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The availability of gonadotropin releasing hormone (GnRH) antagonists did not only offer clinicians an alternative to GnRH agonists but, more importantly, has led to the development of new concepts aiming to increase safety and simplicity in ovarian stimulation. These include the modified natural cycle, mild in vitro fertilization (IVF), the use of GnRH agonist for triggering of final oocyte maturation with elective cryopreservation in patients at risk of developing ovarian hyperstimulation syndrome (OHSS), the administration of antagonists during the luteal phase for management of severe OHSS, as well as control of endogenous luteinizing hormone (LH) with GnRH antagonists in intrauterine insemination (IUI) cycles. Administration of GnRH antagonists can be performed by either a single dose or by using a daily scheme. The need to simplify ovarian stimulation led to the development of long-acting follicle stimulating hormone (FSH).
This chapter reviews the regimens used in controlled ovarian hyperstimulation for in vitro fertilization (IVF) in the following categories: normal, poor, and high responders. Luteal suppression with gonadotropin releasing hormone (GnRH) agonists is usually associated with higher cancellation rates, increased dosages of gonadotropins, and prolonged days of stimulation in low responders. Several studies have compared the use of GnRH antagonist with the long GnRH agonist protocols in low responders. There are two different methods of ovulatory triggers for oocyte maturation: exogenous human chorionic gonadotrpin (hCG) and GnRH agonist in antagonist cycles. Minimal stimulation protocols are being used more commonly in IVF. The use of such stimulation protocols can be applied in cases of both poor and high responders. When in vitro maturation (IVM) is performed, fertilization is usually performed with intracytoplasmic sperm injection (ICSI), and endometrial preparation with estrogen and progesterone is necessary.