Poor responders: Is it time to consider changing the nomenclature?

Sir,

Poor response (POR) in in vitro fertilization (IVF) cycles is a vexing problem. More women are undertaking treatment for subfertility at advanced ages due to various social reasons. These women in their mid-life are often submitted to IVF embryo transfer, and often they respond suboptimally to ovarian stimulation by gonadotropins.

The European Society of Human Reproduction and Embryology (ESHRE) consensus group has defined poor responders as presence of at least two of the following three features: (1) Advanced maternal age or any other risk factor for POR, (2) a previous POR, and (3) an abnormal ovarian reserve test (ORT). Two episodes of POR after maximal stimulation are sufficient to define a patient as poor responder in the absence of advanced maternal age or abnormal ORT.[1]

Undergoing IVF cycles is a stressful time for the couples. Use of the label “poor responder” has negative connotations and might add to the stress of the couple. Nomenclature should reflect the etiopathogenesis and biological features of a condition without being judgmental. The Bologna group deliberated on various labels including “poor,” “inadequate,” “suboptimal,” “bad,” and “slow” but finalized the term “poor responders.”[1] Although it may convey the meaning accurately, but this label might cause significant distress to the couple.

Worldwide, there is recognition that nomenclature of medical conditions and diagnosis has a bearing on the patient perception of his/her condition and the stress of living with the condition. An example is the change in nomenclature from spontaneous abortion to miscarriage, premature ovarian failure to primary ovarian insufficiency and incompetent os to cervical insufficiency.[23] All these new terms describe the same conditions accurately and in a more sensitive manner to the patients and physicians.

We suggest that the “poor responders” be named as “suboptimal responders.” This will signify that this subgroup responds less well to ovarian stimulation. It is known that “poor responders” are a heterogeneous subgroup with a range of ovarian responses. Although ORTs may predict the number of follicles resulting after stimulation, they are poor at predicting pregnancy rates.[4] Data from Netherlands show a moderately reduced but reasonable chance of pregnancy even at the age of 40 years (23%).[5] Previous POR could be because of incorrect choice of protocol or dose or poor quality of drugs. Thus, a “poor responder” by the Bologna criteria still has a reasonable chance of success using tailored protocol and adjuvant therapies. The label of a “poor responder” may dissuade the older women from undertaking an IVF cycle altogether or opt for egg donation straight away. This is more relevant in India where the treatment is self-financed. With more and reproductive rights and freedom afforded to women of all ages, it is appropriate that this change in nomenclature be brought about.

So we suggest that professional bodies take up this issue and advocate that the term “poor responder” be rechristened as “suboptimal responder” which is more patient friendly without losing the meaning of the term.