Poor responder: when stimulation yields few eggs

‘Poor responder’: this term is often mentioned after the first egg retrieval, and it feels like a verdict. However, it refers to very different situations. A 34-year-old woman with few eggs and a 43-year-old woman in the same situation do not have the same chances or the same options.

Definitions

The Bologna criteria (ESHRE, 2011) require at least two of the following three elements: age 40 or over (or another risk factor), three eggs or fewer following conventional stimulation, and a low ovarian reserve test result (AMH below approximately 0.5–1.1 ng/mL or an antral follicle count below 5–7).

The POSEIDON classification (2016) is more useful in practice. It distinguishes four groups based on age (under or over 35 years) and ovarian reserve:

• Groups 1 and 2: good reserve, but an unexpectedly poor response. Often a dose or protocol issue, which can be corrected.
• Groups 3 and 4: low reserve, before or after the age of 35. A poor response is expected.

The value of POSEIDON: focusing on the actual objective, namely obtaining at least one euploid (chromosomally normal) embryo, rather than on the number of eggs.

Why age matters more than number

At the age of 34, even three eggs have a good chance of producing a normal embryo. At the age of 43, the majority of embryos have chromosomal abnormalities, regardless of their number. It is quality — linked to age — that primarily determines the chances; the number acts as a multiplier. See AMH and ovarian reserve.

Options worth discussing

• Adjusting the protocol: gonadotropin doses, adding LH, changing the type of trigger. Above approximately 300 IU per day, further increasing the dose rarely yields more eggs.
• Accumulation of embryos or eggs: several successive stimulations, with freezing, prior to a transfer. This increases the number of available embryos, at the cost of multiple egg retrievals.
• DuoStim: two stimulations within the same cycle (follicular phase, followed by the luteal phase). Useful for saving time; the birth rate per egg retrieval is no better.
• Mild stimulation or natural cycle: fewer drugs, often with comparable results in poor responders, and lower costs.
• Transfer on day 3 or day 5: when there are few embryos, some clinics prefer to transfer earlier. The data are inconclusive.

The protocols themselves are explained in this article.

What has not been proven effective

Growth hormone, DHEA, testosterone gel, ovarian PRP, high-dose coenzyme Q10: none of these has been shown to produce a robust increase in birth rates among poor responders. ESHRE does not recommend them as standard practice. Some may be considered on a case-by-case basis; none should delay an important decision.

When to consider egg donation

There is no universal threshold. Commonly used guidelines include: several cycles without a transferable embryo, age over 43–44, or a very low AMH level combined with advanced age. Egg donation offers chances that depend on the donor’s age, not your own — which is why it changes the outlook so significantly. It is a personal decision that deserves time and, often, support.

My advice

After an initial poor response, ask your doctor which POSEIDON group they place you in, what they would change in the next protocol, and what their estimated probability is of obtaining a transferable embryo. These three answers are more valuable than any general statistics.

Frequently asked questions