How should unexpectedly poor ovarian response be managed during stimulation?

Two ESHRE (2026) recommendations govern this directly. Low response to ovarian stimulation alone is not a reason to cancel a cycle (strong). The physician should counsel the individual unexpected low responder regarding pregnancy prospects and decide individually whether to continue the cycle (good practice point, updated). On dose adjustment mid-cycle, which is the instinctive response: adjustment, whether increase or decrease, of the gonadotropin dose in the mid-stimulation phase is probably not recommended (conditional). The guideline adds a good practice point that, given the absence of evidence for the value of dose adjustment, it is important the starting dose is appropriate to patient characteristics and the desired outcome from the outset. That combination is the practical message: the lever most clinicians reach for mid-cycle is not supported, and the decision that matters was made before stimulation started. Where cancellation is being considered, note the guideline's framing — the decision should rest on counselling about prospects for that individual, not on a follicle-number threshold applied uniformly. A gonadotropin dose above 300 IU/day is not recommended in predicted low responders (strong), so escalation is not an available response either.