Alternatives for Managing Poor Responders in IVF

A/Prof Peter Lutjen National Medical Director Monash IVF, Australia.

One of the most difficult dilemmas in IVF is the treatment of the poor responder. A variety of adjuvant therapies have been proposed to help potentiate gonadotrophin stimulation in patients with poor ovarian response. To date meta-analysis of the studies has been problematic due to the considerable clinical variability between most RCTs in this area. This variability has stemmed from: 1) the lack of a uniform definition of poor ovarian response in IVF; 2) variability in the protocols used for the administration of these adjuvant treatments; and 3) variations in the stimulation protocols and luteal phase support used in these studies. Therapies that have been proposed to assist in the treatment of poor ovarian response include dehydroepiandrosterone (DHEA), growth hormone (GH), recombinant luteinizing hormone (rLH), aromatase inhibitors and more recently, melatonin. Other treatments such as the use of intrauterine hCG at the time of embryo transfer and treatments designed to reduce the number of uterine natural killer cells have also been proposed to increase pregnancy rates in IVF regardless of a patients response to exogenous gonadotrophins. We will examine the proposed mechanisms of action of these treatments and critically evaluate the evidence, or lack of it, that they provide a benefit in the treatment of poor ovarian response in IVF.