Use of an aromatase inhibitor for induction of ovulation in patients with an inadequate response to clomiphene citrate

First-line ovulation induction for polycystic ovary syndrome: an individual participant data meta-analysis

BACKGROUND

Polycystic ovary syndrome (PCOS) is the most frequent cause of anovulatory infertility. In women with PCOS, effective ovulation induction serves as an important first-line treatment for anovulatory infertility. Individual participant data (IPD) meta-analysis is considered as the gold standard for evidence synthesis which provides accurate assessments of outcomes from primary randomised controlled trials (RCTs) and allows additional analyses for time-to-event outcomes. It also facilitates treatment-covariate interaction analyses and therefore offers an opportunity for personalised medicine.

OBJECTIVE AND RATIONALE

We aimed to evaluate the effectiveness of different ovulation induction agents, in particular letrozole alone and clomiphene citrate (CC) plus metformin, as compared to CC alone, as the first-line choice for ovulation induction in women with PCOS and infertility, and to explore interactions between treatment and participant-level baseline characteristics.

SEARCH METHODS

We searched electronic databases including MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials up to 20 December 2018. We included RCTs comparing the following interventions with each other or placebo/no treatment in women with PCOS and infertility: CC, metformin, CC plus metformin, letrozole, gonadotrophin and tamoxifen. We excluded studies on treatment-resistant women. The primary outcome was live birth. We contacted the investigators of eligible RCTs to share the IPD and performed IPD meta-analyses. We assessed the risk of bias by using the Cochrane risk of bias tool for RCTs.

OUTCOMES

IPD of 20 RCTs including 3962 women with PCOS were obtained. Six RCTs compared letrozole and CC in 1284 women. Compared with CC, letrozole improved live birth rates (3 RCTs, 1043 women, risk ratio [RR] 1.43, 95% confidence interval [CI] 1.17-1.75, moderate-certainty evidence) and clinical pregnancy rates (6 RCTs, 1284 women, RR 1.45, 95% CI 1.23-1.70, moderate-certainty evidence) and reduced time-to-pregnancy (6 RCTs, 1235 women, hazard ratio [HR] 1.72, 95% CI 1.38-2.15, moderate-certainty evidence). Meta-analyses of effect modifications showed a positive interaction between baseline serum total testosterone levels and treatment effects on live birth (interaction RR 1.29, 95% CI 1.01-1.65). Eight RCTs compared CC plus metformin to CC alone in 1039 women. Compared with CC alone, CC plus metformin might improve clinical pregnancy rates (8 RCTs, 1039 women, RR 1.18, 95% CI 1.00-1.39, low-certainty evidence) and might reduce time-to-pregnancy (7 RCTs, 898 women, HR 1.25, 95% CI 1.00-1.57, low-certainty evidence), but there was insufficient evidence of a difference on live birth rates (5 RCTs, 907 women, RR 1.08, 95% CI 0.87-1.35, low-certainty evidence). Meta-analyses of effect modifications showed a positive interaction between baseline insulin levels and treatment effects on live birth in the comparison between CC plus metformin and CC (interaction RR 1.03, 95% CI 1.01-1.06).

WIDER IMPLICATIONS

In women with PCOS, letrozole improves live birth and clinical pregnancy rates and reduces time-to-pregnancy compared to CC and therefore can be recommended as the preferred first-line treatment for women with PCOS and infertility. CC plus metformin may increase clinical pregnancy and may reduce time-to-pregnancy compared to CC alone, while there is insufficient evidence of a difference on live birth. Treatment effects of letrozole are influenced by baseline serum levels of total testosterone, while those of CC plus metformin are affected by baseline serum levels of insulin. These interactions between treatments and biomarkers on hyperandrogenaemia and insulin resistance provide further insights into a personalised approach for the management of anovulatory infertility related to PCOS.

