Best IVF Stimulation For Low Ovarian Reserve

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Ageing is a natural process which happens in all organs of the body, including our reproductive organs. With age the eggs in the woman’s ovaries are depleted, she stops menstruating and she is said to have attained menopause.

On the other hand, some women undergo this process of ovarian ageing even before the expected age of menopause (before 40 years). Both these are important causes of infertility in women. Here we are addressing the most common questions about low ovarian reserve and premature ovarian insufficiency which is often called POI.

What is low ovarian reserve?

Every woman is born with a certain fixed number of eggs in her ovaries and unlike other body cells which grows with age, number of eggs does not increase with age. In reality throughout her lifetime egg cells are degenerated with age and until menopause almost all her eggs are exhausted.

This is a normal phenomenon in women. If a woman has a smaller number of eggs in her ovary, it is said that she has low ovarian reserve. It is an important factor in female fertility.

Is low ovarian reserve same as POI or primary ovarian insufficiency?

Having low ovarian reserve and primary ovarian insufficiency both indicate poor female fertility, but they are not exactly the same.

Low ovarian reserve is diagnosed by abnormal ovarian reserve testing using a variety of methods such as:

Elevated-but-not-menopausal level basal follicle-stimulating hormone [FSH] levels
Low anti-mullerian hormone [AMH]
Low antral follicle count [AFC] – as seen by ultrasonogram
A failed clomiphene citrate challenge test – not responding well to clomiphene citrate (a drug used for ovarian simulations) among women who are still having regular periods.

POI is a condition of premature-ovarian-aging with stopping of menses, mostly before 40 years of age. But up to 5-10% women with this condition sometimes spontaneously have follicular development (growth of eggs), might experience return of menses and sometimes even conceive after the diagnosis is made.

Is there any difference in IVF protocol for patients with low ovarian reserve?

IVF protocols are nothing but various hormone and drugs given to stimulate the ovaries during infertility treatment. The aim of the ovarian stimulation drugs are to produce multiple ovarian follicles or eggs during an IVF treatment cycle. These drugs are chosen based on the patient’s health and fertility condition.

Though there is no one perfect protocol for low ovarian reserve, but following additional medications and hormones can be given to improve IVF outcome. Such additional medications can be explored by your fertility doctor to improve the result of an IVF cycle:

GnRH analogues
Androgens
Growth hormone co-treatment
Natural cycle or modified natural cycle
High dose gonadotropins
Glucocorticoids
Coenzyme Q10 supplementation
Autologous Platelet-Rich Plasma – Ovarian Rejuvenation
Combination of the above

Is there any role of naturopathy or alternative medicine in improving ovarian stimulation response in low ovarian reserve patients?

Some studies have shown that acupuncture and holistic medicines have shown optimistic results when it comes to low ovarian reserve patients.

What does the term poor responder mean?

POR or poor responder refers to a woman who exhibits a suboptimal response to the stimulation drugs administered to enhance her ovarian function during an IVF cycle. The term ‘Poor responder’ is clinically defined by the presence of at least two of the following three characteristics:

When a woman is 40 years of age or older.
When a woman has experienced a previous IVF cycle cancellation due to an insufficient number of expected follicles.
An abnormal result on an ovarian reserve test (as described above).

What is the best IVF protocol for low ovarian reserve or diminished ovarian reserve?

There is a lack of conclusive evidence regarding the superiority of specific IVF protocols for cases of low or diminished ovarian reserve. There continues to be an ongoing debate on which protocol yields better outcomes. Options include a long agonist/antagonist protocol for controlled ovarian stimulation, possibly with additional adjuvant medications or hormonal support. Alternatively, ovarian rejuvenation therapy or even IVF with donor eggs may be considered if high-quality eggs are not naturally produced. The choice of treatment is typically tailored to the individual’s fertility status and specific concerns.

Are there any fertility clinics that specialize in treatment for women with low ovarian reserve?

