Fertility Treatment & Overcoming “Poor Response”
The Center for Human Reproduction’s Dr. Vitaly A Kushnir explains how suboptimal ovarian stimulation during fertility treatment may lead to poor response.
There can be a variety of reasons for why somebody doesn’t produce as many follicles or eggs as was hoped for by the treating physician. Sometimes it’s because they weren’t treated appropriately. For example, they recieved too low of a dose of medications or they were put on a protocall that actually supresses their ovaries before the stimulation ever started. Sometimes we see patients with a low ovarian reserve who have been placed on birth control pills or a long course of generic (?) like Lupron before the treatment was ever even initiated. And we know that this will actually decrease their follicular response and the number of eggs that are obtained, so sometimes it’s just a problem of being placed on a protocall that’s not the optimal protocall for that patient. Sometimes it’s an issue where there’s actually very few follicles remaining in the ovary and no matter how hard you stimulate and how much you stimulate the ovary, you may not get more than one or two eggs. So, it really depends on the specific situation. Sometimes we see patients who have had their ovaries operated on and they don’t respond very well because of this. One of the interesting findings has been though that even in patients who produce very few follicles and eggs, sometimes when you stimulate them repetitively, for example in January, then in February, then in March, what we see is that they tend to have an improving response from cycle to cycle. As long as you do those cycles fairly close together. This has been published recently by our group and I think other groups have made the same observation as well. So, the way you treat these patients when they are undergoing IVF is really critical, because they need to be recognized early on. They need to be put on the appropriate pre-treatment before they even start their IVF cycle. For example, if they have low androgens, we normalize their androgrens with DHEA, and then they need to be put on the appropriate stimulation protocall that will maximize the yield of follicles and eggs. Some practices have a policy where they won’t take anybody for an egg retrieval unless they produce so many follicles. And this is somewhat misguided because young patients, even if you get a few eggs from them, they can have a great pregnancy chance. And sometimes there is no other alternative but to proceed with an egg retrieval. We know now that even older patients who move forward with IVF rather than being cancelled or being converted to an insemination cycle, have much higher chances if you just move forward and get the eggs. So, really the strategy that we pursue is to maximize the egg yield, maximize the quality of the eggs that we can get, and transfer the appropriate number of embryos depending on the patient’s age.