Controlled ovarian hyperstimulation: a review for the non-ART patient

Controlled ovarian hyperstimulation (COH) involves the administration of oral and/or injectable medications to induce ovulation in the anovulatory infertile patient, and superovulation in the ovulatory infertile patient. The different types of medication and protocols for COH are reviewed. Oral medications such as clomiphene and letrozole should be considered in most patients initially, except in the case of hypogonadotropic amenorrhea. Pregnancy rates are higher with the injectable medications, follicle stimualtion hormone (FSH) and human menopausal gonadotrpins (hMG), than oral medications; however, injectable medications have a higher risk of multiple gestation, ovarian hyperstimulation syndrome, cost and monitoring. Strategies to enhance the responsiveness to these medications in polycystic ovarian syndrome patients including adjunctive treatment with metformin and/or dexamethasone will be discussed. Combined protocols which use oral and injectable gonadotropins may also lower risks and costs without sacrificing chances of pregnancy. Patients with hypogonadotropic amenorrhea benefit from the addition of leutinizing hormone (LH) activity such as hMG, recombinant leutinizing hormone (rLH) or low dose human chroionic gonadotropin to FSH stimulation. Ovulation and luteal phase support with progesterone is generally recommended in injectable cycles but not with oral medications.