Best Protocols for Poor Ovarian Reserve: What You Need to Know

For women with poor ovarian reserve, selecting the best IVF protocol will vary based on personal health, age, and specific ovarian function.  

In this article, we’ll review the most common protocols for poor ovarian reserve and what makes them effective.  

What is Poor Ovarian Reserve?  

Poor ovarian reserve (POR) is a condition where a woman’s ovaries have fewer eggs, or more diminished egg quality than what would be expected for their age.

Indicators of low ovarian reserve and potentially poor response to IVF treatment include:  

• Follicle-stimulating hormone (FSH) levels of 10 mIIU/mL or less on day three of the menstrual cycle 

• Anti-müllerian hormone (AMH) levels below 0.5 ng/mL 

• Advanced maternal age 

• In some cases, a patient is considered a “poor responder” if they have had a previous IVF cycle with limited egg production or low fertilization rates. 

Essentially, a poor response can be determined either by initial test results before treatment or by evaluating how the patient responded to past treatments. 

This condition can impact a woman’s ability to conceive naturally or through assisted reproductive technologies, such as IVF. 

What are the Best Protocols?  

The best protocols for poor ovarian reserve will be those that stimulate the growth of the most high-quality eggs for retrieval. According to recent research looking at tens of thousands of IVF cycles, the best protocols for poor ovarian reserve are the antagonist “short” protocol and the “flare” or “microdose Lupron” protocol.  Each has been found to provide similar outcomes.

Interestingly, the idea of using more medications to stimulate growth has been proven ineffective. Doing so will only add significant expense to the IVF process.  

That said, it is important to note that these protocols have been found effective on a population basis. There are many individual factors that your specialist will look at to help determine the best protocol for you.  

Let’s review the protocols used to treat women with poor ovarian reserve and how they work.  

Antagonist Protocol (Short Protocol)  

The antagonist protocol has become the most common IVF protocol, as antagonists require less time, fewer injections (lower cost), and are easy to follow.  

Ganirelix or Cetrotide stops the body from releasing LH (Luteinizing Hormone), thereby delaying ovulation. This allows the retrieval of eggs at the optimal moment when most eggs are fully matured.  

Provera is another commonly used medication in an antagonist protocol. Provera prevents premature luteinizing hormone surges and has been found to be especially effective for women at high risk of ovarian hyperstimulation syndrome during ovarian stimulation.

A shot of Human chorionic gonadotropin (hCG) or Lupron is then given to trigger egg maturation around the time of retrieval.  

Research has found that in first-time IVF patients, those predicted to have poor ovarian response, had, on average, slightly higher numbers of eggs, fertilized embryos (2PNs), and blastocysts when using the Antagonist protocol compared to the Flare protocol. Poor ovarian responders on the Antagonist protocol also experienced similar cumulative live birth rates (CLBR) and slightly fewer cycle cancellations. 

For patients on their second cycle, the antagonist protocol was found to provide a slightly improved response compared to the Flare protocol.

Flare or Microdose Lupron Protocol 

This IVF protocol utilizes a GnRH agonist (Lupron) at a lower “micro” dose, beginning on the first day of the cycle.  One or two days later, gonadotropins are introduced.   

The rationale behind this protocol is that the GnRH agonist (Lupron) serves a dual purpose:  

• In combination with gonadotropins, it stimulates follicle growth (known as the flare effect)  

• Later in the cycle, it helps prevent premature ovulation.  

This protocol may be recommended for women with low ovarian reserve or those who had a poor response (few eggs retrieved) in a previous IVF cycle or protocol.  It is usually not used for women at high risk of ovarian hyperstimulation syndrome (OHSS). 

For women with low ovarian reserve, it is believed that the low dose of Lupron can boost the body’s own production of follicle-stimulating hormone (FSH). This increase in FSH may enhance ovarian response, potentially resulting in a higher egg count. By initiating Lupron early in the cycle, there is an initial hormone surge, which is thought to “jump-start” follicle development and help counteract the reduced ovarian response commonly seen in poor responders. 

As we mentioned above, research suggests that for most women with poor ovarian reserve, the antagonist protocol has been found to be slightly more effective than the flare protocol.  

Estrogen Priming Protocol  

Estrogen priming involves taking a birth control pill, estrogen pills, or applying an estrogen patch in the days or weeks before beginning an IVF cycle. This “priming” approach helps regulate and schedule the cycle timing. 

It is particularly beneficial for women with Diminished Ovarian Reserve (DOR) or those who experience uneven follicle growth. By temporarily lowering FSH levels and then enhancing the follicles’ responsiveness to FSH when it’s later introduced via injections, this protocol supports more synchronized follicle stimulation for better results during IVF.

Growth Hormone Supplementation 

Supplementation of growth hormone, most often in the form of a medication called Omnitrope, has been found to improve ovarian response. This is a common treatment practice at CNY Fertility.  

Growth hormone supplementation works by stimulating follicle development and increasing the number of mature eggs retrieved during ovarian stimulation in IVF cycles in women with and without poor ovarian reserve.

Growth hormone has also been found to improve ovarian reserve (the quality of a woman’s remaining eggs). Eggs (oocytes) retrieved from follicles with adequate growth hormone levels in the surrounding fluid have been found to be more fertile than those maturing in follicles with lower growth hormone concentrations.

Recombinant FSH (rFSH) 

Studies have shown that rFSH can improve oocyte maturation, the number of oocytes retrieved, and the quality of embryos.

Tips for Enhancing Success with Poor Ovarian Reserve 

In addition to medical protocols, there are various diet and lifestyle choices that can help improve your chances of getting pregnant with poor ovarian reserve.  

• DHEA supplementation: Studies suggest that DHEA supplementation may improve ovarian response and egg quality in patients with low ovarian reserve.

• Coenzyme Q10 (CoQ10): Pretreatment with CoQ10 has been found to improve ovarian response to stimulation and support embryo development in young women with poor ovarian reserve in IVF-ICSI cycles.

• Diet: A low carb, ketogenic diet has been found in preliminary studies to improve ovarian function in obese women.

• Acupuncture has been found to improve ovarian reserve.

Consult with a Specialist 

The most effective protocol depends on your specific ovarian reserve, health profile, and response to past treatments (if applicable). Consulting with a reproductive endocrinologist will help you receive a tailored approach based on your unique needs and medical history. Click here to schedule a consultation today.