My husband and I are going through our first IVF procedure after having tried artificial insemination six times. I'm on Lupron, Pergonal and Fertinex. So far I've only produced three follicles. My doctor doesn't seem to know why my body isn't responding well to the medication. He has increased the meds, hoping that will make a difference. What are some of the reasons a woman would produce such a small number? How common is this problem? What is the normal treatment approach? And what are my chances of a successful IVF with only three follicles?

P.B.

There are many factors that affect the number of follicles that will develop during ovarian stimulation before IVF. The first and foremost is your age. In about 33 percent of women who undergo IVF in their late 30s or early 40s, it is common to have to cancel IVF cycles because not enough follicles develop. Other factors include the dose of medication prescribed, the length of time you receive Lupron before beginning ovulation induction shots, a history of previous ovarian surgery or the presence of anti-ovarian antibodies all may contribute to diminished response.

In rare cases, changing the way the medications are given or using a higher dose can result in a greater response. Another approach is to try a "flare" stimulation protocol, in which Lupron is begun on the second day of a menstrual cycle and gonadotropin shots are begun on the third day. While this approach may work for some patients, pregnancy rates are less than optimal. The use of baby aspirin, L-arginine or Viagra suppositories may improve ovarian blood flow and subsequently provide better results.

The presence of anti-ovarian antibodies are a potentially reversible cause of poor response. While the cause of this condition is unknown, it is not an infrequent finding after a poor response to IVF stimulation. If a blood test reveals antibodies, the use of a short course of steroid therapy often produces better results on subsequent IVF attempts.