There is insufficient evidence to support the routine use of any particular intervention either for pituitary down regulation, ovarian stimulation or adjuvant therapy in the management of poor responders to controlled ovarian stimulation in IVF. More robust data from good quality RCTs with relevant outcomes are needed.
Comparison of a gonadotropin-releasing hormone (GnRH) antagonist and GnRH agonist flare-up regimen in poor responders undergoing ovarian stimulation.
To compare the efficacy of flare-up and GnRH-antagonist treatment in poor-responder patients.
                Randomized prospective study.
                Assisted reproduction center.
                Fifty-five poor-responder patients undergoing intracytoplasmic sperm injection (ICSI).
                Thirty patients received GnRH agonist on the 1st day of menstruation, followed by exogenous gonadotropins from the 2nd day. Twenty-five patients received exogenous gonadotropins starting on the second day of menstruation, followed by GnRH antagonist when the leading follicle reached 14 mm in diameter.
                The total dose of FSH administered during the ovarian stimulation, as well as the number of mature oocytes retrieved, embryo quality, fertilization, implantation, and pregnancy rates were evaluated.
                The number of ampules and units of FSH administered were significantly less in the flare-up than in the antagonistic group. The numbers of mature oocytes retrieved and of top-quality embryos transferred were significantly greater in the flare-up than in the GnRH-antagonist group. The fertilization rate (84% vs. 63%) was significantly higher in the flare-up than in the GnRH-antagonist group. The implantation and pregnancy rate were similar in the two groups.
                The flare-up protocol appears to be more effective than the GnRH-antagonist protocol in terms of mature oocytes retrieved, fertilization rate, and top-quality embryos transferred in poor-responder patients.