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

Objective: To assess the efficacy of various controlled ovarian hyperstimul ation (COH) regimens in the prior poor-responder patient preparing for assi sted reproductive techniques. Design: English-language literature review. Patient(s): Candidates for assisted reproductive techniques who had been de fined as having a prior suboptimal response to standard COH regimens. Intervention(s): A variety of regimes are reviewed, including increased gon adotropin doses, change of gonadotropins, adjunctive growth hormone (GH), l uteal phase (long) GnRH agonist (GnRH-a) initiation, early follicular phase (flare) GnRH-a initiation, low-dose luteal phase (ultrashort) GnRH-a initi ation, 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, oocyt es retrieved, embryos: transferred, and clinical and ongoing pregnancy rate s. 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 ben eficial are microdose GnRH-a flare and late luteal phase initiation of a sh ort 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 prospectiv e randomized trials an critical. Development of a reliable precycle screen will allow effective differentiation among normal responders, poor responde rs, and those who will not conceive with their own oocytes.