Reproductive healthMasterclass
Random-start protocols and DuoStim: new options in modern practice
19 minAudio: UA
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Olha Romanova devotes her lecture to modern strategies for poor-prognosis patients, opening with a striking case: 36 years, AMH 0.04, short cycle, FSH 16.9 — after estrogen priming, three consecutive stimulations with DuoStim led to a healthy baby girl and one more euploid embryo in reserve.
The case's key message is the power of a cumulative strategy: when a poor-prognosis patient is told upfront about the accumulation path, she finds it psychologically easier to continue after an inevitably modest first result.
The modern patient has changed: one in four couples stops treatment after the first failure — up to 65% in the USA; about half leave without ever achieving pregnancy. Hence a shift in how efficiency is understood — from per-transfer outcome to cumulative live birth per started cycle, time to pregnancy and patient retention.
Physiology is understood differently too: several waves of follicular growth occur within a single cycle. This underpins new approaches — random-start (beginning on any day, especially in oncofertility), luteal-phase stimulation and double stimulation (DuoStim) — two retrievals in one cycle.
Who are poor-prognosis patients: by Bologna criteria — two of three features (age 40+, ≤3 oocytes in a previous cycle, low AMH/AFC), plus POSEIDON groups 3 and 4. By SART data, live birth per IVF cycle falls from 36.9% (under 35) to 2.8% (over 42).
The main comparison is DuoStim versus two consecutive cycles. Interval between retrievals: 15 days versus 141 on average; dropout 8% versus 90%. Per GENERA data, over 10 years the DuoStim share rose from 7% to 34%, and the method gives +66% of cycles with at least one euploid embryo and +125% in live birth for poor-prognosis patients.
Importantly, oocytes and embryos from the follicular and luteal phases do not differ in development, genetic and reproductive competence, and children's perinatal outcomes are comparable. In 2025 DuoStim was added to the ESHRE guideline for patients not planning a fresh-cycle transfer.
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