ESHRE guideline: ovarian stimulation for IVF/ICSI
Abstract STUDY QUESTION What is the recommended management of ovarian stimulation, based on the best available evidence in the literature? SUMMARY ANSWER The guideline development group formulated 84 recommendations answering 18 key questions on ovarian stimulation. WHAT IS KNOWN ALREADY Ovarian sti...
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| creator | Bosch, Ernesto Broer, Simone Griesinger, Georg Grynberg, Michael Humaidan, Peter Kolibianakis, Estratios Kunicki, Michal La Marca, Antonio Lainas, George Le Clef, Nathalie Massin, Nathalie Mastenbroek, Sebastiaan Polyzos, Nikolaos Sunkara, Sesh Kamal Timeva, Tanya Töyli, Mira Urbancsek, Janos Vermeulen, Nathalie Broekmans, Frank |
| description | Abstract
STUDY QUESTION
What is the recommended management of ovarian stimulation, based on the best available evidence in the literature?
SUMMARY ANSWER
The guideline development group formulated 84 recommendations answering 18 key questions on ovarian stimulation.
WHAT IS KNOWN ALREADY
Ovarian stimulation for IVF/ICSI has been discussed briefly in the National Institute for Health and Care Excellence guideline on fertility problems, and the Royal Australian and New Zealand College of Obstetricians and Gynaecologist has published a statement on ovarian stimulation in assisted reproduction. There are, to our knowledge, no evidence-based guidelines dedicated to the process of ovarian stimulation.
STUDY DESIGN, SIZE, DURATION
The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 8 November 2018 and written in English were included. The critical outcomes for this guideline were efficacy in terms of cumulative live birth rate per started cycle or live birth rate per started cycle, as well as safety in terms of the rate of occurrence of moderate and/or severe ovarian hyperstimulation syndrome (OHSS).
PARTICIPANTS/MATERIALS, SETTING, METHODS
Based on the collected evidence, recommendations were formulated and discussed until consensus was reached within the guideline group. A stakeholder review was organized after finalization of the draft. The final version was approved by the guideline group and the ESHRE Executive Committee.
MAIN RESULTS AND THE ROLE OF CHANCE
The guideline provides 84 recommendations: 7 recommendations on pre-stimulation management, 40 recommendations on LH suppression and gonadotrophin stimulation, 11 recommendations on monitoring during ovarian stimulation, 18 recommendations on triggering of final oocyte maturation and luteal support and 8 recommendations on the prevention of OHSS. These include 61 evidence-based recommendations—of which only 21 were formulated as strong recommendations—and 19 good practice points and 4 research-only recommendations. The guideline includes a strong recommendation for the use of either antral follicle count or anti-Müllerian hormone (instead of other ovarian reserve tests) to predict high and poor response to ovarian stimulation. The guideline also includes a strong recommendation for the use of the GnRH antagonist protocol o |
| doi_str_mv | 10.1093/hropen/hoaa009 |
| format | Article |
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STUDY QUESTION
What is the recommended management of ovarian stimulation, based on the best available evidence in the literature?
SUMMARY ANSWER
The guideline development group formulated 84 recommendations answering 18 key questions on ovarian stimulation.
WHAT IS KNOWN ALREADY
Ovarian stimulation for IVF/ICSI has been discussed briefly in the National Institute for Health and Care Excellence guideline on fertility problems, and the Royal Australian and New Zealand College of Obstetricians and Gynaecologist has published a statement on ovarian stimulation in assisted reproduction. There are, to our knowledge, no evidence-based guidelines dedicated to the process of ovarian stimulation.
STUDY DESIGN, SIZE, DURATION
The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 8 November 2018 and written in English were included. The critical outcomes for this guideline were efficacy in terms of cumulative live birth rate per started cycle or live birth rate per started cycle, as well as safety in terms of the rate of occurrence of moderate and/or severe ovarian hyperstimulation syndrome (OHSS).
PARTICIPANTS/MATERIALS, SETTING, METHODS
Based on the collected evidence, recommendations were formulated and discussed until consensus was reached within the guideline group. A stakeholder review was organized after finalization of the draft. The final version was approved by the guideline group and the ESHRE Executive Committee.
