The Bologna criteria for poor ovarian response; has the job been accomplished?

The Bologna criteria for poor ovarian response; has the job been accomplished? Sir, I read with great interest the ESHRE consensus on the definition of 'poor response' to ovarian stimulation for in vitro fertilization by Ferraretti et al. (2011) published recently in the Human Reproduction. The authors, on behalf of the ESHRE working group on poor ovarian response (POR) definition, have presented an attempt to characterize this condition in a simplified and reproducible approach. A consensus was reached on the minimal criteria needed to define POR when at least two of the following three features must be present: (i) advanced maternal age or any other risk factor for POR; (ii) a previous POR and (iii) an abnormal ovarian reserve test (ORT). Let me first applaud the conjoined and sincere efforts of the ESHRE working group to put together these three clinical criteria for one of the main enigmas of modern reproductive medicine. Indeed, POR as an early feature of low ovarian reserve has been complicating the treatment of significant proportion of infertile women since the early days of assisted reproductive technique (Surrey and Schoolcraft, 2000) and continues to be a major issue today. With pregnancy being intentionally delayed in modern societies, ovarian aging has become one of the most detrimental factors of pregnancy achievement and maintenance. The variability regarding the definition of POR has recently been shown to be striking (Polyzos and Devroey, 2011). No doubt that a lack of a well-accepted, appropriate and commonly used definition for POR as an early sign of low ovarian reserve has prevented an accurate estimate of its incidence. Moreover, it has severely impaired progress in ovarian aging clinical research and may have prevented the development of evidence-based efficient and appropriate protocols or modalities of treatment for such women. In order to reach a common and universal definition of POR, every one of the criteria selected should be simple, clearly defined and reproducible as has been the case when the revised polycystic ovary syndrome (PCOS) criteria were introduced (The Rotterdam Consensus, 2004). This approach had led to the performance of properly designed trials with good external validity and evolved into clear consensus on infertility treatment (The Thessaloniki Consensus, 2008) and regarding various women's health aspects (The Amsterdam Consensus, 2012) related to PCOS patients. Notably, when looking into the Bologna criteria for POR, although maternal age (≥40 years), previous POR (three or less than three …