title: Controlled ovarian hyperstimulation protocols for in vitro fertilization: two decades of experience after the birth of Elizabeth Carr.
abstract: 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.
authors.affiliation: Department of Obstetrics and Gynecology, The Jones Institute for Reproductive Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA.
authors.forename: Murat
authors.initials: M
authors.lastname: Arslan
authors.forename: Silvina
authors.initials: S
authors.lastname: Bocca
authors.forename: Sebastián
authors.initials: S
authors.lastname: Mirkin
authors.forename: Gerardo
authors.initials: G
authors.lastname: Barroso
authors.forename: Laurel
authors.initials: L
authors.lastname: Stadtmauer
authors.forename: Sergio
authors.initials: S
authors.lastname: Oehninger
mesh_terms: 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