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).

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.

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.

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.