As women age, their response to ovulation induction is progressively diminished due to the continuous depletion of primordial follicles and to changes in the ovarian endocrine/paracrine microenvironment. While many couples faced with the reality of a diagnosis of low functional ovarian reserve may turn to the use of donor gametes to achieve a pregnancy, some still feel the need to try on their own, despite a poor prognosis. For such women careful preparation and hormonal priming in the months prior to beginning an IVF cycle can increase their chance of a successful outcome. Optimal treatment of these patients differs from the usual treatment of women with normal ovarian reserve in every aspect and needs to be highly individualized.

Chronic anovulation is a very common disorder in polycystic ovary syndrome (PCOS) patients wishing to conceive. In these patients, ovulation induction resulting in restoration of a regular menstrual cycle with monofollicular ovulation may normalize the probability of pregnancy. This may be achieved either by increasing the follicle-stimulating hormone (FSH) serum concentration or by improving the endocrine ovarian milieu resulting in enhanced FSH responsiveness of the ovaries. Later on, this favorable endocrine milieu may also benefit implantation, embryo development and reduce risks in pregnancy for mother and child. A combination of both strategies could be used to individualize treatment in a patient-tailored way: for every patient an optimal effective treatment plan based on specific individual characteristics. Although there has been a tendency to ultimately skip ovulation induction and start in vitro fertilization (IVF) immediately because this would result in better pregnancy chances, this choice neglects the significant risks and physical burden of IVF treatment and significant higher costs. Ovulation induction in PCOS patients, as discussed in this chapter, is a very successful treatment option with a cumulative single live birth of greater than 70% during a 24-month follow-up period.

Infertility is classified as a disease by the WHO and is recognized to have significant impact on the lives of the couples it affects. It is defined by the WHO as the failure of a couple to conceive after 12 months of regular, unprotected intercourse and is estimated to affect 1:7 couples. To determine the underlying cause of infertility, both the female and male should be investigated in parallel. In approximately 40% of couples there is a coexisting male and female factor contributing towards infertility. Assessments should begin after 12 months unless the female age is over 35 years or there are known risk factors, when investigations should be implemented sooner. There is a responsibility of the clinician to explore other avenues of parenthood for couples from the outset, as it is important to manage patient expectations and acceptance of childlessness if treatments fail.

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in women during reproductive life. The aetiology of the syndrome is unknown; however, many endocrine changes occur, such as insulin resistance and hyperinsulinaemia, hyperandrogenaemia, elevated LH and increased anti-Müllerian hormone, which contribute to the pathogenesis of the syndrome. There are three main characteristics which play key roles in the definition of the syndrome – menstrual irregularities, hyperandrogenism and polycystic morphology of the ovaries – but there is no consensus as to the gravity of each of these features. The management of the syndrome depends on the prevailing symptom and whether the woman is interested in becoming pregnant or not. Combined oral contraceptive pills, diet, lifestyle changes, ovulation-inducing drugs and in-vitro fertilization are the main means of treating the syndrome. Treatment should also take into account possible long-term consequences of this condition, such as metabolic syndrome and cancer development.