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Induction of ovulation is one of the major advances in the treatment of subfertility in the last decades. One aspect of ovulation induction that required attention is the occurrence of a premature luteinizing hormone (LH) surge before the leading follicle reaches the optimum diameter for triggering ovulation by human chorionic gonadotrophin (hCG). It was reported that premature LH surge occurs in a significant number of patients undergoing ovulation induction . Such premature LH surge prevents effective induction of multiple follicular maturation for in vitro fertilization (IVF) and resulted in a significant cancellation of IVF cycles .
Ovarian stimulation is the starting point of reproductive medicine but the procedure can result in adverse reactions particularly the dangerous ovarian hyperstimulation syndrome. Fully revised in line with modern practice of ovarian stimulation, this new edition is divided into six sections that cover mild forms, non-conventional forms, IVF, complications and their management, alternatives, and the practicalities of procedures. All aspects of ovarian stimulation are discussed including the different stimulation protocols from which to choose, the management of poor responders and hyper-responders, as well as stimulation in patients with PCOS. Comprehensively reviewing the modern approach to ovarian stimulation, the alternative procedures are also described, both in IVF and other methods of assisted reproduction. Written by leading experts on reproductive health and fertility, this book will assist infertility specialists, gynecologists, reproductive endocrinologists and radiologists in determining successful treatment for their patients.
Prevention of ovarian hyperstimulation syndrome (OHSS) during ovarian stimulation is the important step in the management of this serious complication, which is associated with serious morbidity and possible mortality in a young healthy woman. In two recent meta-analyses comparing the outcome of gonadotropin-releasing hormone (GnRH) agonist versus antagonist, both showed that the incidence of OHSS was reduced in the antagonist protocol. Coasting helps to reduce the incidence of OHSS markedly, however, complete prevention with coasting was not possible. The effectiveness of human albumin administration in prevention of OHSS was published in a Cochrane review. A low dose of human chorionic gonadotropin (hCG) appears to reduce the incidence of OHSS without compromising success rates. The administration of hCG leads to vascular permeability enhancement resulting in loss of fluid and the full blown syndrome. The dopamine agonist cabergoline can reverse VEGFR-2 and the increased vascular permeability.
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.