Selection of agents for enhanced follicular recruitment in an in vitro fertilization and embryo replacement treatment program.

In summary, although clomiphene alone, two combinations of clomiphene and hMG, and high dosages of hMG alone all resulted in similar degrees of enhanced follicular recruitment at the time of hCG administration, the patients in the group receiving clomiphene alone had significantly fewer follicles at the time of laparoscopy compared with those of the other three groups. Although clomiphene alone is able to produce sufficient enhanced follicular recruitment, it appears that it is necessary for gonadotropin support to be continued to prevent atresia of some of the cohort of follicles. Second, even though we achieved our best results (with respect to number of embryos replaced per patient) with the use of high-dose hMG, we believe that the ovarian hyperstimulation produced by that regimen resulted in an abnormal luteal phase which made establishment of clinical pregnancies less likely. It is certainly possible that the observed short luteal phases might be able to be corrected with supplemental hCG and/or progesterone. Similar to the results of others, our best results (that is, the highest percentage of the establishment of continuing clinical pregnancies) occurred when the regimen of follicular recruitment agents was individualized depending upon the individual patient's response with respect to size and number of follicles and peripheral E2 levels. However, the differences in pregnancy rates among groups were not statistically significant. Although the ideal regimen for enhanced follicular recruitment has probably not yet been determined, it appears that a combination of clomiphene plus concurrent and sequential hMG in individualized dosages offers the best chance for sufficient ovarian stimulation to ultimately increase the number of embryos available for uterine replacement, and at the same time minimize the disruption of the subsequent luteal phase.