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...

The success rate of reproductive treatment methods depends on many different factors. The most important and discussed ones in the literature are maternal age, the causes of infertility, the ovarian response to stimulation, the influence of the male factor and sperm quality, embryo quality and the various uterine pathologies. Some couples fail repeatedly after transferring good quality embryos without any obvious reason and this becomes a major continuing problem after IVF/ICSI procedures. It can be speculated that in these couples, insufficiency of the endometrium might be a possible reason for implantation failure. This review article summarized current literature describing the consecutive endomertial procedures involved in successful embryo implantation. It is believed that efforts to align criteria for definition of recurrent implantation failure (RIF) and attempts to classify different RIF types would develop guidelines for treatment procedures which would result in an increase in patients’ opportunities to conceive.

The implementation of safe and maximally effective ovarian stimulation is a major aim forin vitrofertilization (IVF) teams. The goal of controlled ovarian hyperstimulation (COH) is to supply enough oocytes with normal maturation to insure the consequent biological procedures. A variety of different stimulation protocols have been suggested and an individual selection of the correct stimulation protocol is mandatory. The aim of the present study is to evaluate the correlation between number of retrieved oocytes and clinical pregnancy rate (CPR) after IVF or intracytoplasmic sperm injection (ICSI) procedures. We reviewed 1017 cycles in a total of 975 patients. The study results clearly demonstrate that the aspiration of less than 5 oocytes significantly reduced pregnancy rate. The aspiration of a large number of oocytes (>15) does not lead to an increase of the treatment effect and, at the same time, increases the risk of ovarian hyperstimulation syndrome. The major goal is to obtain 5—15 oocytes as a “gold standard”, connected to optimal pregnancy rate after assisted reproduction (ART).

What is the recommended management of ovarian stimulation, based on the best available evidence in the literature? This updated ESHRE guideline on ovarian stimulation for IVF/ICSI provides 121 recommendations, answering 21 key questions on ovarian stimulation for IVF/ICSI. Before the ESHRE guideline on ovarian stimulation for IVF/ICSI was published in 2019, ovarian stimulation for IVF/ICSI had only been discussed briefly in the National Institute for Health and Care Excellence guideline on fertility problems and in a statement by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. The guideline was developed according to the structured methodology for ESHRE guidelines. The 18 key questions from the 2019 version of the guideline were revised by the Guideline Development Group (GDG). This resulted in the addition of one new key question, the splitting of the key question on fertility preservation in three separate key questions (fertility preservation for women facing gonadotoxic treatment, elective oocyte cryopreservation, and oocyte donation) and several new interventions being added to the existing key questions. Papers published between 31 October 2018 and 2 February 2025 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). Based on the available evidence, recommendations were formulated and discussed until consensus was reached within the GDG. Following stakeholder review of the initial draft, the final version was approved by the GDG and ultimately by the ESHRE Executive Committee. The guideline provides a total of 121 recommendations: 42 recommendations remained unchanged in 2019, 4 recommendations were reworded for better understanding, 29 recommendations were updated in view of new evidence, and 46 new recommendations for 2025 have been formulated. The guideline provides 4 recommendations on pre-stimulation evaluation, 7 recommendations on pre-treatment therapies, 50 recommendations on pituitary suppression and ovarian stimulation, 17 recommendations on monitoring, 18 recommendations on triggering of final oocyte maturation and luteal support, and 8 recommendations on the prevention of OHSS. In addition, the guideline provides 17 recommendations on fertility preservation, both oncologic and elective, and oocyte donation. These include 90 evidence-based recommendations, of which only 42 were formulated as strong recommendations and 48 as conditional, as well as 29 good practice points and 2 research-only recommendations. Of the evidence-based recommendations, none were supported by high-quality evidence, 6 by moderate-quality evidence, 36 by low-quality evidence, and 148 by very low-quality evidence. To support future research on ovarian stimulation for IVF/ICSI, a list of research recommendations was provided. 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. 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. The guideline was developed by ESHRE, who funded the guideline meetings, literature searches, and dissemination of the guideline. The guideline group members did not receive any financial incentives; all work was provided voluntarily. BA reports speaker’s fees from Gedeon-Richter, Ferring, IBSA, Intas, Merck, Organon, consulting fees from Merck, Organon, Oxolife, stock options from Global Fertility Solutions LLC (employee co-investment), and was chair of the Turkish Society of Reproductive Medicine. EB reports research grants from Roche Diagnostics and IBSA, consulting fees from MSD, Abbot, Gedeon-Richter, Roche, speaker’s fees from IBSA, MSD, Ferring Pharmaceuticals, Abbot, Gedeon-Richter, Merck, Roche, participation in the advisory board of Ferring Pharmaceuticals, IBSA and Merck, and ownership interest from IVI-RMS Valencia. GG was part of the ESHRE working group on Recurrent Implantation Failure and the ESHRE working group on clinical KPISs, reports travel support from Merck, Organon, Ferring, Theramex, Gedeon-Richter, Abbott, consulting fees from Organon, Ferring, Merck, Gedeon-Richter, Theramex, Abbott, ReproNovo, Igyxos, OxoLife, Philipps, ReprodWissen, PregLem, Guerbet, Roche, IBSA, and Besins, speaker’s fees from Organon, Ferring, Merck, Gedeon-Richter, Theramex, Abbott, ReproNovo, Igyxos, OxoLife, Philipps, ReprodWissen, PregLem, Guerbet, Roche, IBSA, and Besins, and research grants from Besin, Merck, Abbott, Ferring, Theramex. MG reports speaker’s fees from Merck Serono, Ferring, and Gedeon Richter. EK reports travel/hotel expenses from Ferring, Merck SERONO, Vianex, speaker’s fees from Ferring, Merck SERONO, Vianex, and is chair of the Greek Society of Fertility and Sterility. MK reports travel support and speaker’s fees from Ferring. ALM reports research grants from Merck, Ferring, IBSA, Roche, Organon, Theramex, Beckman Coulter, and Gedeon-Richter, consulting fees from Merck, Ferring, IBSA, Roche, Organon, Theramex, Beckman Coulter, and Gedeon-Richter, speaker’s fees from Merck, Ferring, IBSA, Roche, Organon, Theramex, Beckman Coulter, Gedeon-Richter, and participation on an advisory board of Merck, Organon, Ferring, Theramex, Gedeon Richter, and IBSA. GL reports consulting fees from Ferring and Merck, speaker’s fees from Ferring, Merck, Gedeon-Richter, Organon, and Vianex, expert testimony fees from Cook, travel support from ESHRE, Ferring, Merck, Gedeon-Richter, Organon, and Vianex, is on the advisory board of Merck and Ferring, and participated in an ESHRE committee and on the Greek Fertility and Sterility Committee. NM reports research grants from IBSA, Organon, consulting fees from Organon, Merck, GE, Ferring, Abbott, and Cooper, and speaker’s fees from Ferring, GE, Organon, IBSA, Merck, Theramex. NPP reports research grants from Besins Healthcare, Ferring Pharmaceutical, Merck Serono, Organon, Roche Diagnostics, and Theramex, consulting fees from Besins Healthcare, Alife, Ferring, IBSA, Merck Serono, Organon, Abbott, FertilAI, and speaker’s fees from Besins Healthcare, Roche Diagnostics, Ferring Pharmaceuticals, Gedeon-Richter, IBSA, Merck Serono, Organon, and Theramex. SKS reports a research grant from Ferring, travel support from Merck and INTAS, consulting fees from Merck, and speaker’s fees from Merck, MSD, INTAS, and Ferring. TT reports travel support from Merck, speaker’s fees from Merck, Organon, MSD and is editor-in-chief of a Bulgarian journal, Reproductive Health. MT reports travel support from IBSA, Ferring, and Merck, consulting fees from Abbott and is a member of the board of the Finnish Endocrine Society. JU is a member of the Steering Committee of Richter Reproduction Network and received travel support from IBSA. FB reports a research grant from Besins, is on the advisory board of Merck and Abbott, reports speaker’s fees from Ferring, Merck, Besins, Intas Fermaceuticals, PREIS School; he is the owner of FRANKSCHOOL RforL. The other authors have nothing to disclose. N/A. 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. (The full disclaimer is available at www.eshre.eu/guidelines.)

