POOR RESPONDERS DURING IVF STIMULATION

1. POOR RESPONDERS
- Dr. Meenakshi Vempalli
MS OG, DNB OG,
Dept of Reproductive Medicine, CIMAR.

2. • Reduction in follicular response  retrieval of low
number of oocytes despite adequate ovarian
stimulation in an ART cycle.
• Prevalence of poor ovarian response among patients
undergoing IVF treatment is 9-24% ( Keay et
al,1997)
• Wide range – initial lack of consensus when defining
POR.
• Systematic review – 47 studies performed in POR
patients, 41 different definitions with differences in
criteria used for definition& values for each
criterion.

3. • BOLOGNA CRITERIA by ESHRE IN 2011:
Poor Ovarian Response (POR) -presence of any two of three :
Advanced maternal age (≥40 years) or any
other risk factor for POR
Previous POR ( ≤3 oocytes with conventional
stimulation protocol)
Abnormal ovarian reserve test (ORT)
( AFC: <5-7 follicles and/or AMH :<1.1 ng/mL)
1.
2.
3.

4. • All patients above 40 years with abnormal ORT – Poor
responders
• Two episodes of POR after maximal stimulation in the
absence of advanced maternal age or abnormal ORT.
• Atleast one stimulated cycle – diagnosis of POR.

6. Why is Bologna criteria not ideal ?
• Heterogeneity of subgroups due to absence of homogenous
subgroups for LBRs

7. • Specific profiles of abnormal ovarian response like hypo and
suboptimal response not being included

8. • Age related aneuploidies affecting oocyte quality.
• Munne et al – euploidy rate independent of number of
blastocysts but not of the age. Hence, good quality
blastocysts could be aneuploid.
• In 2016, a panel of fertility experts, NEW
CLASSIFICATION – POSEIDON – Patient –Oriented
Strategies Encompassing IndividualiseD Oocyte Number
working group.

9. • Group 1
• Young patients < 35 years with adequate OR (AFC≥5, AMH
≥1.2ng/mL) & with unexpected poor or suboptimal ovarian
response.
SUBGROUP 1a • Less than 4 oocytes
SUBGROUP 1b • 4-9 oocytes retrieved
• After standard ovarian stimulation

10. • Group 2
• Older patients more than or equal to 35 years with adequate
OR (AFC≥5, AMH ≥1.2 ng/mL) & with unexpected poor or
suboptimal ovarian response.
SUBGROUP 2a • Less than 4 oocytes
SUBGROUP 2b • 4-9 oocytes retrieved
• After standard ovarian stimulation

11. • Group 3
Young patients (<35years) with poor ovarian reserve
prestimulation parameters ( AFC ≤ 5 , AMH ≤ 1.2 ng/mL)
• Group 4
Older patients (≥35years) with poor ovarian reserve
prestimulation parameters ( AFC ≤ 5 , AMH ≤ 1.2 ng/mL)
• Not only to consider patients with DOR as poor responders
& also patients with normal ovarian reserve who are
hyporesponders.

12. bh
Women with good ovarian reserve still has poor response or
vice versa.

13. • Group 1&2 – Hyporesponders. Hyposensitivity to FSH &
show suboptimal or unexpected poor response to exogenous
FSH.
• NO WAY TO RELATED TO OVARIAN RESERVE.
(>5 eggs, increase in FSH dose & stimulation length).
• These normo ovulatory normogonadotropic young patients
have initial poor/slow reponse to r-FSH – normal follicular
cohort with no follicle >10mm on D8 of stimulation or
stagnation between D7 & D10. (hyposensitivity of granulosa
cells to standard FSH dose).

14. • Environmental contaminants affects ovarian response during
OS.
• Alviggi et al – elevated intrafollicular levels of benzene –
decreased oocytes retrieved & embryos available for
transfer.
• Benzene – transduction deficiency in FSHR.
• In another study, Polychlorinated biphenyl congeners (PBC)
in follicular fluid associated with decreased ovarian
response during OS.
• Oxidative stress- affects folliculogenesis &
spermatogenesis.
• Increase in free radicals ( ROS) influences quality of
oocytes, spermatozoa, embryos & therefore negatively
affect ART outcome.

