Managing poor responder

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Managing poor responder

  1. 1. Managing poor responderDR G A RAMA RAJUKrishnaivf clinic,Krishnaivf.com
  2. 2. Eshre consensus :Poor responder
  3. 3. Poor responder eshre definitionTwo of the following threefeatures must be present:Advanced maternal age (≥40 years)or any other risk factor for POR;A previous POR (≤3 oocytes with aconventional stimulation protocol);An abnormal ovarian reserve test (i.e.AFC <5–7 follicles or AMH <0.5–1.1ng/ml).
  4. 4. Predicting poor responderAFCAMHOvarianvolumeTestosteronePRIOR POORRESPONSEAGE
  5. 5. Precycle adjuvantsDHEA SimplecystdrainagePrecycleOCP
  6. 6. DHEA
  7. 7. Simple cyst drainage prior to stimulation
  8. 8. Precycle oral contraception or antagonistsuppression combined estrogen priming
  9. 9. Adjuvants at initiation of cycleGnrh analogflareGRHAGONISTMICRODOSEFLAREPROTOCLAGONISTVERSUSANTAGONIST.CLOMIPHENEFLARELETRIZOLEFLARE
  10. 10. Gnrh analog flare protocol
  11. 11. Antagonist versus Agonist protocols
  12. 12. Natural ,clomiphene letrizole ivfLetrizole flareprotocolClomipheneflareprotocol
  13. 13. Poor Responder management in stimulation phaseDOSEHMG VERUSREC FSHLH IN POORRESPONDERMINIMALSTIMULATIONATURALCYCLE IVFDOSINGINTERVAL
  14. 14. Starting dose600units450unitsOncedailyTwicedaily
  15. 15. Role of HMG in intial poor response with rec fsh
  16. 16. Role of lh in poor responder
  17. 17. LABARATORY OPTION
  18. 18. LABARATORY OPTIONICSI FOR LOWOOCYTE NUMBERPREIMPLANTATIONENETIC DIAGNOSISIDEAL DAY OFTRANSFERNUMBER OFEMBRYOSDONOR OOCYTE
  19. 19. Icsi for all ?
  20. 20. Preimplantaion genetic screen for poor responder
  21. 21. Ideal day of transfer• The role of day 5 embryotransfer for poor responders isless clear• Randomized controlled trialdemonstrating increased clinicalpregnancy rates for poorresponders undergoing day 2embryo transfer compared withday 3 embryo transfer
  22. 22. Number of embryos for transferOptimizing the number of cleavage stage embryos totransfer on day 3 in women 38 years of age and older
  23. 23. Donor oocyte
  24. 24. Next 5 years poor responderGenomic proteomic metabolomics will play a majorrole in stimulation protocol.

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