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POOR RESPONDERS: Minimal Vs. Maximal stimulation

Aboubakr Elnashar
Aboubakr Elnashar
Aboubakr ElnasharProfessor Obstetrics and Gynecology at Aboubakr Mohamed Elnashar

ABOUBAKR ELNASHAR

POOR RESPONDERS: Minimal Vs. Maximal stimulation

1 of 11
POOR
RESPONDERS
Minimal Vs. Maximal
stimulation
Prof. Aboubakr Elnashar
Benha university Hospital,
Egypt
ABOUBAKR ELNASHAR
1. DEFINITION OF POOR RESPONDER
ESHRE: Bologna criteria 2011
 At least 2 of 3:
 Age (≥40 y) or any other risk factor for POR
 Previous POR
(≤3 oocytes with a conventional stimulation protocol)
 Abnormal ORT
(AFC <5–7 follicles or AMH <0.5–1.1 ng/ml).
 2 episodes of POR
after maximal stimulation are sufficient to define a patient as poor
responder in absence of advanced maternal age or abnormal ORT.
ABOUBAKR ELNASHAR
The novel POSEIDON stratification
(Humaidan et al, 2017)
POSEIDON
=Patient-Oriented Strategies Encompassing IndividualizeD
Oocyte Number
Based on quantitative and qualitative parameters
1. Age and the expected aneuploidy rate
2. Ovarian biomarkers {AFC and AMH]
3. Ovarian response -provided a previous
stimulation cycle was performed.
4 groups based on oocyte quantity and quality
described the issue as a ‘poor prognosis’ concept rather than
a POR concept
‫البحر‬ ‫اله‬
ABOUBAKR ELNASHAR
ABOUBAKR ELNASHAR
450 IU 375 IU 300 IU
Tronson & Gardner, 2000 Madany et al, 2012 Dercourt et al, 2016
Haas et al.,2015 Berkkanoglu et al, 2010
Lefebvre et al, 2015 Baker et al, 2015
Friedler et al, 2016
2. GONADOTROPHIN DOSE IN POOR RESPONDERS
ABOUBAKR ELNASHAR
 Advantages and disadvantages of mild COS: GnT: 150 IU
(Alper , Fauser, 2017)
ABOUBAKR ELNASHAR
Advantages Disadvantages
Treatment burden:
less
Per cycle cancellation rate:
higher
Risk of OHSS:
Reduced
Embryos for cryopreservation:
Fewer
GnT
dose: Lower
Injections: fewer
May require multiple stimulated
cycles to achieve pregnancy
Per cycle drop out
rates: lower
Cumulative costs associated with
multiple fresh cycles: increased
Embryo quality:
±better
Ad

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POOR RESPONDERS: Minimal Vs. Maximal stimulation

  • 1. POOR RESPONDERS Minimal Vs. Maximal stimulation Prof. Aboubakr Elnashar Benha university Hospital, Egypt ABOUBAKR ELNASHAR
  • 2. 1. DEFINITION OF POOR RESPONDER ESHRE: Bologna criteria 2011  At least 2 of 3:  Age (≥40 y) or any other risk factor for POR  Previous POR (≤3 oocytes with a conventional stimulation protocol)  Abnormal ORT (AFC <5–7 follicles or AMH <0.5–1.1 ng/ml).  2 episodes of POR after maximal stimulation are sufficient to define a patient as poor responder in absence of advanced maternal age or abnormal ORT. ABOUBAKR ELNASHAR
  • 3. The novel POSEIDON stratification (Humaidan et al, 2017) POSEIDON =Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number Based on quantitative and qualitative parameters 1. Age and the expected aneuploidy rate 2. Ovarian biomarkers {AFC and AMH] 3. Ovarian response -provided a previous stimulation cycle was performed. 4 groups based on oocyte quantity and quality described the issue as a ‘poor prognosis’ concept rather than a POR concept ‫البحر‬ ‫اله‬ ABOUBAKR ELNASHAR
  • 5. 450 IU 375 IU 300 IU Tronson & Gardner, 2000 Madany et al, 2012 Dercourt et al, 2016 Haas et al.,2015 Berkkanoglu et al, 2010 Lefebvre et al, 2015 Baker et al, 2015 Friedler et al, 2016 2. GONADOTROPHIN DOSE IN POOR RESPONDERS ABOUBAKR ELNASHAR
  • 6.  Advantages and disadvantages of mild COS: GnT: 150 IU (Alper , Fauser, 2017) ABOUBAKR ELNASHAR Advantages Disadvantages Treatment burden: less Per cycle cancellation rate: higher Risk of OHSS: Reduced Embryos for cryopreservation: Fewer GnT dose: Lower Injections: fewer May require multiple stimulated cycles to achieve pregnancy Per cycle drop out rates: lower Cumulative costs associated with multiple fresh cycles: increased Embryo quality: ±better
  • 8. 3. PROTOCOL Antagonist Vs long agonist Better Griesinger et al, 2006 Franco et al, 2006 No difference Tarlatzis et al, 2003 Sunkara et al, 2007 Pu et al, 2011 Xiao et al, 2013 Nardo et al, 2013 Jeve,Bhandari, 2016 ABOUBAKR ELNASHAR
  • 9.  Advantages of long agonist protocol: 1.Long GnRHa protocol, albeit non-significantly, increased the number of mature oocytes by one oocyte compared to the GnRHan protocol (Sunkara et al. ,2014) . As one more oocyte increases LBR by 5% [Sunkara et al, 2011; De Geyter et al, 2015], 2. Cancellation rate was significantly lower for the long protocol. WHY?: The follicular synchronization obtained after downregulation, which for the expected POR is of utmost importance as these patients usually have increased late luteal FSH levels during their natural cycle, promoting early recruitment of the leading follicle. ABOUBAKR ELNASHAR
  • 10.  The long GnRH agonist protocol should be first line treatment for expected POR, unless a double stimulation is planned for oocyte/embryo accumulation and subsequent frozen thaw embryo transfer. (Ubaldi et al, 2016) ABOUBAKR ELNASHAR
  • 11. Double stimulation 2 Antagonist protocols (with an FSH dose 300IU/d). COS1 started on the 6th day post OCs. COS2 started right after OR1. Triggering: GnRHa in both COS1&2. Similar number of oocytes and blastocysts in COS1 &2 Twice as many oocytes and blastocysts in a 4-week time frame. ABOUBAKR ELNASHAR