15. POSEIDON group – POR as low prognosis group

17. • PREDICTION OF POOR RESPONDERS
Markers of Ovarian reserve for prediction of poor response:
• Age >40 years
• 4-6 months of oligomenorrhoea
• FSH> 25 IU/L at two occasions > 4 weeks apart or once
accompanied by <100pmol/L E2 during COS
• AMH < 0.35 ng/mL
• Day 3 Inhibin < 45 pg/mL
• Low testosterone < 0.51 nmol/L
• TVS – AFC < 5-6 ; ovarian volume <3cmз
Of these, AFC & AMH – high sensitivity & specificity. Both
decrease with age. AFC cut off :≤ 10

19. Ovarian volume correlates with number of growing follicles not
with number of oocytes retrieved
(small ovaries with volume < 3cm₃, high cancellation in IVF cycles,
little prognostic value if LBR is considered)
AMH & DOR – cut off 0.99ng/mL.
• AMH & AFC combined test – did not improve level of prediction
of POR.
• Gives information about primordial follicular pool. Not a panacea
in determining DOR ( discordance between AMH & AFC).
• AMH sample instability – nonreproducibility & sample storage.

20. Day 3 FSH:
• Indirect measure of size of follicle cohort & reflects decreased
granulosa cell function.
• Doesn’t diagnose DOR until high levels are reached & high levels
do not correlate with oocyte quality decline.
• Intercycle and intersample variations .
• ELEVATED DAY 3 FSH-heterogenous group -true reduced
ovarian reserve or presence of heterophilic antibodies or FSH
receptor polymorphism in otherwise normal ovaries.
• PRs higher with normal FSH & age < 36 years.
• Elevated day 3 FSH/LH RATIO –decreased outcome in IVF
cycles.
• With 3 variable model ( FSH, AMH, AFC ), misdiagnosed patients
is almost halved compared to best single variable model of AFC.

21. Day 2 Serum Estradiol :
• Elevated levels > 75-80 pg/mL – inappropriately advanced
stage of follicular development, consistent with DOR,
ovarian aging, presence of functional ovarian cysts.
Inhibin B:
• In predicting DOR- sensitivity – 87%, specificity 49%.
• Cut off 45 pg/mL as threshold for DOR, positive likelihood
ratio of DOR is 1.7. Low levels in obese women.
• Better predictor of cancellation of cycles than ovarian
reserve.

22. CCCT
Reveals poor responders to COS.
EFORT & GAST – only for research purpose.
ANDROGENS IN PREDICTION OF DOR :
• DHEAS – not significantly different between poor & normal
responders or between pregnant & non pregnant.
• Lower basal testosterone is predictive but limited ability as
a single marker for DOR.
• Apart from age, AMH & AFC – better predictive values of
DOR
• AGE - better predictor of PR in women undergoing IVF.

23. Measure of success according to POSEIDON Concept:
The concept of ‘ the more the better’ & ‘ one more oocyte
matters’ – particularly valid for POR patients.
Two tools – To assess & increase probability of having atleast
one euploid blastocyst :
1) FOLLICLE TO OOCYTE INDEX( FOI)
2) ART Calculator

27. MANAGEMENT OF POOR RESPONDERS
POSEIDON 1 & 2 :
• 5% and 35% are Groups 1 & 2 respectively.
5 main strategies :
1)Use of rFSH over urinary gonadotropins
2)FSH dosage increase
3)Use of rLH
4)DHEA supplementation before OS
5)Double- stimulation protocol (DuoStim)

28. USE OF rFSH
• Multiple RCTs & meta analysis – Use of rFSH – more oocytes
retrieved compared to urinary FSH formulations ( both in
GnRH agonist and antagonist cycles)
• This is related to higher biopotency of recombinant
formulations.
• So, stimulation with recombinant formulations ( r-FSH)
should be considered in POSEIDON Group 1 & 2.

29. FSH Dose Increase
• Increasing FSH dose in patients with h/o suboptimal
response – commonly used strategy.
• This strategy used to even rescue ongoing OS in women with
slow intial response to gonadotropins.
• Drakopoulos et al in his study of 160 women with normal
ovarian reserve & h/o suboptimal response ( 4-9 oocytes
retrieved) received increase in rFSH in subsequent fixed
GnRH antagonist co-treated cycle.
• A significantly higher no. of oocytes ( 9 vs 6 , p< 0.001) and
good quality embryos ( 4 vs 3, p< 0.001 ) was retrieved
compared to previous cycle.

