Individualizing ovarian stimulation protocols in ART

The ideal ovarian stimulation regimen for IVF should have a low cancelation rate, minimize drug costs, have low risks and side effects, require limited monitoring for practical convenience, and maximize singleton pregnancy rates. Individualization starts from an assessment before the start of IVF cycle of the ovarian reserve by antral follicle count (AFC), antimullerian hormone (AMH), FSH, and age of the patient. AFC and AMH are the most sensitive markers of ovarian reserve identified to date and should be used to plan individualized treatment. Once the patient is categorized as a hypo-/hyper- or normoresponder the dose of gonadotropin is decided. The selection of dose is of paramount importance for optimal outcome of controlled ovarian stimulation (COS). In case of poor responders and hyper-responders, GnRH antagonist regimes are preferred. This helps in explaining the prognosis and in appropriate counseling and also ensures a safe controlled ovarian stimulation with optimal results which prevent unnecessary psychological and financial burden on the couple. Cycle monitoring is important to decide any alteration in dose or when to add GnRH antagonist. In women at high risk for ovarian stimulation, it is important to start with low doses and intensive monitoring. In case there are indications of hyperstimulation, the regime may be altered by decreasing dose or coasting. Many factors are interdependent, and hence, a careful selection of the type of ovarian stimulation will be the key factor in deciding the success of the same.