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In vitro maturation (IVM), a technique which has the potential to provide the pregnancy rates of conventional in vitro fertilization (IVF) in selected cases while avoiding the risks and costs associated with controlled ovarian hyperstimulation (COH), could be considered a better option. It is not only a recognized treatment alternative for couples who need assisted reproduction technology (ART), but also is considered as an innovative fertility preservation method which extends the options for patients with various diseases that preclude treatment with conventional methods. Young women with high antral-follicle counts achieve the highest pregnancy rates with IVM. Such women also have a high risk of ovarian hyperstimulation syndrome (OHSS) following COH. IVM expands the fertility preservation options for women who are not candidates for IVF and embryo cryopreservation (EC) for various reasons. Women with hormonesensitive tumors may undergo immature oocyte collection and cryopreserve resultant embryos.
Ovarian cryopreservation presents a valid alternative to egg freezing in some circumstances. The possibility to store oocytes for a later use is also an important consideration for women who choose to postpone motherhood for personal or professional reasons. Any newly developed protocol should consider the biochemical and physical properties of the oocyte. In addition to surviving the cryopreservation/warming process, the oocyte needs to maintain competence to fertilize and develop in vitro to the appropriate embryonic stage without any structural alterations. Slow cooling protocol is characterized by a slow decreasing temperature rate. Several mathematical models define an optimal curve applicable to oocytes since the freezing rate is vital to achieve sufficient and progressive dehydration, and thereby minimize the potential of intracellular ice formation. During fresh cycles only a few oocytes can be inseminated; therefore, cryopreservation is the only option to avoid wastage of surplus eggs and consequent repeated ovarian stimulation.
Management of the poor responder remains one of the greatest challenges of controlled ovarian hyperstimulation (COH) in preparation for the assisted reproductive technologies. This chapter reviews a variety of approaches which have been employed in this poorly defined patient group. The profound suppression of gonadotropins induced by traditional long luteal gonadotropin-releasing hormone agonist (GnRHa) protocols may be particularly devastating for poor responders. Decreasing the GnRHa dose during the luteal phase prior to COH would theoretically decrease the extent of endogenous gonadotropin suppression while preventing premature ovulation. The administration of estradiol in the luteal phase may induce follicle-stimulating hormone (FSH) receptor formation in more resistant follicles and result in a more coordinated gonadotropin response. The ability to enhance endogenous follicular phase gonadotropin release by the administration of either clomiphene citrate or an aromatase inhibitor would represent an attractive adjunct to GnRHant protocols in poor-responder patients.
Male reproductive dysfunction is the sole or contributory cause in half of infertile couples. Some health issues are more prevalent in infertile men and must be sought and the opportunity taken to assess and improve general and sexual health. Spontaneous conception may occur in many couples with male factor subfertility. In counseling patients, the severity of the male's reproductive problem, the duration of unprotected intercourse, and its frequency and timing, and the female partner's age and reproductive status are all important variables. There is a substantial background rate of spontaneous conception in subfertile men such that about 30% of couples with sperm densities of 1-5 million/ml as the only apparent fertility issue, achieved pregnancy over a two- to three-year period. Depending on the couple's age and reproductive history, some couples are happy to delay treatment in the hope that they will conceive while others express a wish for immediate intervention.