30. • An increase in 50IU of initial rFSH lead to retrieval of one
more oocyte.
• Even patients with FSH polymorphisms seems to benefit
with increase in rFSH dosage .
• Behre et al, randomised Ser680/Ser680 carriers to receive
a daily dose of 150IU or 225IU.
• 225IU/ day dose was able to restore estradiol levels of
Ser680/Ser680 carriers similar to those women with wild
type genotype at the end of stimulation.
• In conclusion, increasing r-FSH dose are effective in
POSEIDON 1& 2 patients.

31. rLH supplementation
• Adding rLH as of days 7-10 to rescue an ongoing ‘’slow’’
stimulation cycle more efficient than increasing dose of rFSH.
• De Placido et al in an RCT, following long GnRHa downregulation
protocol in 260 women started dose of 225IU rFSH, 10 patients
showed slow response- Serum estradiol < 180ng/mL & follicles <
10 mm in dm on D8 of stimulation .
• On this day, patients were randomised to receive either rLH in
addition to rFSH or to have an increase in rFSH dose of another
150IU.
• No. of oocytes retrieved was higher in patients who received rLH
( 9.0 ± 4.3) compared to those who had increase in rFSH dosage (
6.1±2.6, p < 0.01).

32. • IR ( 14.2% vs 18.1%, p <0.05) & ongoing PR( 32.5% vs 40.2%)
similar to those observed in control group, consisting of
normal responders.
• RCT by Yilmaz et al in which hyporesponders to OS were
identified using same criteria as in De Placido et al.
• Patients randomised to receive either supplementation with
75 IU rLH or increase of 75IU in rFSH dose.
• PR were higher in rLH supplementation (57.8%) & control
(64.7%) groups compared to increased rFSH group (32.4%,
p< 0.02).

33. • As for LH dosage, 150 IU rLH is superior to 75IU rLH when
long GnRHa protocol is used. ( RCT – hyporesponders were
randomised to receive 150 IU or 75IU of rLH. Patient who
received 150 IU rLH had higher no. of oocytes retrieved
than those with 75IU rLH( 9.65± 2.16 vs 6.39±1.53, p< 0.05).
• The beneficial effect of adding rLH to OS until now was
shown only in studies using long GnRHa protocol & no data of
adding it in GnRH antagonist cycles in patients with
hyporesponses to rFSH only.

34. • Excessive suppression of endogenous LH after
downregulation with GnRH analogue
• Polymorphism in LH molecule ( LH β chain variant) reducing
bioactivity of molecule or polymorphisms of LH receptor.
• Alviggi et al reported that carriers of LH β chain variant
had ovarian resistance to exogenous gonadotropins &
required higher doses of rFSH during OS. This
polymorphism is common worldwide with carrier frequency
ranging from 0 to 52% depending on ethnicity.

35. • Recent systematic review & meta analysis – showed that
adding r-LH to OS protocol is beneficial in two subgroup of
patients :
i) women with adequate ovarian reserve having unexpected
hyporesponse to rFSH monotherapy ie, POSEIDON groups 1
& 2
ii) patients 36-39 years of age
• Therefore adding rLH to OS in POSEIDON groups 1 & 2
should be considered, starting with 75-150IU rLH either on
days 7-10 of stimulation in an attempt to rescue ongoing
hyporesponse or from day 1 of stimulation in subsequent
cycle to increase no. of folliclesoocytes.

36. DHEA SUPPLEMENTATION
• According to Cochrane meta analysis, pretreatment with DHEA
before OS  improves birth rate in POR & patients with
advanced age.
• As a precursor of testosterone, DHEA supplementation –
counterbalances the impaired theca function & androgen
production observed in women with advanced age.
• Tartagni et al conducted RCT in 109 women fulfilling POSEIDON
group 2 criteria, randomised to receive 75mg/day DHEA
supplementation or placebo for a total of 8 weeks before
starting OS.
• Patient receiving DHEA had higher LBR ( 22/53 vs 18/53 , p <
0.05).

37. • In another RCT, Moawad et al had similar beneficial effect
in patients who received DHEA of 75mg/day for 12 weeks
prior to OS compared to no treatment.
• Thus , ongoing PR higher (11/58 vs 7/47 , p< 0.05) in patients
who received DHEA pretreament.