MAIN RESULTS AND THE ROLE OF CHANCE
The guideline provides 84 recommendations: 7 recommendations on pre-stimulation management, 40 recommendations on LH suppression and gonadotrophin stimulation, 11 recommendations on monitoring during ovarian stimulation, 18 recommendations on triggering of final oocyte maturation and luteal support and 8 recommendations on the prevention of OHSS. These include 61 evidence-based recommendations—of which only 21 were formulated as strong recommendations—and 19 good practice points and 4 research-only recommendations. The guideline includes a strong recommendation for the use of either antral follicle count or anti-Müllerian hormone (instead of other ovarian reserve tests) to predict high and poor response to ovarian stimulation. The guideline also includes a strong recommendation for the use of the GnRH antagonist protocol over the GnRH agonist protocols in the general IVF/ICSI population, based on the comparable efficacy and higher safety. For predicted poor responders, GnRH antagonists and GnRH agonists are equally recommended. With regards to hormone pre-treatment and other adjuvant treatments (metformin, growth hormone (GH), testosterone, dehydroepiandrosterone, aspirin and sildenafil), the guideline group concluded that none are recommended for increasing efficacy or safety.
LIMITATIONS, REASON FOR CAUTION
Several newer interventions are not well studied yet. For most of these interventions, a recommendation against the intervention or a research-only recommendation was formulated based on insufficient evidence. Future studies may require these recommendations to be revised.
WIDER IMPLICATIONS OF THE FINDINGS
The guideline provides clinicians with clear advice on best practice in ovarian stimulation, based on the best evidence available. In addition, a list of research recommendations is provided to promote further studies in ovarian stimulation.
STUDY FUNDING/COMPETING INTEREST(S)
The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payment. F.B. reports research grant from Ferring and consulting fees from Merck, Ferring, Gedeon Richter and speaker’s fees from Merck. N.P. reports research grants from Ferring, MSD, Roche Diagnositics, Theramex and Besins Healthcare; consulting fees from MSD, Ferring and IBSA; and speaker’s fees from Ferring, MSD, Merck Serono, IBSA, Theramex, Besins Healthcare, Gedeon Richter and Roche Diagnostics. A.L.M reports research grants from Ferring, MSD, IBSA, Merck Serono, Gedeon Richter and TEVA and consulting fees from Roche, Beckman-Coulter. G.G. reports consulting fees from MSD, Ferring, Merck Serono, IBSA, Finox, Theramex, Gedeon-Richter, Glycotope, Abbott, Vitrolife, Biosilu, ReprodWissen, Obseva and PregLem and speaker’s fees from MSD, Ferring, Merck Serono, IBSA, Finox, TEVA, Gedeon Richter, Glycotope, Abbott, Vitrolife and Biosilu. E.B. reports research grants from Gedeon Richter; consulting and speaker’s fees from MSD, Ferring, Abbot, Gedeon Richter, Merck Serono, Roche Diagnostics and IBSA; and ownership interest from IVI-RMS Valencia. P.H. reports research grants from Gedeon Richter, Merck, IBSA and Ferring and speaker’s fees from MSD, IBSA, Merck and Gedeon Richter. J.U. reports speaker’s fees from IBSA and Ferring. N.M. reports research grants from MSD, Merck and IBSA; consulting fees from MSD, Merck, IBSA and Ferring and speaker’s fees from MSD, Merck, IBSA, Gedeon Richter and Theramex. M.G. reports speaker’s fees from Merck Serono, Ferring, Gedeon Richter and MSD. S.K.S. reports speaker’s fees from Merck, MSD, Ferring and Pharmasure. E.K. reports speaker’s fees from Merck Serono, Angellini Pharma and MSD. M.K. reports speaker’s fees from Ferring. T.T. reports speaker’s fees from Merck, MSD and MLD. The other authors report no conflicts of interest.
Disclaimer
This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained.
Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type.
ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose. (Full disclaimer available at
www.eshre.eu/guidelines.)
