Poor Response Protocols
Poor ovarian response to stimulation occurs in 9-24 percent of patients. Poor responders are patients with peak estradiol levels < 500pg/ml, < 4 dominant follicles on day of hCG, patients >40 years of age and those with diminished ovarian reserve based on day 3 FSH. Several stimulation protocols have been proposed in an attempt to improve ovarian stimulation. These include: 1) initiating GnRH agonist and gonadotropins together in the follicular phase (flare protocol), 2) co-treatment with estrogen, growth hormone or oral contraceptives or 3) using clomiphene citrate plus gonadotropins without GnRH agonist down-regulation. Currently, most centers are using microflare protocols in which patients are pretreated with a monophasic OC for approximately 6 weeks followed by 20ug leuprolide acetate twice daily (versus 1 mg daily in conventional IVF) and 6 ampules of gonadotropins 3 days later. Studies have shown that patients respond with higher peak estradiol levels, an increase in the number of follicles and an increase in the number of oocytes retrieved.

With the A/ACP, low dose Antagon/Cetrotide is commenced at the onset of spontaneous menstruation or following bleeding that follows initiation of GnRH agonist (e.g. Lupron) therapy using a long-down-regulation protocol arrangement. We currently prescribe the A/ACP to most of our IVF patients regardless of whether they are “normal responders” or “poor responders”. Preliminary results suggest a significant improvement in egg number, egg/embryo quality as well as in implantation and viable IVF pregnancy rates. The A/ACP has however, proven to be most advantageous in “poor responders” where additional enhancement of ovarian response to gonadotropins may be achieved through incorporation of “estrogen priming”. We have reported on the fact that the addition of estradiol for about a week following the initiation of the A/ACP, prior to commencing FSH-dominant gonadotropin stimulation appears to further enhance ovarian response, presumably by up-regulating ovarian FSH-receptors. ”. We refer to l this as the A/ACP+ E2V.

Но забележи, че тук става дума за дълъг протокол.

Me:  Would you recommend a change in protocol if I cycle again?

Dr. S:  Yes, I'd want to try antagonist with estrogen priming.

Me:  What is estrogen priming?  I've read about it but am not clear on it.

Dr. S:  We give the patient estrogen for a month prior to the IVF cycle.  The estrogen primes the ovarian FSH receptors and increases response, and also avoids a situation of lead follicles
 

Само да поясня че съм на 40 години и хормоните ми са в норма ,изследванията сочат съхранен яйчников резерв но при първото ИКСИ резултата можеше да се окачестви най-много като задоволителен независимо от сериознта стимулация.Явно възрастта на жената си е самостоятелен фактор независимо от това какво сочат изследванията и.

Poor ovarian response to standard FSH treatment is a major concern in assisted reproduction processes. The current study, which demonstrates the enhanced ovarian sensitivity to gonadotropin in poor IVF responders, by pretreatment with transdermal testosterone, could serve as a novel approach to achieve enhanced success of IVF treatment.

Pretreatment with transdermal testosterone may improve the ovarian sensitivity to FSH and follicular response to gonadotrophin treatment in previous low-responder IVF patients. This approach leads to an increased follicular response compared with a high-dose gonadotrophin and minidose GnRH agonist protocol.

Treatment of poor-responder patients to controlled ovarian stimulation for assisted reproduction, who have normal basal FSH concentrations, is one of the most difficult challenges in reproductive medicine. This study investigated the usefulness of testosterone pretreatment in such patients.