The aim of our study was to determine the type and frequency of chromosomal aberrations and polymorphisms in men with different degrees of spermatogenic failure in comparison to men with normozoospermia, in order to find correlations between cytogenetic findings and the abnormal results of semen analysis. In our study, we performed cytogenetic analysis in 901 infertile men, divided into five groups according to semen analysis—normozoospermia (86), asthenozoospermia (394), oligoasthenozoospermia (182), severe male factor (100), and azoospermia (139). The frequency of polymorphisms was similar in all groups (11–16%, without significant differences). The frequency of numerical and structural aberrations increases with the degree of the spermatogenic failure (3.5% in normozoospermia, 5.6% in asthenozoospermia, 9.8% in oligoasthenozoospermia, 9% in severe male factor, and 13.5% in azoospermia). We found a significantly higher incidence of numerical chromosomal aberrations in severe male factor (7%) and azoospermia (9.3%). Oligoasthenozoospermia occured in 45% of cases with translocation, compared to 20% in the group with a normal karyotype. We revealed that chromosomal translocations are tightly associated with oligoasthenozoospermia, whereas numerical chromosomal aberrations—with severe male factor and azoospermia. The impact of chromosome polymorphisms on male infertility should be studied in greater detail.

Granulosa cells represent an essential part of the ovary's somatic compartment that maintains oocyte development and maturation and also provides the hormonal environment necessary to coordinate uterine receptivity with ovulation and, subsequently, to sustain early pregnancy. Primarily due to their major role in the processes of steroidogenesis and folliculogenesis, the study of granulosa cells is likely to be essential for comprehending and elucidating the cellular and molecular mechanisms underlying ovarian development and functions in both physiological and pathological conditions. Density gradient centrifugation is the primary method for the isolation of these cells from follicular fluid. However, this technique is time-consuming and in demand of additional reagents, experience, and dexterity. Furthermore, the limited half-life and proliferative potential of human granulosa cells put additional challenges for their study, making the conventional approaches for cultivation less applicable. Our aim was to develop dependable and effective protocols for the isolation and long-term cultivation of primary granulosa cells while preserving their functional and morphological characteristics. Human granulosa cells were isolated from follicular fluid by centrifugation and treatment with hyaluronidase without using density gradient centrifugation and/or red blood cell lysis buffer procedures. Steroidogenesis, growth dynamics, and the population doubling time of granulosa cells cultivated in a newly designed expansion medium, were determined. The medium consisted of DMEM/F12 supplemented with 5% human serum and 33% human follicular fluid. The isolation technique described in this study ensures the generation of granulosa cells with a very high level of purity. Granulosa cells cultivated in the newly developed expansion medium actively grew without changing morphologically and without losing the ability to produce estradiol and progesterone. Moreover, in this particular expansion medium, granulosa cells demonstrated a significantly increased proliferation rate, with a much shorter population doubling time compared to the control cultures grown in medium containing fetal bovine serum. Here we present a simple, fast, and cost-effective procedure for human granulosa cell isolation, combined with a reliable approach for their rapid growth and long-term cultivation based on a newly formulated expansion medium. Together, these two methods provide a comprehensive system for generating granulosa cell cultures, enabling their extensive study for the purposes of reproductive biology and medicine.