Evidence-based recommendations for managing poor ovarian response

Introduction: Ovarian response is crucial in assisted reproductive technology, and mature oocyte retrieval is directly linked to higher live birth rates. Poor ovarian responders (POR) experience limited stimulation outcomes that contribute to significant cycle cancellations. Managing POR involves tailored protocols, yet no single approach has been universally validated as the most effective. Methods: Addressing this challenge, the Indian Fertility Society (IFS) developed comprehensive evidence-based guidelines for the diagnosis and management of POR. Using the PICO framework, a Guideline Development Group (GDG) conducted a comprehensive literature review across major databases up to October 31, 2023. Key outcomes included efficacy, safety, and patient-related measures. The GDG employed the GRADE approach to assess the quality of evidence and risk of bias. Recommendations were formulated based on the strength of evidence, benefit-harm balance, feasibility, stakeholder acceptability, and resource implications. The resulting evidence-based recommendations (EBRs) reflect the certainty of evidence and consensus among GDG members. Results: The guidelines offered 44 EBRs (33 strong and 11 conditional) addressing 37 key questions to guide the management of POR. Among the EBRs, 1 was based on high-quality evidence, 6 on moderate-quality evidence, 25 on low-quality evidence, and 8 on very low-quality evidence and lack of evidence with recommendation for further research in 4. Most of the EBRs were based on low or very low-quality evidence, underscoring the need for further research. Conclusion: These guidelines prioritize patient safety and improve clinical outcomes, offering actionable insights into POR diagnosis and treatment protocols. Anti-Müllerian hormone and antral follicle count are reliable predictors for identifying patients at high risk of POR. The Corifollitropin alfa offers a comparable alternative to traditional gonadotropins. These guidelines serve as a valuable resource for assisted reproductive technology professionals by promoting a structured approach to managing POR and highlighting areas for future research.