†ESHRE Pages content is not externally peer reviewed. The manuscript has been approved by the Executive Committee of ESHRE.</description><identifier>ISSN: 2399-3529</identifier><identifier>EISSN: 2399-3529</identifier><identifier>DOI: 10.1093/hropen/hoaa009</identifier><identifier>PMID: 32395637</identifier><language>eng</language><publisher>England: Oxford University Press</publisher><subject>Care and treatment ; ESHRE Pages ; Fertilization in vitro, Human ; Methods ; Ovaries ; Practice guidelines (Medicine)</subject><ispartof>Human reproduction open, 2020, Vol.2020 (2), p.hoaa009</ispartof><rights>The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. 2020</rights><rights>The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology.</rights><rights>COPYRIGHT 2020 Oxford University Press</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c4029-85f8a6e62b046669c6c8192f7ab86838f489f79313540d9bac3ec1a415c8110c3</citedby><cites>FETCH-LOGICAL-c4029-85f8a6e62b046669c6c8192f7ab86838f489f79313540d9bac3ec1a415c8110c3</cites><orcidid>0000-0002-0606-5804 ; 0000-0001-8046-6799 ; 0000-0002-3865-7142 ; 0000-0003-4574-1809 ; 0000-0003-1366-2727</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7203749/pdf/$$EPDF$$P50$$Gpubmedcentral$$Hfree_for_read</linktopdf><linktohtml>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7203749/$$EHTML$$P50$$Gpubmedcentral$$Hfree_for_read</linktohtml><link.rule.ids>230,315,729,782,786,866,887,1586,1606,4026,27930,27931,27932,53798,53800</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/32395637$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Bosch, Ernesto</creatorcontrib><creatorcontrib>Broer, Simone</creatorcontrib><creatorcontrib>Griesinger, Georg</creatorcontrib><creatorcontrib>Grynberg, Michael</creatorcontrib><creatorcontrib>Humaidan, Peter</creatorcontrib><creatorcontrib>Kolibianakis, Estratios</creatorcontrib><creatorcontrib>Kunicki, Michal</creatorcontrib><creatorcontrib>La Marca, Antonio</creatorcontrib><creatorcontrib>Lainas, George</creatorcontrib><creatorcontrib>Le Clef, Nathalie</creatorcontrib><creatorcontrib>Massin, Nathalie</creatorcontrib><creatorcontrib>Mastenbroek, Sebastiaan</creatorcontrib><creatorcontrib>Polyzos, Nikolaos</creatorcontrib><creatorcontrib>Sunkara, Sesh Kamal</creatorcontrib><creatorcontrib>Timeva, Tanya</creatorcontrib><creatorcontrib>Töyli, Mira</creatorcontrib><creatorcontrib>Urbancsek, Janos</creatorcontrib><creatorcontrib>Vermeulen, Nathalie</creatorcontrib><creatorcontrib>Broekmans, Frank</creatorcontrib><creatorcontrib>The ESHRE Guideline Group on Ovarian Stimulation</creatorcontrib><title>ESHRE guideline: ovarian stimulation for IVF/ICSI</title><title>Human reproduction open</title><addtitle>Hum Reprod Open</addtitle><description>Abstract
STUDY QUESTION
What is the recommended management of ovarian stimulation, based on the best available evidence in the literature?
SUMMARY ANSWER
The guideline development group formulated 84 recommendations answering 18 key questions on ovarian stimulation.
WHAT IS KNOWN ALREADY
Ovarian stimulation for IVF/ICSI has been discussed briefly in the National Institute for Health and Care Excellence guideline on fertility problems, and the Royal Australian and New Zealand College of Obstetricians and Gynaecologist has published a statement on ovarian stimulation in assisted reproduction. There are, to our knowledge, no evidence-based guidelines dedicated to the process of ovarian stimulation.
STUDY DESIGN, SIZE, DURATION
The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 8 November 2018 and written in English were included. The critical outcomes for this guideline were efficacy in terms of cumulative live birth rate per started cycle or live birth rate per started cycle, as well as safety in terms of the rate of occurrence of moderate and/or severe ovarian hyperstimulation syndrome (OHSS).
PARTICIPANTS/MATERIALS, SETTING, METHODS
Based on the collected evidence, recommendations were formulated and discussed until consensus was reached within the guideline group. A stakeholder review was organized after finalization of the draft. The final version was approved by the guideline group and the ESHRE Executive Committee.
