Even the area of reproductive medicine is touched by the commonly held misconception “a lot helps a lot” when it comes to taking medicines. We often encounter situations in which patients undergoing hormonal stimulation (ovarian stimulation) want to increase the prescribed dosage of their own accord, saying they had read something about it and believed that this would be beneficial to a successful outcome, i.e. contribute to improving oocyte maturation.
To start with, I should like to point out that the selection of an optimal stimulation protocol shall be based on the following factors:
- medical history (anamnesis)
- risk factors
- response to previous stimulations
- BMI (Body-Mass-Index)
- health status
- hormonal status
- antral follicle count (AFC)
- AMH level etc.
This means, the dosage in FSH-/HMG-stimulation must be perfectly balanced and the planned therapy must be tailored to the individual patient situation. In our view neither under- nor over-dosing is likely to provide optimum treatment results (intact pregnancy if possible during the currently planned cycle).
Such poor patient compliance is frequently observed in so-called “low responders” and in women over the age of 40. These women are often subjected to ovarian stimulation using far too high doses of FSH/HMG (more than 5 ampoules at 75 IU).
It is only in very rare cases that it is sensible and necessary to use FSH/HMG doses greater than 300 IU in ovarian stimulation. This was how Prof. Bruno Lunenfeld, the pioneer of FSH/HMG-stimulation, phrased it in a personal meeting. I fully endorse his opinion, particularly in the light of my previous experiences.
Stimulation of the best oocyte cohort
It has long been known and has been described in the literature on many occasions that too high doses of FSH/HMG may result in a higher proportion of chromosomally abnormally oocytes (aneuploidies, mosaics). This scientific subject has not yet been fully clarified.
We should not focus our efforts on obtaining one or more additional oocytes, but should give more weight to the physiology of the ovaries, thus promoting the stimulation of the best cohort of oocytes in order to achieve a successful pregnancy.
Suppression of prolactin levels has a similar effect as taking the “Pill”
If patients make unauthorized changes to the prescribed dosages specified in their treatment plan or if they use depot preparations instead which are known to push the prolactin levels to the lowest possible normal value, then this will lead to impaired oocyte maturation. Excessive suppression of prolactin levels acts in a similar way as the contraceptive pill.
Here, too, optimum dosing, for instance as regards the daily administration of Bromocriptin tablets and the maintenance of prolactin levels in the upper third of the normal range are key to successful treatment.
Tailored treatments enhancing the chances of achieving pregnancy
The matter, however, is not as simple as that and it seems a bit like a naive fallacy – higher stimulation doses → more oocytes → better pregnancy rates. It is indeed a pious hope, but is clearly the wrong medical approach.
Experience in therapy planning, a customized approach, optimal monitoring of follicle growth by ultrasound examinations and, if necessary, the determination of estrogen levels together with the best available laboratory techniques in the hands of an experienced lab-team as well as embryo transfer carried out under optimal conditions will most rapidly yield the desired results, i.e. intact pregnancy and the birth of a healthy child.
(Literature available from the author)
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