Effects of letrozole and clomiphene citrate on Wnt signaling pathway in endometrium of polycystic ovarian syndrome and healthy women†

Polycystic ovary syndrome (PCOS) is an endocrine disorder in women of reproductive age. In addition to anovulation, endometrial dysfunction can reduce fertility in PCOS. The cyclical changes of endometrium are controlled by estrogen and progesterone via modulating the Wnt/B-catenin pathway. Clomiphene citrate (CC) and letrozole are used to induce ovulation; unlike letrozole, there is a discrepancy between ovulation and pregnancy rates in CC-treated cycles. Because of the anti-estrogenic effects of CC on endometrium, we compared the expression of the key molecules of the Wnt/B-catenin pathway in the endometrium of women taking CC and letrozole. This study included PCOS and healthy women divided into the groups stimulated with letrozole (5 mg) or CC (100 mg) as well as NO-treatment groups. The endometrial thickness and hormonal profile were measured on day 12 of the menses. Using real-time polymerase chain reaction and western blot, we evaluated mRNA and protein expression of B-catenin, glycogen synthase kinase 3 beta (GSK3B), dickkopf Wnt signaling pathway inhibitor 1 (DKK1), and estrogen receptor 1 (ESR1) in the endometrial samples. Significantly, the mean serum estrogen and progesterone were lower and higher, respectively, in letrozole than CC groups. The endometrial thickness was significantly reduced in CC. The proteins expression of active B-catenin, inactive GSK3B, and ESR1 were significantly decreased in CC-treated groups. The mRNA and protein assessment of DKK1 showed significantly higher expression in CC. Our results indicate that letrozole can provide an acceptable activation of the Wnt/B-catenin pathway, resulting in adequate proliferation of endometrium in the women receiving letrozole compared to CC.

Effects of letrozole combined with human menopausal gonadotrophin in ovarian stimulation for intrauterine insemination cycles

Background

The effects of letrozole plus human menopausal gonadotropin (HMG) on ovarian stimulation (OS) of intrauterine insemination (IUI) cycles were examined.

Methods

In all, 1,005 IUI cycles were included in this study. Couples underwent natural cycle (NC) IUI (n=150) or IUI after OS with letrozole (n=207) or IUI after OS with letrozole + HMG (n=648).

Results

The clinical pregnancy rates were 9.0%, 13.0%, and 17.0%, and the live birth rates were 7.0%, 9.0%, and 14.0% in the NC, letrozole, and letrozole + HMG IUI groups, respectively. The twin pregnancy rate of the letrozole + HMG group (11.0%) was higher than that of the NC (7.0%) and letrozole groups (4.0%). To date, the only triplet pregnancies to occur were in the letrozole + HMG group. On the day of human chorionic gonadotropin (hCG), the number of follicles with an average follicle diameter greater than 18 mm in the letrozole + HMG group (1.21±0.56) and letrozole group (1.14±0.48) was greater than that in the NC group (0.85±0.36). The thickness of the endometrium in the letrozole + HMG group (8.8±2.1 mm) was significantly greater than that in the letrozole group (7.3±1.6 mm).

Conclusions

The letrozole + HMG protocol of OS in IUI can improve follicular development, increase the thickness of endometrium, significantly increase the live birth rate, but not significantly increase the multiple pregnancy rate.

The role of Letrozole (LE) in controlled ovarian stimulation (COS) in patients at high risk to develop ovarian hyper stimulation syndrome (OHSS). A prospective randomized controlled pilot study

BACKGROUND

Recently, it has been shown that PCOS patients with extremely high anti-Mullerian hormone (AMH) level are more likely to experience OHSS during IVF, compared to PCOS patients with lower AMH level. While recent data questioned the effect of Letrozole (LE) on the occurrence of OHSS in non-PCOS patients, it role in PCOS patients with very high AMH level was never investigated in a prospective manners. Hence, our main objective was to evaluate the clinical outcome of PCOS patients at very high risk for OHSS undergoing two different COS protocols (with or without LE).

