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Poor Responders – who are they?

Few problems in IVF are more frustrating than the poor responder to gonadotrophin stimulation, most commonly seen in advanced fertile age but also after ovarian surgery, advanced endometriosis, endometriomas, obesity, previous pelvic infection/adhesions, smoking, post-chemotherapy/radiotherapy. Many definitions have been proposed but the most widely accepted definition of a poor response is < 3 eggs retrieved using maximal ovarian stimulation. An anti-Mullerian hormone (AMH) level of <3 pmol/l or antral follicle count of <5 is predictive of low response which, depending on female age, would generally also predict a low chance of pregnancy. An age of >37 years is by far the most important predictor of a low response and consequently a low live birth rate. From this age on there is a steep downward slope in the number of follicles in the cohort available that are able to respond to stimulation. There is a plethora of treatment modalities that have been proposed for the poor responder, bearing witness that none of them have been successful and that you cannot stimulate follicles that aren’t there. Only testosterone patches and letrozole have offered some glimmer of hope for treating the poor responder but evidence is inconsistent and flimsy.

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