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poor responders: looking for a new stimulation regimen

Dear friends

I have a patient who is 37 y o who do not respond properly to FSH stimulation. The number of oocytes are really poor. Is any one can recommend a different and unique way is stimulation?

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Answer by Sherman Silber

The answer is clear. She should respond to a different paradigm of stimulation, that involves minimal stimulation ironically.

A very simple and cheap protocol involving clomid and abd very low dose FSH with GNRH agonist triggering, and multiple cycles to store up a few embryos at a time (vitrifying them) will eventually give you a pretty good number of good quality embryos and high implantation rates. But it may take several cycles of the simple and cheap minimal stimulation protocol to store up enough embryos to feel comfortable. Avoid the temptation to transfer embryos as you go. You need to store them up while she can still make anything at all. Time is of the essence just to focus on one thing, and that is storing up embryos with vitrification.

Sherman Silber, USA

Answer by Purushottam Sah

I have developed a low cost protocol for poor responders, I have treated only two patients of age 35-36 so far. Both of them did not develop any follicle with long protocol. I started them with oral contraceptive pill from day-2 of a cycle for 21 days (along with pyridoxine 100mg daily continued in next cycle).

After the OCP induced withdrawal bleeding, they were started on
Clomiphene 100mg one daily- day2 to day6
Acetylcysteine 600mg one daily- day2 to day11
Dexamethasone 0.25 mg one daily- day2 to day11

One of them developed two follicles of more than 20 mm on day 12 and underwent successful fertilization of two ova by IVF.

Other one developed one follicle of more than 20 mm on day 12 which ruptured spontaneously on day 13. She did not want IVF and is waiting for her next cycle which is due in 3-4 days.

Purushottam Sah MBBS, DGO,Calcutta, India

[email protected]

 

Answer by Joaquín Llácer

Hi everybody.

Taking into account the age of the patient to try again is a good option. The key could be in the modification of the previous cycle. 

My experience using transdermal Testosterone and Estogen priming seems good in this patients. Considering the previous failure, the introduction of uhMG-HP in the stimulation regime is advisable as well.

In my opinion. the use of minimal stimulation and accumulation of vitrified eggs or embryos, have emotional and financial implications and must be the last option before considering egg donation.

Joaquín LlácerInstituto Bernabeu. Alicante. Spain

[email protected]

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