METHODS

A prospective randomized controlled study (RCT) of 51 patients with specifically high levels of AMH undergoing one of two COS protocols. The control group (group A) consisted of 24 PCOS women who received low-dose gonadotropins using the multiple-dose GnRH-antagonist protocol, GnRH agonist-triggered and "freeze all". The study group (group B) consisted of 24 women with PCOS who received the same protocol combined with LE. High risk criteria for OHSS were: PCOS patients with low BMI, young age, and extremely high level of serum AMH (inclusion criteria for AMH > 50 pmol/L).

RESULTS

Cumulative live birth rates per retrieval were similar in both groups. While no single case of severe OHSS was observed in, in the study group (group B), the rate of moderate and mild OHSS was 5 times lower compared to the control group (P < 0.05).

CONCLUSION

In PCOS patients with extremely high AMH levels the LE co-administration to GnRH-Ant protocols results in reduced incidence of OHSS than conventional GnRH-Ant protocols. LE co-administration may prove to be highly effective in preventing OHSS, even in the women who are at high risk to these dangerous complications.

A Review of First Line Infertility Treatments and Supporting Evidence in Women with Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is the most common cause of anovulatory infertility in women of reproductive age. Lifestyle change is considered the first line treatment for the management of infertile anovulatory women with PCOS, and weight loss for those who are overweight or obese. First line medical ovulation induction therapy to improve fertility outcomes is letrozole, whilst other less efficacious ovulation induction agents, such as clomiphene citrate, metformin, and metformin combined with clomiphene citrate, may also be considered. Metformin combined with clomiphene citrate is more effective than clomiphene citrate alone. In obese women with PCOS, clomiphene citrate could be used in preference to metformin alone whilst clomiphene citrate could be added to metformin alone in order to improve reproductive outcome in all women with PCOS. Gonadotrophins, which are more effective than clomiphene citrate in therapy naïve women with PCOS, can be considered a first line therapy in the presence of ultrasound monitoring, following counselling on the cost and the potential risk of multiple pregnancy.

Dissociable involvement of estrogen receptors in perirhinal cortex-mediated object-place memory in male rats

Estrogens and the estrogen receptors (ER) - ERα, ERβ, and the G-protein coupled estrogen receptor (GPER) - are implicated in various forms of hippocampus (HPC)-dependent memory. However, the involvement of ER-related mechanisms in perirhinal cortex (PRh), which is necessary for object memory, remains much less clear. Moreover, there is a paucity of data assessing ER contributions to cognition in males,despite documented sex differences at the cellular level.We hypothesized that estrogens in PRh are important for object memory in males, assessingthe role of 17-βestradiol (E2), ERα, ERβ, GPER, and their downstream signaling pathways, in PRh-mediated object-in-place (OiP) memory in gonadally-intact male rats. Intra-PRh administration of E2 enhanced both long-term memory (LTM; 24 h) and short-term memory (STM; 20 min). Conversely, aromatase inhibition with letrozole impaired LTM and STM. The semi-selective ER inhibitor ICI 182780 impaired LTM, but not STM. This effect may be due to inhibition of ERβ, as the ERβagonist DPN, but not ERαagonist PPT, enhanced LTM. GPER was also found to be necessary in PRh, as the antagonist G15 impaired both LTM and STM. Western blot analyses demonstrated that phosphorylation levels of the extracellular signal-related kinase (ERK2 isoform), awell-establisheddownstream signaling pathway activated by estrogens through ERα/ERβ, was elevated in PRh 5 min following OiP learning.We also reportincreased levels of c-Jun N-terminal kinase (JNK; p46 and p54 isoforms) phosphorylation in PRh 5 min following learning,consistent with recent research linking GPER activation and JNK signaling in the HPC. This effect was abolished by intra-PRh administration of G15, but not letrozole, suggesting that JNK signaling is triggered via GPER activation during OiP learning, and is possibly E2-independent, similar to findings in the HPC. These results, therefore, reveal interesting dissociations between the roles of various ERs, possibly involving both estrogen-dependent and independent mechanisms, in PRh-mediated object-place learning in male rats.

