The document discusses controlled ovarian stimulation (COS) for in vitro fertilization (IVF). It notes that the number of oocytes retrieved during COS is a key prognostic factor for live birth, and that tests like antral follicle count (AFC) and anti-Müllerian hormone (AMH) can help predict ovarian response. The goal of COS is to optimize oocyte yield while avoiding over-response and risks like ovarian hyperstimulation syndrome (OHSS). Personalizing regimens based on individual factors like age and ovarian reserve tests may improve outcomes.

1. Background
• Number of oocytes retrieved following controlled
ovarian stimulation (COS) is an important prognostic
variable in IVF (Sunkara et al., 2011)
• There is a strong association between the number of
oocytes retrieved and live birth (LB) following IVF
• The number of oocytes is a robust surrogate
outcome for clinical success

2. Background
• The relationship between the number of oocytes
retrieved and LB following IVF is non-linear

3. Background
• This valuable information is helpful in
planning IVF treatment regimens
• COS regimens should aim to optimise the
number of oocytes and maximise IVF success
• Essential to personalise COS regimens as
there is diversity among couples and women
seeking ART

4. Background
• Female age and tests of ovarian reserve have a
predictive value for ovarian response to COS
• AFC and AMH are sensitive predictors of poor
response and hyper-response to COS (Broer et al.,
2009; Broer et al., 2011)
• Use of these tests can therefore provide a very
specific characterisation of individual women

5. Discussion
• The primary aim of IVF treatment is to achieve a
healthy live birth
• Two particular challenges to COS are women with
poor ovarian response and women likely to hyper-
respond
• Whilst poor responders have lower success rates
compared to normal responders (Ulug et al., 2003),
hyper-responders have an increased risk of OHSS

6. Discussion
• Moreover, it has been shown that the chance of LB is
reduced with very high number of oocytes following
a fresh IVF cycle (Sunkara et al., 2011)
• The GnRH agonist long regimen is the most widely
used in COS (Maklon et al., 2006)

7. Discussion
• The GnRH antagonist regimen is likely to be
beneficial for women with PCOS compared to the
GnRH agonist regimen (Pundir at al., 2012)
– associated with a lower incidence of moderate and severe
OHSS
– comparable live birth rates

8. Discussion
• Several interventions have been proposed to
improve the IVF outcome of poor responders
– various pituitary suppression regimens
– variations in gonadotrophin type and dose
– adjuvant therapies such as androgen, luteinising hormone
(LH) and growth hormone supplementation
• Inconclusive evidence that any particular
intervention is beneficial for poor responders
(Panadian et al., 2010)

9. Discussion
• Minimal or mild ovarian stimulation regimens are
considered to be cost effective with similar success
rates compared to the standard agonist regimen
(Heijnen et al., 2008)
• However, local guidelines and funding policies are
likely to influence decisions by clinicians and women

10. Conclusion
It is important to individualise COS regimens in order
to achieve desired outcome of a healthy live birth
with minimum costs and side effects