles, the number of oocytes obtained and the serum estradiol levels in response to ovarian stimulation.
Also, the various definitions can be retrospective or prospective depending on whether the poor ovarian response was observed in previous cycles or whether it was expected in the next ones based on the poor ovarian reserve, the woman’s advanced age, previous ovarian surgeries, etc. .
Recently, in an effort to establish a universally accepted definition of “poor ovarian response”, it was suggested that a woman be classified as a “poor responder” if at least two of the three criteria are present:
Advanced age of the woman (≥40 years) or the presence of another risk factor for poor ovarian response.
Previous poor ovarian response (≤3 oocytes following conventional ovarian stimulation protocol).
Abnormal ovarian reserve (Mϋller pore inhibitory hormone (AMH) 0.5-1.1 ng / ml).
Two episodes of poor ovarian response after maximal ovarian stimulation are considered sufficient to characterize a patient as a “poor responder” in the absence of advanced age or abnormal ovarian reserve.
Causes of poor ovarian response include a woman’s advanced age, previous ovarian surgery, pelvic adhesions, and increased body mass index. However, a poor ovarian response can also occur unexpectedly, reflecting premature ovarian aging.
Predicting the ovarian response of an IVF cycle would contribute significantly to the early identification of “poor responders”, with a view to addressing and modifying their stimulation protocols.
The question therefore arises as to whether the poor ovarian response can be predicted. In this light, various indicators have been proposed, such as FSH, estradiol (E2), inhibitory B and AMH.
Elevated patient serum FSH concentrations on the second or third day of the menstrual cycle have been associated with reduced pregnancy rates, while FSH levels> 20 IU / L in at least two cycles are associated with a low probability of pregnancy. In addition, it has been suggested that AMI could be a new indicator of ovarian response, as its low concentrations occur earlier than all other indicators associated with ovarian aging.
Dealing with poor responders remains a challenge in the field of assisted reproduction.
The options given to a woman who has a reduced ovarian supply and is a poor respondent, that is, does not respond to IVF drugs, are:
The natural IVF cycle, although it has its difficulties, has been an excellent tool in the hands of an experienced IVF specialist.
Ovarian rejuvenation (PRP PLATELET RICH PLASMA) is a new experimental process, which helps in the natural production of oocytes in the ovaries. It is a worthwhile alternative to egg donation. In addition, it offers hope to women of advanced reproductive age who have a reduced number and usually of poor quality eggs.
Essentially, though, the option with the highest pregnancy rates is egg donation. It is a simple medical technique, but a complex process both emotionally and psychologically for the couple who will decide to make this choice.