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SL ‘00

Antagonists in patients with previous poor ovarian response. Geoffrey H Trew Consultant in Reproductive Medicine & Surgery, Hammersmith Hospital Chief of Service, Imperial College NHS Trust London. SL ‘00. Poor responders………. Difficult group for ; Patients Staff Results. Definitions…….

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SL ‘00

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  1. Antagonists in patients with previous poor ovarian response Geoffrey H Trew Consultant in Reproductive Medicine & Surgery, Hammersmith Hospital Chief of Service, Imperial College NHS Trust London SL ‘00

  2. Poor responders………. Difficult group for ; • Patients • Staff • Results

  3. Definitions……. • Main ; number of egg < 5, cancelled cycles But also a lot of American studies use ; • Raised FSH • Female age >40 • AFC < 5 • Endometriosis grade III or IV

  4. Variation The greater the number of protocols there are - the poorer the evidence for any particular one.....

  5. Evidence Based Medicine • Archie Cochrane • Do we need evidence ? • Why ? • What evidence do we have ?

  6. The evidence Or some of it ……

  7. Best outcome………… But…. There are other important outcomes as well ; • Egg collection • Embryo transfer

  8. Agonist v Antagonist • Cancellation Rates • Previous agonist cycle cancelled • New cycle – increased dose • Randomised to either agonist or antagonist

  9. Cancellation Rate on following cycle with poor responders 50 45 47.5 Brook…Trew, J Obstet & Gynecol, 2006 40 35 30 % 25 P=0.011 20 15 10 9.4 5 0 Antagonist Buserelin

  10. A Prospective RCT of microdose leuprolide v ganirelix …… • Pilot study - 48 pts • previous poor response • … ganirelix appears to be as effective as the microdose protocol and may be a superior choice in terms of cost and convenience Schmidt et al Fertil steril May 2005

  11. Antagonists in IVF poor responders – results of randomised trial • Antagonist v standard long ; 60 pts Antagonist group ; • less drugs P = 0.0001 • more eggs P = 0.02 • Fewer cycles cancelled • PR 17% per ET v 7% per ET Marci et al RBM Online Aug 2005

  12. Flexible GnRH Antagonistv flare up GnRH Agonist in poor responders…a RCT • 5 or less oocytes with dose = or > 300iu • Antagonist (180pts) v flare agonist (90pts) • PR ; 12.2% v 4.4% ( p<0.048) Lainas…Kolibianakis, et al : Hum Reprod April 2008

  13. Poor responders • Just about every different protocol tried • Different FSH doses • Different Agonist doses • Antagonists fixed / flexible • Various additives inc LH growth hormone etc • ‘Soft’ / Natural protocols • Still poor results!

  14. What is your preferred ovarian stimulation regime for “poor responders” ? • Clomifene/ gonadotrophin 26% • Ultrashort agonist 23% • Short agonist 30% • Long agonist 17% • Antagonist 58% (Serono Symposia Mtg Athens Dec 2006)

  15. What is your preferred ovarian stimulation dose for “poor responders” • 200 iu 2% • 225 iu 4% • 300 iu 21% • 375 iu 9% • 450 iu 47% • > 450 iu 15%

  16. What should the maximum FSH dose be in poor responders ? • “ little or no clinical benefit in doses > 300 iu” • “…but costs and side effects were higher” Siristatidis & Hamilton, J Obstet Gynecol May 2007

  17. Other options • Give up / expectant management • Corrective surgery of underlying problem • Natural cycle IVF • IUI - If no significant male factor / tubal factor • IUI and donor sperm if significant male factor • Egg Donation • 50% + pregnancy rates

  18. Conclusions • Difficult group to treat • Poor pregnancy rates in true poor responders • Antagonist protocols • High dose of FSH

  19. Please ! • Do not use antagonists just for poor responders use them for all groups of patients !! • Results are good • Patients love them !

  20. Thank You ! g.trew@imperial.ac.uk

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