The Ideal Stimulation Protocol: Is There One?

Excerpt

The first successful in vitro fertilization (IVF) attempt and most treatment cycles for a while thereafter were conducted in spontaneous menstrual cycles. Nevertheless, realization that availability of a crop of mature oocytes markedly increased chances of success in this therapy prompted most centers to adopt some form of controlled ovarian hyperstimulation (COH). At the outset, clomiphene citrate alone or in combination with human menopausal gonadotropins (hMG) was used, but eventually exogenous gonadotropins emerged as the sole stimulatory drug for COH. Exogenous gonadotropins, and specifically hMG products, have been used in the treatment of infertility since the 1960s, when the first hMG product became available. Subsequently, over the last 25 years, they have become the mainstay of fertility treatment worldwide. The gonadotropins are indicated in isolation as a treatment to induce ovulation, normally in cases where Clomiphene has failed or as a first-line treatment in specific cases of amenorrhea. They are also indicated for Hypogonadotropic hypogonadism in men and women. The most widespread use of gonadotropins is for women undergoing superovulation within a medically assisted reproductive program, like IVF. Superovulation is the stimulation of the ovaries to produce more than one follicle, which enables several embryos to be created. We are still in the search for that “perfect” or “ideal” ovarian stimulation protocol combining both GnRH analogs and gonadotropins that will give us an “adequate” number of oocytes; these oocytes should be of good quality resulting into embryos with a very good morphokinetic score [1] with a high implantation potential and with elimination of ovarian hyperstimulation syndrome (OHSS). The resulting pregnancies should carry to term as a result of the optimal uterine and endocrinological environment that has resulted as a consequence of using that “ideal” stimulation protocol. In the quest for that perfect stimulation protocol, we must imbibe knowledge of the use of GnRH analogs and gonadotropins in different endocrine milieus such as “poor responders” and from natural and artificially stimulated hypogonadotropic hypogonadic states. Newer Gonadotropin preparations are being introduced continuously over the past few years in the quest of that “perfect” but elusive stimulation protocol. Research and practice in the field has led to the era of “Individualized” treatment protocols in the last decade [2, 3]. …