Expert consensus on ovarian stimulation strategies for assisted reproductive technology: insights from the ASEAN region

Background Infertility remains a major global public health issue, affecting an estimated 17.5% of couples of reproductive age in their lifetime. Fertility rates in ASEAN countries have declined below replacement thresholds, highlighting the urgent need to enhance assisted reproductive technology (ART) strategies. Controlled ovarian stimulation is central to optimising ART outcomes, yet guidance tailored to ASEAN population is limited. Methods A comprehensive literature review (January 2015 to April 2025) informed the development of thirty statements, referencing the European Society of Human Reproduction and Embryology (ESHRE) Guideline on Ovarian Stimulation for in-vitro fertilisation/intracytoplasmic sperm injection (IVF/ICSI) 2025. A modified Delphi methodology and GRADE-ADOLOPMENT framework were employed to ensure evidence-based, context-sensitive recommendations. Statements deemed irrelevant to this consensus discussion were excluded. Consensus was defined as ≥70% expert agreement. Results Of 30 draft statements, consensus was achieved on 28 final statements after three Delphi rounds. Gonadotrophin-releasing hormone (GnRH) antagonist protocols were considered safe and preferred in predicted normal and high responders with comparable efficacy. In freeze-all cycles, progestin protocol was considered probably equivalent to GnRH analogues for pituitary suppression. Recombinant follicle-stimulating hormone (rFSH) and highly-purified human menopausal gonadotrophin (HP-hMG) were equally recommended; however, in predicted high responders, HP-hMG was noted to potentially reduce the risk of ovarian hyperstimulation syndrome (OHSS). Mixed stimulation protocols combining rFSH and HP-hMG from the start of stimulation are favoured over mid-follicular phase combinations for predicted normal and low responders. Follitropin delta and alpha/beta were considered probably equivalent, with algorithm-guided follitropin delta preferred when OHSS risk is a concern. Adjunctive letrozole or clomiphene was generally not recommended. Mid-cycle dose adjustments may be used pragmatically to reduce the risk of cycle cancellation or OHSS, and recombinant luteinising hormone (rLH) supplementation may benefit selected subgroups (e.g., advanced age or low responders), although evidence remains heterogeneous. Conclusion This consensus provides evidence-informed ovarian stimulation strategies tailored to different patient profiles, emphasising safety, efficacy, and personalisation to optimise IVF/ICSI outcomes. Where evidence is limited, statements reflect expert consensus and should be applied as conditional guidance. It balances global best practices with regional realities to support effective, safer, and personalised ART in ASEAN.