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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).
The aim of treatment with a gonadotropin-releasing hormone (GnRH) agonist is elimination of the luteinizing hormone (LH) surge and fluctuating LH concentrations, which compromise outcome in cycles of ovarian stimulation for in-vitro fertilization (IVF). This chapter addresses the characteristics of the standard long-course protocol. It is most common to initiate treatment in the luteal phase to minimize the consequences of the flare effect seen in the first few days of treatment with a GnRH agonist. The down-regulation effect of agonists can be established and maintained by multiple applications of nasal spray, single daily injection, or depo formulations lasting variable lengths of time. When the patient is down-regulated at the start of follicle stimulating hormone (FSH) treatment, subsequent follicular growth and recruitment is dictated by two elements: the ovarian reserve, which dictates the number of follicles available for recruitment, and the profile of circulating FSH concentrations.
This chapter reviews the role of endometrial and subendometrial blood flow determined by Doppler ultrasound in the prediction of pregnancy during in vitro fertilization (IVF) treatment. Uterine Doppler study may not reflect the actual blood flow to the endometrium as the major compartment of the uterus is the myometrium and there is collateral circulation between uterine and ovarian vessels. Absent endometrial and subendometrial blood flow has been shown to be associated with no pregnancy or a significantly lower pregnancy rate. In combination with a 3D ultrasound, power Doppler provides a unique tool with which to measure the blood flow towards the whole endometrium and the subendometrial region. There was a significant elevation in the middle to late follicular phase, followed by a substantial fall and a secondary slow luteal phase rise that was maintained until the onset of menstruation. Doppler flow study of spiral arteries is not predictive of pregnancy.
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