Seeking fertility treatment at fertility clinics with a proven track record in assisting women with poor ovarian reserve is crucial. The greater the experience of the IVF centre in dealing with patients with low ovarian reserve, the more favourable the expected outcomes. Patients with low ovarian reserve usually do not have too much time on their hands to try out different options, hence it becomes imperative that they take an informed decision to undergo the IVF cycle with the most suited IVF Protocol so that the IVF result is not compromised.

What is the best IVF stimulation protocol for women with low ovarian reserve?

A variety of options exist for improving the oocyte yield or in simpler words, the number of eggs retrieved during an IVF cycle. Some of the options include nutritional supplements started before the actual IVF stimulation and using a mild stimulation protocol (using a lower dose of hormones) for stimulating the ovaries. It is important to choose the right stimulation protocol based on the person’s ovarian reserve, age and other health parameters.

What is the typical IVF success rates for women with low AMH or low ovarian reserve?

The usual success rate of infertility treatment for women with low ovarian reserve is lower compared to those with normal ovarian reserve. This is primarily due to a reduced number of retrievable eggs, often accompanied by compromised egg quality. Research indicates that the live birth rate, which estimates the chances of having a live-born baby, in patients with premature ovarian insufficiency (POI) and poor ovarian reserve (POR) typically ranges from less than 1% to 10% per cycle of IVF stimulation.

Is there any benefit in starting any oral supplement in patients with poor ovarian reserve ?

Maintaining a healthy lifestyle during infertility treatment is crucial, which includes a balanced and nutritious diet, regular exercise, good sleep and abstaining from addictive substances. Additionally, incorporating proven oral supplements can enhance the treatment’s effectiveness. These may include:

DHEA
Coenzyme Q10
Evening primrose oil
Inositol
Vitamin D

Does ovarian rejuvenation therapy help patients with poor ovarian reserve?

Ovarian rejuvenation therapy is a newer technique of reviving the ovarian function to improve the number of eggs retrieved in women with low ovarian reserve. It has shown promising results, but it is still in experimental phase. For more information on ovarian rejuvenation, do check out our blog about it.

Is there any perfect embryo transfer strategy for patients with low ovarian reserve?

Freeze All strategy of embryo transfer, where all embryos created during the IVF cycle are stored and transferred after the current IVF cycle has ended, has shown good results in low ovarian reserve patients. In other words, the embryos are not transferred to the uterus in the same cycle during which eggs are harvested by OPU. The embryos are frozen and can be transferred during subsequent cycle depending on patient comfort.

What is embryo pooling?

Embryo pooling is a technique in IVF (In Vitro Fertilization) where embryos from multiple IVF cycles are combined and frozen together. This can be done for several reasons:

Better embryo selection: It allows for the selection of the best embryos from different cycles for transfer.
Reducing the cost and stress of repeated embryo transfer: Since Embryo Pooling involves saving embryos from multiple cycle and then transferring the best of the lot, it involves lesser attempts of embryo transfer reducing the emotional stress of having to go through multiple failures.
Planning for second baby : Patients with diminished ovarian reserve may wish to safeguard their future chances of pregnancy after the current one by undergoing ovarian stimulation while they are still young and then transfer the embryos when they plan for their second baby.

How does embryo pooling help in case of low ovarian reserve woman?

Women with low ovarian reserve mostly belong to higher age group and as we know age impacts the quality of the eggs and the resulting embryo. By pooling embryos we make sure that we collect the best embryos from multiple IVF cycles and only transfer the best of the available embryos during an embryo transfer. This increases the chances of pregnancy.

Is there any benefit in using mild IVF stimulation protocol compared to conventional stimulation protocol for patients with low ovarian reserve?

Yes, mild stimulation protocol is preferred in low ovarian reserve patients. Various studies have compared mild stimulation versus conventional or high dose stimulation and now many IVF specialists favour mild stimulation over conventional stimulation protocols.

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