Introduction
Due to advanced reproductive age, genetic and, iatrogenic factors,
diminished ovarian reserve (DOR) patients are becoming a large
proportion of assisted reproductive technology (ART) practices. The
prevalence of DOR increased from 19% to 26% during 2004 to 2011 in US
ART Population[1].
Ovarian stimulation has been undeniably one of the biggest breakthroughs
in ART. The conventional ovarian stimulation protocol aims to provide
the maximum number of oocytes retrieved for fertilization and thus
several embryos for selection[2]. In past 30
years, many attempts have been proposed to improve the IVF outcomes in
DOR patients, however, the clinical prognosis of DOR patients remains
poor regardless. We must realize that a good oocyte can merely be
encountered occasionally and randomly for this group of patients with
very poor ovarian reserve.
In this context, mild/minimal stimulation protocol has been raised and
proven effective, but controversial. According to the proposed
definition by the International Society for Mild Approaches to Assisted
Reproduction (ISMAAR) in 2007, the term mild stimulation may apply in
three scenarios: (i) when oral compounds (anti-estrogens or aromatase
inhibitors) are used (alone or with
gonadotropins)[3] (ii) when stimulation is
performed with low gonadotropin doses[4] and (iii)
in case of delay in the start of stimulation (shorter duration) in a
GnRH antagonist cotreated cycle[5]. The American
Society for Reproductive Medicine recommended that in patients who are
considered to be poor responders, ‘strong consideration’
should be given to a mild ovarian stimulation protocol (≤150 IU FSH) due
to lower costs and comparable pregnancy rates[6](ASRM, 2018). Montoya-Botero P et al. concluded
that mild/minimal stimulation could be considered as an option in low
prognosis poor responder patients, given that it results in similar
fresh and cumulative live birth rate (CLBR) [7].
In this article, we aim to investigate the effectives of minimal
stimulation protocol women in comparison with conventional ovarian
stimulation protocol on severe DOR women. We compared the outcomes in
women seeking minimal stimulation protocol according to the patient’s
previous IVF/ICSI(below as IVF) history, we then stratified patients
according to numbers of previous cycles done. We compared the clinical
outcomes and propose that if a DOR patient is seeking fertility
treatment, when is wise to turn to minimal stimulation protocol IVF
after no more than two conventional stimulation cycles.