MAIN RESULTS AND THE ROLE OF CHANCE
The guideline provides 84 recommendations: 7 recommendations on pre-stimulation management, 40 recommendations on LH suppression and gonadotrophin stimulation, 11 recommendations on monitoring during ovarian stimulation, 18 recommendations on triggering of final oocyte maturation and luteal support and 8 recommendations on the prevention of OHSS. These include 61 evidence-based recommendations—of which only 21 were formulated as strong recommendations—and 19 good practice points and 4 research-only recommendations. The guideline includes a strong recommendation for the use of either antral follicle count or anti-Müllerian hormone (instead of other ovarian reserve tests) to predict high and poor response to ovarian stimulation. The guideline also includes a strong recommendation for the use of the GnRH antagonist protocol over the GnRH agonist protocols in the general IVF/ICSI population, based on the comparable efficacy and higher safety. For predicted poor responders, GnRH antagonists and GnRH agonists are equally recommended. With regards to hormone pre-treatment and other adjuvant treatments (metformin, growth hormone (GH), testosterone, dehydroepiandrosterone, aspirin and sildenafil), the guideline group concluded that none are recommended for increasing efficacy or safety.
LIMITATIONS, REASON FOR CAUTION
Several newer interventions are not well studied yet. For most of these interventions, a recommendation against the intervention or a research-only recommendation was formulated based on insufficient evidence. Future studies may require these recommendations to be revised.
WIDER IMPLICATIONS OF THE FINDINGS
The guideline provides clinicians with clear advice on best practice in ovarian stimulation, based on the best evidence available. In addition, a list of research recommendations is provided to promote further studies in ovarian stimulation.
STUDY FUNDING/COMPETING INTEREST(S)
The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payment. F.B. reports research grant from Ferring and consulting fees from Merck, Ferring, Gedeon Richter and speaker’s fees from Merck. N.P. reports research grants from Ferring, MSD, Roche Diagnositics, Theramex and Besins Healthcare; consulting fees from MSD, Ferring and IBSA; and speaker’s fees from Ferring, MSD, Merck Serono, IBSA, Theramex, Besins Healthcare, Gedeon Richter and Roche Diagnostics. A.L.M reports research grants from Ferring, MSD, IBSA, Merck Serono, Gedeon Richter and TEVA and consulting fees from Roche, Beckman-Coulter. G.G. reports consulting fees from MSD, Ferring, Merck Serono, IBSA, Finox, Theramex, Gedeon-Richter, Glycotope, Abbott, Vitrolife, Biosilu, ReprodWissen, Obseva and PregLem and speaker’s fees from MSD, Ferring, Merck Serono, IBSA, Finox, TEVA, Gedeon Richter, Glycotope, Abbott, Vitrolife and Biosilu. E.B. reports research grants from Gedeon Richter; consulting and speaker’s fees from MSD, Ferring, Abbot, Gedeon Richter, Merck Serono, Roche Diagnostics and IBSA; and ownership interest from IVI-RMS Valencia. P.H. reports research grants from Gedeon Richter, Merck, IBSA and Ferring and speaker’s fees from MSD, IBSA, Merck and Gedeon Richter. J.U. reports speaker’s fees from IBSA and Ferring. N.M. reports research grants from MSD, Merck and IBSA; consulting fees from MSD, Merck, IBSA and Ferring and speaker’s fees from MSD, Merck, IBSA, Gedeon Richter and Theramex. M.G. reports speaker’s fees from Merck Serono, Ferring, Gedeon Richter and MSD. S.K.S. reports speaker’s fees from Merck, MSD, Ferring and Pharmasure. E.K. reports speaker’s fees from Merck Serono, Angellini Pharma and MSD. M.K. reports speaker’s fees from Ferring. T.T. reports speaker’s fees from Merck, MSD and MLD. The other authors report no conflicts of interest.
Disclaimer
This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained.
Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type.
ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose. (Full disclaimer available at
www.eshre.eu/guidelines.)