38. Double Stimulation
• DuoStim combines conventional follicular phase stimulation with
luteal phase stimulation during same cycle.
• AIM: Maximise number of oocytes obtained per cycle.
• A large multicentre study showed comparable fertilisation ,
blastocyst, euploidy, PR from follicular phase stimulation & luteal
phase stimulation.
• Rate of patients obtaining atleast one euploid blastocyst
significantly increased from 42.3 % after follicular phase
simulation only to 65.5% with DuoStim.
• Hence it’s a promising strategy for patients who had
unexpectedly poor response to stimulation during their follicular
phase stimulation.

39. Dual Stimulation

41. CONCLUSION-Clinical management of
POSEIDON Groups 1 & 2
• These two groups respond unexpectedly poorly to OS despite
good ovarian reserve.
• Main difference between these two groups of patients is their
age – consequently difference in oocyte euploidy and thus LBR.
• Group 1 – better prognosis due to age related lower oocyte
aneuploidy rate.
• Group2 – Although older with age related higher oocyte
aneuploidy , still have good chance of getting estimated no. of
oocytes needed for one euploid blastocyst.
• For both groups, this is achieved by increasing dosage of rFSH,
rLH supplementation , DuoStim protocol.

42. POSEIDON Groups 3& 4
Constitutes 10% and 55% .
Group 4 – has poor prognosis
Strategies:
1) Choosing appropriate individualised stimulation protocol
2) Individualising ovulation trigger strategy
3) Adjuvant treatment to OS or prior to initiation of OS

43. STIMULATION PROTOCOLS:
• Previously, it was suggested that natural cycle IVF or
mild stimulation would be more optimal for the
Poseidon group 3 and 4 patients when compared to
coventional OS, as ovarian stimulation with high-dose
exogenous gonadotropins was thought to increase the
aneuploidy rates of oocytes and embryos.
• However, abundant recent scientific evidence does not
support this concern.
• Very low live birth rates per cycle of 2.6% have been
reported in Bologna POR patients undergoing natural
cycle IVF

44. • In contrast, an 11% live birth rate per cycle was reported
in the until now largest RCT including Bologna POR patients,
using a GnRH agonist long protocol and 300 IU rFSH in
combination with 150 IU rLH daily from day one of
stimulation.
• Furthermore, recently, a 20% ongoing pregnancy rate was
reported in poor ovarian reserve patients using follicular as
well as luteal phase stimulation(DuoStim).
• To conclude, ovarian stimulation with exogenous
gonadotropin stimulation at a maximum of 300 rFSH should
be used rather than natural cycle IVF in POSEIDON
groups 3 and 4 patients.

45. • As for the choice of the stimulation protocol, Sunkara et al.
reported a non-significant increase in the number of mature
oocytes by one oocyte, and a signficant decrease in
cancellation rates when a long GnRH agonist protocol was
used in patients with POR compared to a GnRH antagonist
protocol.
• This increase in oocyte yield is most probably caused by
follicular synchronization obtained after downregulation,
which is crucial for POSEIDON groups 3 and 4 patients, as
they usually have increased luteal phase FSH, promoting
early recruitment of the leading follicle, and subsequently
the suppression of those other few follicles left in the
ovaries

46. • Importantly, one more oocyte increases the live birth rate
by 5%, making the long GnRH agonist protocol the preferred
stimulation for expected POR.
• However, the inhibitory effect of late luteal phase
endogenous FSH and thus early recruitment can also be
achieved in GnRH antagonist cycles by a 5-day treatment
with estradiol 4mg, daily prior to menses, or oral
contraceptives for 12-16 days, followed by a 5-day wash-out
period.

47. • When pretreatment with estrogen or oral contraceptives
was compared to a long GnRH agonist protocol in two RCTs,
there was no difference in the duration of stimulation, FSH
consumption, number of embryos obtained, and pregnancy
rates.
• Moreover, double stimulation(DuoStim)might be considered
to accumulate the number of blastocysts needed to increase
the probability of having atleast one euploid blastocyst for
subsequent frozen thaw embryo transfer.
• Vaiarelli et al. reported that a single DuoStim cycle in poor
prognosis patients, essentially POSEIDON group 4 patients,
resulted in 65.5% of patients having atleast one eulpoid
blastocyst for transfer.

