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Management of Poor Responders in IVF

Introduction. Before starting ovarian stimulation, a prospective analysis of the ovarian reserve of the patient, definition of the goals of the ovarian stimulation and selection of the correct stimulation protocol are mandatory ( Penzias,2004 ).. Several factors could be associated with ovarian response to ovarian stimulation as reduced ovarian reserve, previous ovarian surgery and pelvic adhesions (Nikolau and Templeton 2003 )..

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Management of Poor Responders in IVF

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    1. Management of Poor Responders in IVF By Ayman Nady Abdelmeged M.D. Lecturer of Obst.&Gyn. Minia University, Egypt. anady@repromed.ca

    3. Several factors could be associated with ovarian response to ovarian stimulation as reduced ovarian reserve, previous ovarian surgery and pelvic adhesions (Nikolau and Templeton 2003 ).

    4. It is of paramount to try to predict poor ovarian response to ovarian stimulation in order to tailor the correct stimulation regimen (Ubaldi et al.,2005 ).

    5. Prevalence The reported prevalence of poor responders amongst patients undergoing ovarian stimulation for IVF is 9 – 24 % (Keay et al.,1997).

    6. Definition Several criteria could be used(controversial) : 1.Number of mature follicles. 2.Number of oocytes retrieved. 3.Peak serum E2 concentration.

    7. 4.Dominant follicles with E2. 5.Dose of Gonadotrophin. 6. Dominant follicles and GnH. 7.Failed slandered ovarian stimulation and at least one cancelled IVF cycle.

    8. Aetiology of Poor Ovarian Response Diminished ovarian reserve. Oocyte quality. Production line hypothesis. Meiotic non disjunction.

    10. Polymorphic FSH receptor. Ovarian antibodies. Aromatase activity. Decreased blood flow. GnSAF bioactivity. Acquired factors.

    11. Prediction for Poor Responders 1.Hormonal assay. 2.Ultrasonography. 3.Dynamic Tests. 4.Tests under research.

    12. 1.Hormonal assay 1.1 Day 3 FSH concentration. 1.2 Basal E2 concentration. 1.3 Inhibin B concentration. 1.4 Anti-mullerian hormone. (Broekmans et al., 2006 )?

    13. 1.1 Day 3 FSH concentration [ Poor Response]

    14. 1.1 Day 3 FSH concentration [ Non Pregnancy]

    15. 1.2 Basal E2 concentration [Poor Response]

    16. 1.2 Basal E2 concentration[Non Pregnancy]

    17. 1.3 Inhibin B concentration [Poor Response]

    18. 1.3 Inhibin B concentration [Non Pregnancy]

    19. 1.4 Anti-mullerian hormone [Poor Response]

    20. 1.4 Anti-mullerian hormone [Non Pregnancy]

    21. 2.Ultrasonography of the ovary 2.1 Antral Follicle Count 2.2 Ovarian Volume (Broekmans et al., 2006 )?

    22. 2.1 Antral Follicle Count [Poor Response]

    23. 2.1 Antral Follicle Count [Non Pregnancy]

    24. 2.2 Ovarian Volume [Poor Response]

    25. 2.2 Ovarian Volume [Non Pregnancy]

    26. 3.Dynamic tests of ovarian reserve 3.1 Clomiphene Citrate Challenge Test. 3.2 Exogenous FSH ORT. 3.3 GnRH Agonist Stimulation Test. (Broekmans et al., 2006 )?

    27. 3.1 Clomiphene Citrate Challenge Test [Poor Response]

    28. 3.1 Clomiphene Citrate Challenge Test [Non Pregnancy]

    29. 3.2 Exogenous FSH ORT [Poor Response]

    30. 3.3 GnRH Agonist Stimulation Test [Poor Response]

    31. 3.3GnRH Agonist Stimulation Test [Non Pregnancy]

    32. Multivariate Models

    33. 4.Prediction Tests under research 1- Surge – attenuating gonadotrophin factor( GnSAF). 2- DNA fingerprints. (Ubaldi et al., 2005 )?

    34. Management of Poor ovarian Response Gonadotrophins. GnRH agonists. GnRH antagonists. Natural cycles. Luteal E2. Growth hormone. L.arginine.

    35. 1.Gonadotrophins (Tarlatzis et al.,2003)

    36. 2.GnRH agonist (Tarlatzis et al.,2003)

    37. 3.GnRH antagonist (Tarlatzis et al.,2004)

    38. 4. Microdose GnRH agonist flare-up versus GnRH antagonist (Kahraman et al., 2008)?

    39. 5. Natural Cycle (Ubaldi et al., 2005 )?

    40. 6.Luteal E2 protocol (Frattareli et al.,2008)?

    41. Conclusion A variety of different stimulation protocols have been suggested,but the lack of any large scale,prospective,randomized,controlled trials of the different management strategies and the lack of uniform definition make it difficult to draw any definitive conclusions.

    42. THANK YOU

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