†ESHRE Pages content is not externally peer reviewed. The manuscript has been approved by the Executive Committee of ESHRE.</description><subject>Care and treatment</subject><subject>ESHRE Pages</subject><subject>Fertilization in vitro, Human</subject><subject>Methods</subject><subject>Ovaries</subject><subject>Practice guidelines (Medicine)</subject><issn>2399-3529</issn><issn>2399-3529</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2020</creationdate><recordtype>article</recordtype><sourceid>TOX</sourceid><recordid>eNqFkd1LQyEYhyWKFrXbLuNAN3Wxza_j0S6CGKsGQdCqW3FON-McXboT9N_n2BoFQXih-D7vw6s_AE4R7CMoyGARw9L4wSIoBaHYA0eYCNEjJRb7P84d0E3pDUKIOK4gJoegQ3KxZKQ6Amg0uX8aFfPWzUztvLkqwoeKTvkirVzT1mrlgi9siMX49XYwHk7GJ-DAqjqZ7nY_Bi-3o-fhfe_h8W48vHnoaQqx6PHScsUMw1NIGWNCM82RwLZSU8444ZZyYStBECkpnImp0sRopCgqM4egJsfgeuNdttPGzLTxq6hquYyuUfFTBuXk74p3CzkPH7LCkFRUZMHFVhDDe2vSSjYuaVPXypvQJolp_hFEKIQZPd-gc1Ub6bwN2ajXuLxhvKowLRnKVP8PKq-ZaZwO3liX7_9q0DGkFI3dTY-gXCcoNwnKbYK54eznm3f4d14ZuNwAoV3-J_sCrLukBQ</recordid><startdate>2020</startdate><enddate>2020</enddate><creator>Bosch, Ernesto</creator><creator>Broer, Simone</creator><creator>Griesinger, Georg</creator><creator>Grynberg, Michael</creator><creator>Humaidan, Peter</creator><creator>Kolibianakis, Estratios</creator><creator>Kunicki, Michal</creator><creator>La Marca, Antonio</creator><creator>Lainas, George</creator><creator>Le Clef, Nathalie</creator><creator>Massin, Nathalie</creator><creator>Mastenbroek, Sebastiaan</creator><creator>Polyzos, Nikolaos</creator><creator>Sunkara, Sesh Kamal</creator><creator>Timeva, Tanya</creator><creator>Töyli, Mira</creator><creator>Urbancsek, Janos</creator><creator>Vermeulen, Nathalie</creator><creator>Broekmans, Frank</creator><general>Oxford University Press</general><scope>TOX</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope><scope>5PM</scope><orcidid>https://orcid.org/0000-0002-0606-5804</orcidid><orcidid>https://orcid.org/0000-0001-8046-6799</orcidid><orcidid>https://orcid.org/0000-0002-3865-7142</orcidid><orcidid>https://orcid.org/0000-0003-4574-1809</orcidid><orcidid>https://orcid.org/0000-0003-1366-2727</orcidid></search><sort><creationdate>2020</creationdate><title>ESHRE guideline: ovarian stimulation for IVF/ICSI</title><author>Bosch, Ernesto ; Broer, Simone ; Griesinger, Georg ; Grynberg, Michael ; Humaidan, Peter ; Kolibianakis, Estratios ; Kunicki, Michal ; La Marca, Antonio ; Lainas, George ; Le Clef, Nathalie ; Massin, Nathalie ; Mastenbroek, Sebastiaan ; Polyzos, Nikolaos ; Sunkara, Sesh Kamal ; Timeva, Tanya ; Töyli, Mira ; Urbancsek, Janos ; Vermeulen, Nathalie ; Broekmans, Frank</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c4029-85f8a6e62b046669c6c8192f7ab86838f489f79313540d9bac3ec1a415c8110c3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2020</creationdate><topic>Care and treatment</topic><topic>ESHRE Pages</topic><topic>Fertilization in vitro, Human</topic><topic>Methods</topic><topic>Ovaries</topic><topic>Practice guidelines (Medicine)</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Bosch, Ernesto</creatorcontrib><creatorcontrib>Broer, Simone</creatorcontrib><creatorcontrib>Griesinger, Georg</creatorcontrib><creatorcontrib>Grynberg, Michael</creatorcontrib><creatorcontrib>Humaidan, Peter</creatorcontrib><creatorcontrib>Kolibianakis, Estratios</creatorcontrib><creatorcontrib>Kunicki, Michal</creatorcontrib><creatorcontrib>La Marca, Antonio</creatorcontrib><creatorcontrib>Lainas, George</creatorcontrib><creatorcontrib>Le Clef, Nathalie</creatorcontrib><creatorcontrib>Massin, Nathalie</creatorcontrib><creatorcontrib>Mastenbroek, Sebastiaan</creatorcontrib><creatorcontrib>Polyzos, Nikolaos</creatorcontrib><creatorcontrib>Sunkara, Sesh Kamal</creatorcontrib><creatorcontrib>Timeva, Tanya</creatorcontrib><creatorcontrib>Töyli, Mira</creatorcontrib><creatorcontrib>Urbancsek, Janos</creatorcontrib><creatorcontrib>Vermeulen, Nathalie</creatorcontrib><creatorcontrib>Broekmans, Frank</creatorcontrib><creatorcontrib>The ESHRE Guideline