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IVF in Poor Responders: Mild Versus Conventional Stimulation

Relative to traditional treatments with higher dosages of hormonal medications, is mild stimulation of the ovaries for in vitro fertilization (IVF) better? Certainly, mild stimulation has potential advantages, including reduced cost per cycle, lower risk of ovarian hyperstimulation syndrome, and less physical and emotional demands on the patient. Based upon a medical literature search (766 studies of which 21 were included) the American Society of Reproductive Medicine published a guideline: https://doi.org/10.1016/j.fertnstert.2018.03.019

In patients expected to be poor responders with IVF (Age>40 years, poor response in prior IVF attempt, low AMH, elevated FSH, reduced antral follicle count), pregnancy rates are low, no matter which treatment plan is used. There is fair to good evidence that clinical pregnancy rates are not substantially different using mild stimulation protocols compared with conventional IVF in poor-responder populations. There is fair evidence that mild ovarian stimulation is cost-effective.

In patients who are classified as poor responders and pursuing IVF, strong consideration should be given to a mild ovarian stimulation treatment plan (low-dose gonadotropins with or without clomiphene or letrozole) due to lower costs and comparable low pregnancy rates compared with traditional IVF stimulation protocols.

In short, it may be time to reduce the dosages, the costs, the physical and emotional stress, the logistics, and where appropriate, the expectations for pregnancy among poor prognosis patients considering IVF.

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