Frontiers in gynecological endocrinology: volume 2: from basic to clinical application

Poor response to ovarian stimulation (POR) usually indicates a reduction in follicular response to ovarian stimulation during in vitro fertilization (IVF) cycles resulting in a reduced number of retrieved oocytes. In recent years, mainly due to the postponement of childbearing and the consequent decrease of ovarian reserve, often a POR occurs during IVF despite the high dose of gonadotropins administered. Incidence of POR has been reported from 9 to 24 %, and even if this condition may occur unexpectedly, its prevalence increases with age, and it is >50 % in patients over 40 years [ 3 ]. Patients with POR are defi ned as poor responders . In March 2010, the European Society of Human Reproduction and Embryology (ESHRE) established the criteria for POR diagnosis. Until that, in fact, there was not a uniform defi nition and the term POR indicated heterogeneous groups of patients. The ESHRE established that at least two of the following three features must be present, in order to diagnose POR: 1. Advanced maternal age (≥40 years) or any other risk factor for POR 2. Previous POR (<3 oocytes) with a conventional stimulation protocol 3. Abnormal ovarian reserve test (ORT) (i.e., AFC <5–7 follicles or AMH <0.5–1.1 ng/ml) Two episodes of POR after maximal stimulation are suffi cient to defi ne a patient as a “poor responder” without advanced maternal age or abnormal ORT. In the case of women over 40 years with an abnormal ORT, we are allowed to talk about “expected POR”. Poor responders remain a challenging group of patients to manage in an IVF program. Despite that in literature there are several publications about poor ovarian response, there is not enough evidence to support the use of any particular protocol in poor responder patients. We analyzed the effect of DHEA supplementation on follicular microenvironment and on in vitro fertilization (IVF) outcomes among 24 poor responder patients. Despite the need of more strong data from good-quality randomized controlled trials (RCTs) with relevant outcomes and follow-up [ 26 ], it seems clear that DHEA represents a promising option for the treatment of a large number of women who are really challenging for IVF specialists. In addition to the possible benefi ts in terms of increase of reproductive parameters, DHEA offers the possibility to choose a milder and more cost-effective hormonal protocol. Without supplementation with DHEA, specialists would be forced to use heavy hormonal doses, with minimal response or, as the last resort, egg donation.