Ovarian drilling in polycystic ovary syndrome: Long term pregnancy rate

Objective

To report long term pregnancy rate in polycystic ovary syndrome (PCOS) treated by ovarian drilling. To evaluate predictive factors of pregnancy and possibility of a second drilling.

Design

Retrospective, observational, multicenter study.

Setting

Gynecologic departments of two teaching's hospitals.

Patients

All infertile women with PCOS who were treated by ovarian drilling from 2004 to 2013. The Rotterdam criteria were applied to define PCOS.

Interventions

Surgical ovarian drilling by laparoscopy and trans vaginal hydro laparoscopy.

Main Outcome Measures

The primary endpoint was pregnancy rate after ovarian drilling. The secondary endpoints were the predictive factors of pregnancy and the possibility of a second ovarian drilling.

Results

289 women were included in the study. The mean follow-up period was 28.4 months (25.3-31.5). A pregnancy was obtained in at least 137 (47.4%) women after a drilling, and 71 (51.8%) of these pregnancies were spontaneous, 48 (16.6%) women achieved at least two pregnancies after drilling, and 27 (56.3%) of these were spontaneous. The predictive factors for effectiveness were a normal body mass index (BMI), an infertility period of less than three years, an AFC of less than 50, and an age of less than 35. Second drillings were performed on 33 women. Among them, 19 (57.6%) achieved at least one pregnancy, and 10 (52.6%) of these were spontaneous. It appeared that a second drilling was effective either when the first drilling had been successful (pregnancy achieved after drilling) or when it had failed in cases of high AFC (greater than 55).

Conclusion

Ovarian drilling permitted to obtain spontaneous pregnancy for women with PCOS. This surgery could have durably effect permitted to obtain more than one pregnancy.

A Review of Second- and Third-line Infertility Treatments and Supporting Evidence in Women with Polycystic Ovary Syndrome

In clomiphene-citrate-resistant anovulatory women with polycystic ovary syndrome (PCOS) and no other infertility factors, either metformin combined with clomiphene citrate or gonadotrophins could be used as a second-line pharmacological therapy, although gonadotrophins are more effective. Gonadotrophins could also be used as a second-line pharmacological therapy in anovulatory women with PCOS and clomiphene-citrate-failure. Laparoscopic ovarian surgery can also be used as a second-line therapy for ovulation induction in anovulatory women with clomiphene-citrate-resistant PCOS and no other infertility factors. The usefulness of letrozole as a second-line pharmacological treatment for ovulation induction in clomiphene-citrate-resistant women with PCOS requires further research. In terms of improving fertility, both pharmacological anti-obesity agents and bariatric surgery should be considered an experimental therapy in anovulatory women with PCOS and no other infertility factors. Where first- or second-line ovulation induction therapies have failed, in vitro fertilization (IVF)/ intracytoplasmic sperm injection (ICSI) could be offered as a third-line therapy in women with PCOS in the absence of an absolute indication for IVF/ICSI. For women with PCOS undergoing IVF/ICSI treatment, the gonadotropin-releasing hormone (GnRH) antagonist protocol is preferred and an elective frozen embryo transfer strategy could be considered. In assisted conception units with sufficient expertise, in-vitro maturation (IVM) of oocytes could be offered to women with PCOS.

Impact of letrozole versus clomiphene citrate on endometrial receptivity in Iraqi women with polycystic ovarian syndrome

WHAT IS KNOWN AND OBJECTIVES

Letrozole is widely known for its use as an ovulation inductor. This study aims to investigate the effects of letrozole and clomiphene citrate in females with polycystic ovarian syndrome.

METHODS

This is a randomized non-blinded controlled trial study that included 80 infertile females with polycystic ovarian syndrome receiving a standard dose of either clomiphene citrate or letrozole on day 2 of the cycle. An ultrasound was done to examine growth of the follicle, endometrial thickness on days 12-13, and a Doppler study to measure resistance index (RI), pulsatility index and ratio of systolic/diastolic velocity.

