Survey: Poor responders: How to define, diagnose and treat?
"Poor responders" or cases of patients with "Poor ovarian function" represent a significant percentage of couples treated in  IVF units.  Still there are uncertainties on definitions, choice of stimulation protocols and   the overall best modalities  of treatment. It was first described in 1983 as one who on a standard stimulation regimen, had a peak estradiol concentration  of <300 pg/mL and who had poor follicular recruitment  leading to a smaller number of eggs retrieved and therefore few  embryos available for transfer. Even though "poor responders" do not reflect on one single pathology,  the below survey is conducted to let us all know what are the various ways to approach this problem. Your individual contribution would help us all to find the best or commonest way to define and treat these patients. The survey was compiled by:  Pasquale Patrizio, Director Yale Fertility Center and REI medical practice from New Haven , CT , USA . And Milton Leong  Director of IVF Center, Hong Kong Sanatorium and Hospital, Adjunct Professor of O+G, McGill University, Montreal, Canada   Your time and efforts are very much appreciated and your contribution will obviously support better treatment for our patients. The personal data requested aims only to assure the safety and authenticity of the data submitted. No personal data will be published.
Name
Name of IVF Center (Unit)
E-mail
1. Country
1. Country
2. Estimated number of total IVF cycles performed by the unit annually
Less Than 100 cycles 100-200 cycles 200-300 cycles 300-400 cycles 400-500 cycles 500-600 cycles 600-700 cycles 700-800 cycles 800-900 cycles 900-1000 cycles 1000-1200 cycles 1200-1400 cycles 1400-1600 cycles 1600-1800 cycles 1800-2000 cycles 2000-2500 cycles 2500-3000 cycles 3000-3500 cycles 3500-4000 cycles >4000 cycles
3. Should the definition be based on ovarian response only?
1-Yes 2-No
4. Should definition include endometrial response?
1-Yes 2-No
5. How you define poor responders based on number of follicles?
1-Less than 2 follicles 2-Less than 3 follicles 3-Less than 4 follicles 4-Less than 5 follicles 5-Do not use follicle number
6. How you define poor responders based on level of serum estradiol?
1-Less than 3500 pmol/l (910 pg/ml) 2-Less than 3000 pmol/l (780 pg/ml) 3-Less than 2500 pmol/l (650 pg/ml) 4-Less than 2000 pmol/l (520 pg/ml) 5-Less than 1500 pmol/l (390 pg/ml) 6-Less than 1000 pmol/l (260 pg/ml) 7-Less than 500 pmol/l (130 pg/ml) 8-Do not use estradiol for screening
7. Is History important? Previous performance before and during IVF
1-Yes 2-No
8. What screening methods do you use to identify poor responders?
1-FSH 2-FSH and estradiol 3-FSH, AFC (antral follicular count) 4-FSH, Estradiol, AFC (antral follicular count) 5-FSH , AMH (Anti Mullerian Hormone) 6-FSH , estradiol, AFC and AMH (Anti Mullerian Hormone)
9. Do you measure FSH/LH ratio?
1-Yes 2-No
10. At what level of day 2 FSH would you identify a poor responder?
1- 10 - 12 U/L 2- 12 - 15 U/L 3- 15 - 19 U/L 4- > 19 U/L 5- None of the above
11. In normally cycling patients, would you cancel IVF treatment if day 2 FSH is
1- > 10U/L 2- > 13U/L 3- >18U/L 4- >20U/L 5- If patients is cycling I will not cancel cycle
12. Do you do any dynamic testing?
1-GnRH agonist 2-Clomiphene Citrate challenge test (CCCT) 3-Both of the above 4-None of the above
13. Do you use the ultrasound for diagnosis?
1-3-D Ultrasound and Doppler study 2-Antral follicle count 3-Both 4-None of the above
14. Would you do genetic testing?
1-Fragile X 2-Karyotype 3-Both 4-None
15. What, in your opinion and experience, is the most important predictor of the above?
1-No of follicles 2-Estradiol Level 3-Previous history 4-FSH 5-AMH 6-Dynamic testing 7-3-D Ultrasound 8-Karyotype 9-Other
