Does optimizing treatment protocols from the start prevent hypo-response in ART cycles?

Biljana Popović-Todorović addresses a question that often falls outside scientific debate: the cost of getting the first protocol wrong. Her lens is real-world evidence — routine-practice data, not only randomised trials.

The central fact setting the tone: up to half of patients discontinue treatment after the first or second attempt. The first cycle therefore carries disproportionate weight — it is often the only one, and an under-target result at the start frequently closes the whole path for a couple.

Hence the notion of the cost of a suboptimal first protocol. It is measured not only in lost oocytes but in lost time, emotional and financial burden and, ultimately, lost patients — those who leave the programme before reaching a result.

The speaker's recommendation is direct: there is no reason not to start with recombinant FSH combined with LH from the beginning, especially in groups at risk of hypo-response. The logic is not to "rescue" a cycle by adding LH midway, once time is already lost, but to build in adequate support from the outset.

This shifts hypo-response prevention to the planning stage. Instead of reactive correction — proactive choice of drug and dose to fit the patient's phenotype. This is especially true for older patients and those with presumed reduced receptor sensitivity.

The lecture's quote sums up the message: "Up to half of our patients give up as early as the first or second trial — one more reason to get it right from the start." Patient retention here appears not as an organisational metric but as a clinical one.

This view naturally connects to the concept of cumulative live birth: a programme's success is measured not by a single transfer but by the chance of a baby per started treatment cycle. If the first cycle loses the patient, the cumulative figure resets to zero — no matter how good the second or third protocol might have been.