Group on Ovarian Stimulation</creatorcontrib><collection>Access via Oxford University Press (Open Access Collection)</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><collection>PubMed Central (Full Participant titles)</collection><jtitle>Human reproduction open</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Bosch, Ernesto</au><au>Broer, Simone</au><au>Griesinger, Georg</au><au>Grynberg, Michael</au><au>Humaidan, Peter</au><au>Kolibianakis, Estratios</au><au>Kunicki, Michal</au><au>La Marca, Antonio</au><au>Lainas, George</au><au>Le Clef, Nathalie</au><au>Massin, Nathalie</au><au>Mastenbroek, Sebastiaan</au><au>Polyzos, Nikolaos</au><au>Sunkara, Sesh Kamal</au><au>Timeva, Tanya</au><au>Töyli, Mira</au><au>Urbancsek, Janos</au><au>Vermeulen, Nathalie</au><au>Broekmans, Frank</au><aucorp>The ESHRE Guideline Group on Ovarian Stimulation</aucorp><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>ESHRE guideline: ovarian stimulation for IVF/ICSI</atitle><jtitle>Human reproduction open</jtitle><addtitle>Hum Reprod Open</addtitle><date>2020</date><risdate>2020</risdate><volume>2020</volume><issue>2</issue><spage>hoaa009</spage><pages>hoaa009-</pages><issn>2399-3529</issn><eissn>2399-3529</eissn><abstract>Abstract
STUDY QUESTION
What is the recommended management of ovarian stimulation, based on the best available evidence in the literature?
SUMMARY ANSWER
The guideline development group formulated 84 recommendations answering 18 key questions on ovarian stimulation.
WHAT IS KNOWN ALREADY
Ovarian stimulation for IVF/ICSI has been discussed briefly in the National Institute for Health and Care Excellence guideline on fertility problems, and the Royal Australian and New Zealand College of Obstetricians and Gynaecologist has published a statement on ovarian stimulation in assisted reproduction. There are, to our knowledge, no evidence-based guidelines dedicated to the process of ovarian stimulation.
STUDY DESIGN, SIZE, DURATION
The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 8 November 2018 and written in English were included. The critical outcomes for this guideline were efficacy in terms of cumulative live birth rate per started cycle or live birth rate per started cycle, as well as safety in terms of the rate of occurrence of moderate and/or severe ovarian hyperstimulation syndrome (OHSS).
PARTICIPANTS/MATERIALS, SETTING, METHODS
Based on the collected evidence, recommendations were formulated and discussed until consensus was reached within the guideline group. A stakeholder review was organized after finalization of the draft. The final version was approved by the guideline group and the ESHRE Executive Committee.
MAIN RESULTS AND THE ROLE OF CHANCE
The guideline provides 84 recommendations: 7 recommendations on pre-stimulation management, 40 recommendations on LH suppression and gonadotrophin stimulation, 11 recommendations on monitoring during ovarian stimulation, 18 recommendations on triggering of final oocyte maturation and luteal support and 8 recommendations on the prevention of OHSS. These include 61 evidence-based recommendations—of which only 21 were formulated as strong recommendations—and 19 good practice points and 4 research-only recommendations. The guideline includes a strong recommendation for the use of either antral follicle count or anti-Müllerian hormone (instead of other ovarian reserve tests) to predict high and poor response to ovarian stimulation. The guideline also includes a strong recommendation for the use of the GnRH antagonist protocol over the GnRH agonist protocols in the general IVF/ICSI population, based on the comparable efficacy and higher safety. For predicted poor responders, GnRH antagonists and GnRH agonists are equally recommended. With regards to hormone pre-treatment and other adjuvant treatments (metformin, growth hormone (GH), testosterone, dehydroepiandrosterone, aspirin and sildenafil), the guideline group concluded that none are recommended for increasing efficacy or safety.
