Stimulating ovulation with gonadotropins has proven through the years to be a very effective component of infertility management. Yet, to no surprise, success can also be accompanied by a number of significant hazards. For this reason it becomes essential to adopt some very precise rules of protocol that must be respected in order to ensure a harmonious as well as a safe stimulation. These rules include establishing an accurate diagnosis, recognizing appropriate goals, and adapting basic principles of ovulation induction to each patient’s own situation.
One essential principle to remember is that no serious complication of the stimulation process will occur in the absence of hCG. Regardless of the protocol, intensity of the stimulation, or the nobility of objectives, hCG administration should be withheld when the situation develops an established risk, and carefully weighed even when the doubt arises. A trustworthy clinician must never turn the patient’s problem of infertility into something worse.
Some patients will always be more difficult to stimulate than others, no matter the selected protocol and despite imaginative efforts undertaken to resolve the problem. Furthermore, ovulation stimulation remains far from an exact science: starting doses, dose adjustment, and intervals between monitoring controls will always require a practiced judgment that can reasonably be thought of as an art. In this regard, an estimation error or an unexpected downturn of conditions will always be possible at one moment or another. If an effective shift of strategy remains elusive, one has to be prepared to simply stop the treatment.
Everybody is of course conscious that a canceled cycle is an uncomfortable moment for all concerned, above all when it is not the first time. One must call upon a modest amount of courage to persuade the correct decision with the necessary, truthful explanations when a patient claims ownership of her own risks and responsibilities. A clinician must always retain sufficient self-control to disregard hopes for a magic touch or a guardian angel in order to avoid an unfortunate outcome.
Many patients are prematurely referred to assisted reproductive technology centers, only to be burdened with unnecessarily difficult procedures that would have been avoided with better management in their primary setting. Classic stimulation protocols are presently within reach of every gynecologist’s practice. It would be advantageous for these clinicians to manage at least the initial steps of ART therapy for the patient who has already entrusted her care to his/her hands.