The low response to ovarian stimulation: causes and treatments

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The low response to ovarian stimulation is a problem that occurs between 7 and 24% of patients undergoing in vitro fertilization treatments. This percentage increases if we treat women over 38 years of age, mainly due to ovarian aging and the reduction of ovarian reserve.

Below you have an index with all the points that we will discuss in this article.

Index

The low response to ovarian stimulation: causes and treatments

What is low ovarian response?

The low ovarian response refers to the poor obtaining of mature ovules after follicular puncture in an IVF treatment.

To determine that there is a low response, you have to assess together a number of factors:

The number of follicles in the ovariese observe 5 or less antral follicles by transvaginal ultrasound. Number of ovules recovered from 3 to 5 recovered ovules, although according to the Spanish Fertility Society (SEF) 3 ovules or less are considered. Stimulation protocol is considered low response when a low number of ovules is recovered with FSH doses lower than 3000UI.Concentration of estradiol (E2) lower than 500 pg / ml after following a stimulation protocol.

Low responder woman

A woman is considered to be a low responder when, after having undergone two cycles of ovarian stimulation, she obtains 3 or less follicles in each of them and serum estradiol levels lower than 500 pg / mL on the day of the hCG injection.

This type of women need a continuous emotional support, since there are more possibilities to cancel the cycle and repeat the stimulation treatment a greater number of times. In addition, it would be important to apply a personalized stimulation treatment in the IVF cycle of each patient.

Ovarian age does not correspond exactly with the biological one. There are women who are born with a smaller number of ovules in their ovarian reserve, and others capable of developing a greater number of follicles in each cycle.

How to predict a low response?

Cases of low response are confirmed after ovarian stimulation. However, there is evidence to make an early diagnosis that allows to guide the treatment protocol.

Diagnosis of low ovarian response

There are different factors that can predict the low ovarian response in the patient:

  • Age.
  • Observation by baseline ultrasound of less than 5 preantral follicles.
  • Antimüllerian hormone less than 1 ng / ml.
  • Baseline FSH greater than 10 mIU / ml.
  • Basal estradiol greater than 50 pg / ml.
  • Ratio FSH / LH.
  • Inhibin B: levels below 45 pg / ml are an early sign of ovarian aging.
  • Others: clomiphene test, ovarian volume.
  • Having had a previous cycle with low ovarian response.
High FSH values ??not only predict a low response, but also predict poor oocyte quality, which decreases the pregnancy rate and increases the abortion rate.

Causes of low response

The main causes of low ovarian response are the following:

  • Age: factor inversely related to the ovarian reserve. The older the younger the number of ovules.
  • Autoimmune process: FSH receptors in granulosa cells blocked by antibodies.
  • Reduction of ovarian mass due to surgery or endometriosis.
  • Aging of the ovary

You can consult how to measure the ovarian reserve in the following post: Ovarian reserve test.

Consequences of low response in an IVF cycle

The purpose of an IVF treatment is to provoke a controlled ovarian stimulation that allows recovering a sufficient number of ovules and reach the transfer of at least one embryo.

That is why the low response has unintended consequences, since you get a low number of ovules to fertilize and decreases the probability of pregnancy, with the added risk of canceling the transfer of embryos.

In addition to this, there is usually a worsening of the quality of the ovules that compromises the survival of the embryos in the laboratory, which aggravates the situation of these women.

Cancellation of embryo transfer

In the following article you can read more about this topic: How many ovules do you need to get for IVF?

Solution for low responders

Fortunately, there are several options and alternatives for women with low ovarian response.

Pretreatment with androgens

After having a cycle with low response, you can try pretreatment with androgens to get a greater number of follicles in the stimulation.

These treatments can be with transdermal testosterone or with DHEA, although their effectiveness in these cases is not proven.

Conversion of an IVF cycle into an AI cycle

In case of observing the development of only 1 or 2 follicles by ultrasound, the possibility of converting the IVF cycle into an artificial insemination cycle can be considered, evaluating the rest of the factors and provided that there is no severe male factor.

Modified ovarian stimulation protocols

In these patients it is always tried to offer a more personalized treatment in order to obtain the greatest possible number of ovules.