LIMITATIONS, REASON FOR CAUTION
Several newer interventions are not well studied yet. For most of these interventions, a recommendation against the intervention or a research-only recommendation was formulated based on insufficient evidence. Future studies may require these recommendations to be revised.
WIDER IMPLICATIONS OF THE FINDINGS
The guideline provides clinicians with clear advice on best practice in ovarian stimulation, based on the best evidence available. In addition, a list of research recommendations is provided to promote further studies in ovarian stimulation.
STUDY FUNDING/COMPETING INTEREST(S)
The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payment. F.B. reports research grant from Ferring and consulting fees from Merck, Ferring, Gedeon Richter and speaker’s fees from Merck. N.P. reports research grants from Ferring, MSD, Roche Diagnositics, Theramex and Besins Healthcare; consulting fees from MSD, Ferring and IBSA; and speaker’s fees from Ferring, MSD, Merck Serono, IBSA, Theramex, Besins Healthcare, Gedeon Richter and Roche Diagnostics. A.L.M reports research grants from Ferring, MSD, IBSA, Merck Serono, Gedeon Richter and TEVA and consulting fees from Roche, Beckman-Coulter. G.G. reports consulting fees from MSD, Ferring, Merck Serono, IBSA, Finox, Theramex, Gedeon-Richter, Glycotope, Abbott, Vitrolife, Biosilu, ReprodWissen, Obseva and PregLem and speaker’s fees from MSD, Ferring, Merck Serono, IBSA, Finox, TEVA, Gedeon Richter, Glycotope, Abbott, Vitrolife and Biosilu. E.B. reports research grants from Gedeon Richter; consulting and speaker’s fees from MSD, Ferring, Abbot, Gedeon Richter, Merck Serono, Roche Diagnostics and IBSA; and ownership interest from IVI-RMS Valencia. P.H. reports research grants from Gedeon Richter, Merck, IBSA and Ferring and speaker’s fees from MSD, IBSA, Merck and Gedeon Richter. J.U. reports speaker’s fees from IBSA and Ferring. N.M. reports research grants from MSD, Merck and IBSA; consulting fees from MSD, Merck, IBSA and Ferring and speaker’s fees from MSD, Merck, IBSA, Gedeon Richter and Theramex. M.G. reports speaker’s fees from Merck Serono, Ferring, Gedeon Richter and MSD. S.K.S. reports speaker’s fees from Merck, MSD, Ferring and Pharmasure. E.K. reports speaker’s fees from Merck Serono, Angellini Pharma and MSD. M.K. reports speaker’s fees from Ferring. T.T. reports speaker’s fees from Merck, MSD and MLD. The other authors report no conflicts of interest.
Disclaimer
This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained.
Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type.
ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose. (Full disclaimer available at
www.eshre.eu/guidelines.)
†ESHRE Pages content is not externally peer reviewed. The manuscript has been approved by the Executive Committee of ESHRE.</abstract><cop>England</cop><pub>Oxford University Press</pub><pmid>32395637</pmid><doi>10.1093/hropen/hoaa009</doi><orcidid>https://orcid.org/0000-0002-0606-5804</orcidid><orcidid>https://orcid.org/0000-0001-8046-6799</orcidid><orcidid>https://orcid.org/0000-0002-3865-7142</orcidid><orcidid>https://orcid.org/0000-0003-4574-1809</orcidid><orcidid>https://orcid.org/0000-0003-1366-2727</orcidid><oa>free_for_read</oa></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 2399-3529 |
| ispartof | Human reproduction open, 2020, Vol.2020 (2), p.hoaa009 |
| issn | 2399-3529 2399-3529 |
| language | eng |
| recordid | cdi_pubmedcentral_primary_oai_pubmedcentral_nih_gov_7203749 |
| source | DOAJ Directory of Open Access Journals; Access via Oxford University Press (Open Access Collection); Elektronische Zeitschriftenbibliothek - Frei zugängliche E-Journals; Oxford University Press Journals All Titles (1996-Current); PubMed Central |
| subjects | Care and treatment ESHRE Pages Fertilization in vitro, Human Methods Ovaries Practice guidelines (Medicine) |
| title | ESHRE guideline: ovarian stimulation for IVF/ICSI |
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