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  3. Ovarian Stimulation
  • Cited by 1
Publisher:
Cambridge University Press
Online publication date:
August 2011
Print publication year:
2010
Online ISBN:
9780511762390
DOI:
https://doi.org/10.1017/CBO9780511762390
Subjects:
Obstetrics and Gynecology, Reproductive Medicine, Medicine
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Information

Book description

Ovarian Stimulation covers all the basic and advanced aspects of ovarian stimulation for women undergoing ovulation induction and assisted reproduction. It gives a comprehensive review of the modern approach to ovarian stimulation and its alternatives - both in IVF and in other areas of reproductive endocrinology where it is employed. The book is divided into six sections that cover mild forms, non-conventional forms, IVF, complications and their management, alternatives, and procedures. The chapters are clearly written and well illustrated, discussing a wide range of relevant topics, including the protocols of gonadotropin, oral agents for ovulation induction, aromatase inhibitors and surgical induction of ovulation, ovarian hyperstimulation syndrome, and alternatives to drug treatment. Written by leading experts on reproductive health and fertility, it will assist infertility specialists, gynecologists, reproductive endocrinologists and radiologists in determining their patients' treatment.

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Contents

Page 2 of 2

Contents
  • Chapter 17 - In vitro maturation of oocytes
    pp 181-194
  • View abstract

    Summary

    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.
  • Chapter 19 - Ovarian cautery for polycystic ovary syndrome
    pp 209-216
  • View abstract

    Summary

    Polycystic ovarian syndrome (PCOS) is one of the most prevalent endocrinopathies, affecting 5-10% of women of reproductive age. PCOS is one of the commonest causes of anovulatory infertility. The characteristic clinical features of PCOS include menstrual irregularity such as oligomenorrhoea and signs of hyperandrogenaemia including hirsutism, acne, and/or obesity. A recent study observed a significant and progressive correlation between body mass index (BMI) and both blood pressure and clinical features in women with PCOS. Clomifene citrate has been the standard treatment for induction of ovulation in women with anovulatory infertility for many years. The beneficial endocrinologic and morphologic effects of laparoscopic ovarian diathermy appear to be sustained for up to 9 years in most patients with PCOS. In vitro maturation (IVM) protocols are now a valuable alternative to conventional in vitro fertilization (IVF) as a strategy to prevent ovarian hyperstimulation syndrome (OHSS).
  • Chapter 20 - Ultrasound monitoring for ovulation induction: pitfalls and problems
    pp 217-232
  • View abstract

    Summary

    Ovarian hyperstimulation syndrome (OHSS) is the most serious iatrogenic complication of ovulation induction. The ovaries are noted to have a significant degree of stromal edema, interspersed with multiple hemorrhagic follicular and theca-lutein cysts, areas of cortical necrosis, and neovascularization. Mutations in follicle-stimulating hormone (FSH) receptors could be activating, resulting in OHSS, or inactivating, resulting in sterility. Bone morphogenic protein-15 (BMP-15) appears to be associated with mechanisms of infertility and superfertility in a dosage-sensitive manner. Human chorionic gonadotropin increases vascular endothelial growth factor (VEGF) production by granulosa cells and endothelial cells, which results in increased vascular permeability. Increased intraovarian blood flow and low intravascular ovarian resistance are correlated with the severity of OHSS in patients who develop the syndrome. The medical treatment of OHSS consists of correction of circulatory volume and electrolyte imbalance. Ultrasonographic guidance of transvaginal or transabdominal aspiration of ascites improves the symptoms of patients with OHSS.
  • Chapter 21 - Triggering of final oocyte maturation in ovarian stimulation
    pp 233-243
  • View abstract

    Summary

    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.
  • Chapter 22 - Luteal phase support in in vitro fertilization
    pp 244-254
  • View abstract

    Summary

    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.

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