Controlled ovarian hyperstimulation protocols for in vitro fertilization: two decades of experience after the birth of Elizabeth Carr.
OBJECTIVE
To critically discuss the current protocols for the management of controlled ovarian hyperstimulation in assisted reproduction technology.


METHODS
Review of the literature and presentation of our experience.


METHODS
Ovarian response (peak serum estrogen levels, number of oocytes retrieved, quality of oocytes and embryos) and pregnancy outcome (clinical, delivery, and multiple pregnancy rates).


RESULTS
Controversies still exist regarding selection of gonadotropin preparation, choice of adjuvant therapy with GnRH analogues, and use of oral contraceptive pills. Patients identified as intermediate responders have an excellent outcome with adjuvant therapy with either a GnRH agonist (long protocol) or a GnRH antagonist, but tailoring of gonadotropin dose must be performed to achieve optimized results. High responders perform favorably with gentler gonadotropin stimulation that minimizes the occurrence of ovarian hyperstimulation syndrome. On the other hand, results in low responders remain suboptimal both in terms of ovarian response and oocyte/embryo quality in spite of a variety of stimulation regimens used.


CONCLUSIONS
Ovarian stimulation is a critical step in in vitro fertilization therapy. A variety of controlled ovarian hyperstimulation regimens are available and efficacious, but individualization of management is essential and depends on assessment of the ovarian reserve. Identification of the etiologies of poor ovarian response constitutes a formidable challenge facing reproductive endocrinologists.
Arslan
Murat
M
Department of Obstetrics and Gynecology, The Jones Institute for Reproductive Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA.
Bocca
Silvina
S
Mirkin
Sebastián
S
Barroso
Gerardo
G
Stadtmauer
Laurel
L
Oehninger
Sergio
S
D005260:Female; D005307:Fertilization in Vitro / Q000379:methods / Q000706:statistics & numerical data / Q000639:trends*; D006801:Humans; D050498:Live Birth / Q000453:epidemiology*; D016471:Ovarian Hyperstimulation Syndrome / Q000453:epidemiology; D010062:Ovulation Induction / Q000379:methods / Q000706:statistics & numerical data / Q000639:trends*; D011247:Pregnancy