A rational approach to ovulation induction

Appropriate investigation has led to the recognition of five major endocrinologic categories of anovulatory patients. The clinician is able to follow a definitive therapeutic program for each of these; and except where the FSH levels are elevated, pregnancy rates should approach values observed for normally ovulating women. Although clomiphene citrate is likely to remain the most common drug prescribed to anovulatory women, treatment programs with clomiphene have recently been modified with much improved success rates resulting. Bromocriptine, the drug of choice for women with hyperprolactinemia, restores ovulatory cycles in most women treated. It not only restores fertility, however, but also reduces tumor growth in patients with pituitary adenomas, making surgical removal often unnecessary. Exogenous gonadotropin therapy should be reserved for patients who do not respond to treatment with clomiphene and/or bromocriptine. With adequate monitoring, the multiple pregnancy rate should be able to kept below 20% and high-multiple pregnancies avoided. Pulsatile GnRH therapy is likely to replace gonadotropin therapy for most patients, because this therapy has distinct advantages in terms of cost, patient convenience, and a lowering of multiple pregnancy rates.