48. • Moreover, there was no difference in the ongoing pregnancy
rate per single euploid blastocyct transfer between
blastocysts obtained from the follicular phase and those
obtained from the luteal phase stimulation, which were
39.5% and 49.4% respectively.
• In POSEIDON group 4 patients, an ongoing pregnancy rate
per DuoStim of 20.7% can be considered highly successful in
this challenging group.

49. • Recombinant FSH is the preferred choice of gonadotropins
in POR patients, and there is ample high-quality evidence
showing that rFSH is superior to urinary FSH and human
menopausal gonadotropin (hMG) as a means to increase the
oocyte yield.
• This is crucial, since the POSEIDON criteria of success
relies on oocyte numbers to increase the chances of having
at least one euploid blastocyst for transfer.
• As mentioned previously, the recommended maximum daily
dose of rFSH is 300 IU, as higher doses do not increase
neither the clinical pregnancy rate nor the live birth rate.

50. • Corifollitropin alpha , long acting rFSH has the advantage of a
rapid increase in FSH serum level, which leads to early
recruitment and an increase in the number of pre-ovulatory
follicles.
• In a RCT, including Bologna POR patients, Corifollitropin alfa did
not increase the pregnancy rate compared to rFSH; however,
significantly more embryos were available for freezing, which is
likely to increase the CLBR by increasing the chance of having at
least one euploid embryo for transfer.
• Finally, two systematic reviews suggested that rLH
supplementation during OS is beneficial in women with
hyporesponse to exogenous FSH-only stimulation and specifically
in women aged 36-39 years.
• Humaidan et al. published the largest RCT in poor prognosis
patients aligned with the POSEIDON group 4 patients.

51. • A total of 939 patients were randomised to either a fixed
daily dose of 300 IU rFSH and 150IU rLH or rFSH 300 IU
alone.
• There was no significant difference in LBR between the two
groups.
• However, a post hoc analysis, stratifying patients into mild,
moderate, and severe POR , showed that moderate and
severe POR patients had a significantly higher LBR and a
lower pregnancy loss rate when 150 IU rLH was added to
the stimulation protocol from day one of stimulation.
• Thus, physiological as well as clinical evidence suggests a
beneficial effect of rLH supplementation in the POSEIDON
group 4 patients.

52. Ovulation Trigger
• In addition to individualised OS, Individualised OT strategy
increases mature oocyte yield.
• Low FOI- Mutations of LH receptor – which might be improved
by OT strategies.
• Final oocyte maturation & ovulation trigger – hCG
• GnRH agonist trigger used in GnRH antagonist cycles to prevent
OHSS in OHSS risk patients.
• LBR using GnRHa trigger is comparable to hCG provided modified
luteal phase support is applied.
• Two RCTs- Increase in no. of good quality embryos after GnRHa
trigger compared to hCG trigger. This is because GnRHa trigger
leads to surge of endogenous LH & FSH , adding further
physiological benefit for activation of oocyte maturation.

53. • Two new OT strategies – dual trigger and double trigger.
• Dual trigger – Both GnRHa and Low dose hCG are
administered simultaneously
• Double trigger – GnRHa and hCG are administered at 40 and
34 h prior to oocyte pick up.
• Both strategies combine advantages of GnRHa and hCG in
terms of LH activity & early phase luteal support mediated
by hCG & endogenous secretion of LH & FSH mediated by
GnRHa.
• In addition, a double trigger might increase maturity rate of
retrieved oocytes in some patients who need longer interval
between OT & oocyte retrieval to allow for the cumulus to
expand & detachment of oocyte.

54. Adjuvants
Low dose aspirin
• Improves gonadotropin responsiveness, implantation rates &
PRs due to enhanced blood flow to ovaries.( Rubintein et al,
1999)
• In women undergoing IVF- poor & controversial ( Nardo et
al,2009).
• Revelli et al , 2008 – Low dose aspirin plus prednisolone – no
beneficial effects.