The short protocol with agonists of the GnRH known as flare-up offers better results in the low responders, since it avoids the deep ovarian suppression of the long treatment and takes advantage of the flare-up effect.

Flare-up: immediate release of FSH and LH at the beginning of treatment, whose effect is added to that of hormones administered exogenously.

Accumulation of ovules with vitrification cycles

In order to obtain a greater number of ovules in the laboratory that increase the probability of obtaining quality embryos for the transfer, several cycles of ovule accumulation are carried out. These consist of vitrifying all the ovules obtained in each cycle until reaching an optimal number. It is then when they devitrify, join with those obtained in the last puncture, and an ICSI is performed to fertilize them.

Accumulation of ovules for women with low ovarian response

Ovodonation

When several IVF cycles have been canceled due to the low response, the most successful alternative is the donation of ovules, where a young woman donates her eggs to another and these are fertilized by the sperm of the husband of the recipient woman.

Given the delay of motherhood, egg donation is widely used in all assisted reproduction clinics since, as the woman ages, the quality of her own eggs is very low. For this reason, to become a mother, you need the ovules of a young woman if you have not previously preserved your eggs.

You can obtain more information about oocyte donation in the following link: Egg donation or ovodonation.

Discounts on assisted reproduction

Low responding women have to face another, no less important challenge to achieve pregnancy. We refer to the large economic outlay that involves having to complete several cycles of IVF.

An IVF treatment costs approximately ? 3,000-5,000, plus medication that is not usually included. If after several failed cycles it is decided to opt for ovodonation, the price may rise to ? 4,500-9,000.

In Assisted Reproduction ORG we want to help you achieve pregnancy and that these techniques can be available to a greater number of people. Therefore, we have reached agreements with many Spanish clinics so that you have a special price in your treatment.

In our Discount Section you can get a free first visit to the center you choose to go to inform you without commitment of the most appropriate treatment to achieve pregnancy.

You will also find all the discounts that you can access with the download of the discount coupons. You have them below:

  • See discounts for IVF
  • See discounts for IVF with ovodonation

In each discount coupon you have detailed all the techniques included in the price of the treatment. It is important that you check this because some coupons do not include vitrification or frozen embryo maintenance.

Some clinics offer discounts starting in the second or third cycle. It is important to ask this, especially in the case of low respondents.

Questions from users

What are the chances of a natural pregnancy with a low ovarian response?

Women with low ovarian response are women who have already gone to an assisted reproduction clinic because they have not achieved a natural pregnancy. Therefore, this possibility is low, probably due to the decrease in ovarian reserve and aging.

Would PGD be a possible solution for low ovarian response?

No, PGD is a method to detect genetic abnormalities in embryos. Therefore, it is not an advantage for women who obtain few eggs to fertilize. You can know what the DGP consists of in the following link: What is the preimplantation genetic diagnosis or PGD?

Is the Omifin recommended for low responders?

Yes, Omifin is a drug composed of clomiphene citrate that can be used as adjuvant treatment. The advantages are the following:

  • It allows a moderate follicular growth.
  • There is no blockage of endogenous FSH and LH.
  • It allows the stable and progressive increase in estradiol levels.
  • The number of injections in the patient is lower.
  • The cost is cheaper.

Is the natural cycle a good option for low responders?

The natural cycle consists of follicular development without ovarian stimulation and the programming of the puncture. There are some clinics that opt ??for this method in low-response women since, although only the development of a follicle in the ovary is achieved, a good quality embryo is usually obtained and the endometrial preparation is better. It has the disadvantage of the high probability of cancellation by spontaneous ovulation.

Recommended reading

Controlled ovarian stimulation is the previous step in all IVF treatments. If you want to know what it is step by step, here you have all the information: Ovarian stimulation: process, medicines and symptoms.

We have talked about GnRH agonists as an adequate treatment for low responders. You can obtain more information about its indications, advantages and disadvantages in the following link: GnRH analogues.

The opposite of the low ovarian response is the high response or ovarian hyperstimulation syndrome. You can know what it is by reading the following article: Ovarian hyperstimulation syndrome.


freezing of early cleavage embryos in Murcia(Spain)

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