Older women are increasingly seeking and obtaining IVF and it is estimated that 37% of all IVF cycles are performed in older women. At present, the ovarian stimulation regimen for women with poor ovarian reserve, regardless of their age, includes high doses of gonadotropins—up to 600 IU/d— combined with various protocols in an attempt to achieve high follicular recruitment. Despite these high doses of gonadotropins, oocyte yield remains poor and cancellation rates are high. This is due to a patient factor that is completely unrelated to ovarian stimulation per se.
Because there are at present no means for improving ovarian reserve, the question arises as how to obtain the best possible outcome, with the least patient discomfort and lowest costs while maintaining overall success rates in IVF. During the years several low doses of gonadotropins and gonadotropins combined with oral compounds for ovarian stimulation regimens have been suggested as alternatives for women with poor ovarian reserve, aiming at reducing the dose of gonadotropins or shortening the duration of stimulation using oral compounds such as antiestrogens or aromatase inhibitors. Striving for low doses of gonadotropins in women with poor ovarian reserve is a valid approach for two reasons. First, high doses have been shown not to be beneficial in women with poor ovarian reserve. Second, high doses increases the costs of IVF, a consequence that would only be acceptable if paralleled by an improvement in IVF outcome.