Evidence-Based Guidelines for Management of Poor Ovarian Response in Assisted Reproduction

Poor ovarian response (POR) poses a major and increasing challenge in assisted reproductive technology (ART), often leading to reduced oocyte yield and increased cycle cancellations. Despite numerous treatment strategies, there remains a lack of agreement on the best strategy. To fill this void, the Indian Fertility Society (IFS) developed evidence-based good practice recommendations (EGPRs) to guide clinicians in the diagnosis and management of POR. A multidisciplinary Guideline Development Group (GDG) was constituted by IFS. Using the PICO (population, intervention, comparator, outcome) framework, the GDG conducted a comprehensive literature search across multiple databases up to October 2023. Relevant studies were evaluated for efficacy, safety, and patient-centred outcomes. The GRADE (grading of recommendations, assessment, development, and evaluations) methodology was employed to assess the quality of evidence and develop recommendations. Recommendations were formulated based on evidence certainty, benefit-harm balance, feasibility, stakeholder values, and resource use. The guideline comprises 45 EGPRs addressing 37 key clinical questions. Among these, 44 are evidence-based recommendations (32 strong, 12 conditional), and 1 is a good practice point (GPP). Of the 44 evidence-based recommendations, only one recommendation is supported by high-quality, robust data, 6 on moderate-quality, while the majority depend on low (25) to very-low quality (8) evidence, highlighting the urgent need for further, more rigorous research in 4. The current guidelines offer a structured, patient-focused approach to managing POR in ART. They provide clinically relevant, actionable recommendations while highlighting gaps for future investigation.