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Clomiphene citrate (CC) and follicle stimulating hormone (FSH) are the two main modalities used for ovarian stimulation (OS). Decisions are based not only on randomized clinical trials (RCT), but also on other basic science and clinical evidence supporting their use. This chapter presents the effectiveness of adjuncts in enhancing outcomes in women having OS for in-vitro fertilization (IVF). The adjuncts include leuprolide acetate (LA) and gonadotropin-releasing hormone (GnRH) agonists, oral contraceptive (OC) pretreatment, estrogen pretreatment, dexamethasone (DEX), metformin (Met), human chorionic gonadotropin, aspirin (ASA), growth hormone (GH), dopamine agonists, and androgens and androgenic drugs. Most of these adjuncts are medications approved for other uses but not specifically as adjuncts for OS. The risk/benefit ratio in their use is quite favourable. Adjuncts aimed at improving ovarian response by increasing ovarian androgen concentrations appear to have real promise, but require further well-controlled studies to verify their effectiveness.
The future of assisted reproduction lies in optimization of each treatment phase starting with ovarian stimulation through laboratory procedures, selecting the best embryo for transfer, embryo transfer, luteal phase support leading to pregnancy, and the birth of a healthy single ton baby. Gonadotropin-releasing hormone (GnRH) agonists have changed the course of ovarian stimulation for in vitro fertilization (IVF). GnRH antagonists have been introduced recently in ovarian stimulation for pituitary suppression. High implantation and pregnancy rates in oocyte donation cycles irrespective of acceptors' age imply that ovarian stimulation impairs endometrial receptivity in stimulated cycles. Embryo transfer procedure plays a pivotal role in the success of assisted reproduction. Improving embryo implantation continues to pose a major challenge to clinicians. The future developments in assisted reproduction should encompass individualized approach to ovarian stimulation, vitrification, single blastocyst transfer, and development of new tools for genetic testing.
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