What is the optimal gonadotropin starting dose for women with diminished ovarian reserve?

ESHRE (2026): a gonadotropin dose higher than 300 IU/day is not recommended for predicted low responders (strong recommendation). Conventional dosing is defined in this guideline as 150–225 IU. The guideline states explicitly that there are limited indications to deviate from conventional dosing. The rationale is that higher doses do not improve oocyte yield or live birth rates in this group, while increasing cost and side-effect burden. Dose escalation is an intuitive response to low reserve that the evidence does not support. Two related recommendations shape practice here: Mid-stimulation dose adjustment, increase or decrease, is probably not recommended (conditional), with a good practice point that the starting dose should therefore be appropriate from the outset. For predicted high responders, a reduced dose of 100 to under 150 IU is probably recommended to decrease OHSS risk (conditional) — noting the direction of individualisation runs downward, not upward. For prediction of response, either AFC or AMH is recommended (strong). Age, BMI, basal FSH, inhibin B, basal oestradiol, basal progesterone and basal LH are not recommended for predicting response (strong).