55. Transdermal testosterone
• Increases intraovarian androgen concentration.
• Induces FSH receptors on granulosa cells increase in
recruitability & growth of pre antral and antral follicles
through insulin like growth factor 1 (IGF-1).
• Pretreament – decreased duration & total dose of
gonadotropins & increased number of COC retrieved-
increases CPR by 15% & LBR by 11%.
• Bosdou et al in 2016- did not increase number of COCs &
LBRs.
• International clinical trial TTRANSPORT TRAIL for Bologna
POR patients evaluates daily dose of 5.5mg transdermal
testosterone as pre treatment for 60 days & results of this
might provide further evidence for use of androgens in
POSEIDON group 3 & 4.

56. Growth hormone
• Enhances response of granulosa cells to gonadotropins
• Increased local production of IGF-1, modulates action of FSH on
granulosa cells, improves ovarian steroidogenesis.
• Induces LH receptor formation, augments aromatase activity.
• Dose : 8-12 IU/ day from D2 OR 3 along with gonadotropins till
hCG .
• Bassiouny et al,2014 – increase in oocytes collected, MII
oocytes, more ETs, More LBRs. Despite this, no statistical
significance. Cost should be kept in mind.
Growth Hormone releasing Factor (GHRF)
• Increases GH & IGF-1.

57. Antioxidants
• Oxidative stress- cause of female infertility due to ROS.
• Oxidative stress & increased ROS- oocyte maturation,
ovarian steroidogenesis, formation of corpus luteum&
luteolysis, fertilisation, embryo development, pregnancy.
• Oxidative damage affects oocyte quality, poor oocyte
fertilisation.
• Antioxidant therapy 3 months before IVF cycles decreases
oxidative stress both in serum & follicular fluid proteins,
improve follicular microenvironment, increases number of
good quality oocytes.

58. Coenzyme Q10
• Reduction of mitochondrial oxidative stress improving
oocyte competence.
• Recent RCT assessed effectiveness of CoQ 10 pretreatment
for 60 days prior to OS in POSEIDON group 3 patients,
reporting increase in no. of oocytes retrieved in CoQ 10
supplemented group compared to controls.
• In addition, CoQ 10 group had more high quality day 3
embryos assessed by cytoplasmic fragmentation & size of
blastomeres.

60. CONCLUSION-Clinical management of
POSEIDON Groups 3& 4
• These two groups- low reproductive prognosis & pose a
clinical challenge.
• Current best practise is to individualise OS for better
oocyte yield & LBR.
• Even increasing oocyte yield from 2 to 3  25% relative
increase in LBR across all age groups.
• Ongoing pregnancy rates > 20% per cycle of DuoStim in
these difficult groups – successful achievement.

61. • On a more experimental basis, future management of
expected POR might include in vitro follicle activation , to
improve IR & quality of embryos & development of oocytes
from stem cells.

62. Newer treatment modalities
• Ovarian Fragmentation and In Vitro Activation
Promotes follicle growth through different mechanisms.
• Kawamura et al – fragmentation of ovaries promoted actin
polymerization & disrupted ovarian Hippo signaling –
increased expression of downstream growth factors,
promotion of follicle growth & generation of mature oocytes.
• Additional follicle growth when ovarian fragmentation
combined with Akt stimulator treatment followed by
autografting.

64. Preimplantation Genetic Screening for
Poor Responders
• Chance of aneuploidy is higher as they are old or have low
ovarian reserve. PGS – identifies euploid embryo for
transfer, optimising treatment outcome.
• Despite increased implantation rate, studies have not shown
increased LBRs.

65. Conclusion
• POR patient – Major challenge in RM.
• POSEIDON – 4 homogenous groups- better understanding of
different subgroups, better individualised treatment regimens.
• UNEXPECTED POR PATIENTS WITH GOOD OVARIAN
RESERVE – Group 1 (<35 years) and 2 (≥ 35 years)
• EXPECTED POR PATIENTS WITH LOW OVARIAN RESERVE –
Group 3 (<35 years) and 4 (≥ 35 years)
• PRIMARY GOAL OF MANAGEMENT OF POR PATIENT –
Maximise oocyte yield  atleast one euploid embryo for transfer
• This demands individualised approach at all steps.
• FOI & ART Calculator – help counsel patients regarding
reproductive prognosis.

66. • With this approach, even very poor prognosis patient in
POSEIDON Group 4 may achieve PR of > 20 % per cycle
(DuoStim).
• POSEIDON Groups 1&2 – need to be studied separately
from POSEIDON groups 3&4.

67. Thank you