16. Can you estimate the scale of poor responders in your clinic?
1-Less than 5% 2- 6-10% 3- 11-15% 4- 16-20% 5- 20-25% 6- 25-30% 7- >31%
17. Have you seen any change in the incidence during the last 10 years?
1-The incidence decreased 2-The incidence increased 3-No change
18. Would you continue treatment if no oocytes were retrieved at a prior cycle ?
1-Yes, for another cycle 2-No
19. Will you continue treatment if oocytes were aspirated but no embryo(s) developed?
1-Yes, for another cycle 2-No
20. Of the following GnRH analogues protocols, which one do you use more often for poor responders?
1-GnRH agonists, long protocol 2-GnRH agonist short protocol 3-Short protocols microdose 4-GnRH agonist using flexible regimen 5-GnRH antagonists 6-No analogues
21. What combination of gonadotropins do you use?
1-FSH alone 2-hMG alone 3-FSH and recLH 4-FSH and hMG 5-FHS and low dose hCG 6-None of the above
22. What should be the starting dose of of gonadotropins (FSH alone or hMG) that you use?
1-Usual dose (150-225 IU) 2-300-375 IU daily 3-375-450 IU daily 4-450-600 IU daily 5-More than 600 IU a day 6-None of the above
23. What is the maximum daily dose of gonadotropins (FSH alone or hMG) that you use?
1-600 2-900 3-1200 4-1500 5-More
24. If you add hMG how many daily units and when?
1- 75-150 IU from the onset of stimulation 2- 75-150 IU after 5-6 days of stimulation 3- 225-300 IU from the onset of stimulation 4- 225-300 IU after 5-6 days of stimulation 5- A higher dose 6- Do not add hMG
25. If you add rec.LH how many daily units and when?
1- 75-150 IU from the onset of stimulation 2- 75-150 IU after 5-6 days of stimulation 3- 225-300 IU from the onset of stimulation 4- 225-300 IU after 5-6 days of stimulation 5- A higher dose 6- Do not add rec.LH
26. Would you divide the daily dose into two administrations?
1-Yes if is more than 225/day 2-Yes, if is more than 300/day 3-Yes if is equal or more than 450/day 4-No, always one administration
27. How long will you continue with the maximum dose, if there is no response, before you will stop treatment (cycle cancellation)?
1- 4-6 days 2- 7-9 days 3- 9-11 days 4- >11 days
28. Do you use Clomiphene Citrate and gonadotropin?
1-Yes 2-No
29. Will you add hGH to the treatment protocols?
1-Yes 2-No
30. Will you add DHEA (dehydroepiandrostendione 75 mg daily) to the protocol?
1-Yes 2-No
31. If you add DHEA when do you start?
1-Around 3 month before treatment 2-At the beginning of the cycle 3-I do not add
32. Do you add Aspirin?
1-Yes 2-No
33. Do you add Low Weight Molecular Heparin at any time of the stimulation or luteal phase?
1-Yes 2-No
34. Would you prefer natural cycle in these cases?
1-Yes 2-No
35. Would you recommend IVM in such cases?
1-Yes 2-No
36. Do you start gonadotropins in the luteal phase prior to stimulation?
1-Yes 2-No
37. Do you increase dose of exogenous luteal progesterone?
1-Yes 2-No
38. In addition to progesterone, do you support the luteal phase with estrogen, aspirin, or steroids?
1-Estrogen and baby aspirin 2-Estrogen and steroids 3-Estrogen and steroids and baby aspirin 4-Estrogen 5- None
39. Do you bank oocytes for poor responders?
1-Yes 2-No
40. Do you do embryo banking in this group of patients? (Get the embryos freeze and accumulate to replace several embryos in one cycle)
1-Yes 2-No
41. Do you offer assisted Zona hatching?
1-Yes 2-No
42. Assuming none financial constraints, is there a maximum number of failed cycles after which you recommend to stop?
1- 2 failed cycles 2- 3 failed cycles 3- 4 failed cycles 4- 5 failed cycles 5- None
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