RESULTS AND DISCUSSION

The mean levels of dominant follicle and oestradiol were significantly higher in the clomiphene citrate group than in the letrozole group. The letrozole group had a significantly greater endometrial thickness than the clomiphene citrate group. The resistance index and pulsatility index were lower in the letrozole group and in pregnant women than in the clomiphene citrate group and the non-pregnant group.

WHAT IS NEW AND CONCLUSION

The use of letrozole for ovulation induction in polycystic ovarian syndrome patients has a better effect on endometrial receptivity markers when compared to clomiphene citrate.

Letrozole versus laparoscopic ovarian drilling in clomiphene citrate-resistant women with polycystic ovary syndrome: a systematic review and meta-analysis of randomized controlled trials

The objective of this systematic review was to examine the literature and to compare the effectiveness of letrozole (LE) versus laparoscopic ovarian drilling (LOD) for the induction of ovulation in women with clomiphene citrate (CC)-resistant polycystic ovary syndrome (PCOS). The PUBMED, Web of Science, and EMBASE databases were searched systematically for eligible randomized controlled trials (RCTs) from English language articles published from database inception to September 2018. Data were independently extracted and analyzed using the fixed-effects model or random-effects model according to the heterogeneity of the data. Four RCTs including 621 patients (309 in the LE group and 312 in the LOD group) met the inclusion criteria. There were no differences with regard to ovulation rate (relative risk [RR] 1.12; 95% confidence interval [CI] 0.93 to 1.34; P = 0.12, I² = 90%, 541 patients, three studies), pregnancy rate (RR 1.21; 95% CI 0.95 to 1.53; P = 0.12, I² = 0%, 621 patients, four studies), live birth rate (RR 1.27; 95% CI 0.96 to 1.68; P = 0.09, I² = 19%, 541 patients, three studies), and abortion rate (RR 0.7; 95% CI 0.3 to 1.61; P = 0.40, I² = 0%, 621 patients, four studies) between the two groups. These results indicated that LE and LOD appear to be equally effective in achieving live birth rate in patients with CC-resistant PCOS.

Pharmacology of medications used for ovarian stimulation

Medications to stimulate the ovaries may be used to induce ovulation in patients with anovulatory infertility or to hyperstimulate the ovaries in a controlled fashion in ovulatory patients as part of assisted reproductive treatments (ART). The pharmacology of all current major medications used to stimulate ovarian function is reviewed in this article, including letrozole, clomiphene citrate, gonadotropins, and pulsatile gonadotropin releasing hormone (GnRH). Novel potential compounds and adjuvant treatment approaches are also discussed, such as kisspeptin agonists and androgens.

Evidence summaries and recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome: assessment and treatment of infertility

STUDY QUESTION

What is the recommended assessment and management of infertile women with polycystic ovary syndrome (PCOS), based on the best available evidence, clinical expertize and consumer preference?

SUMMARY ANSWER

International evidence-based guidelines, including 44 recommendations and practice points, addressed prioritized questions to promote consistent, evidence-based care and improve the experience and health outcomes of infertile women with PCOS.

WHAT IS KNOWN ALREADY

Previous guidelines on PCOS lacked rigorous evidence-based processes, failed to engage consumer and multidisciplinary perspectives or were outdated. The assessment and management of infertile women with PCOS are inconsistent. The needs of women with PCOS are not being adequately met and evidence practice gaps persist.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Governance included a six continent international advisory and a project board, a multidisciplinary international guideline development group (GDG), consumer and translation committees. Extensive health professional and consumer engagement informed the guideline scope and priorities. The engaged international society-nominated panel included endocrinology, gynaecology, reproductive endocrinology, obstetrics, public health and other experts, alongside consumers, project management, evidence synthesis and translation experts. Thirty-seven societies and organizations covering 71 countries engaged in the process. Extensive online communication and two face-to-face meetings over 15 months addressed 19 prioritized clinical questions involving nine evidence-based reviews and 10 narrative reviews. Evidence-based recommendations (EBRs) were formulated prior to consensus voting within the guideline panel.

STUDY DESIGN, SIZE, DURATION

International evidence-based guideline development engaged professional societies and consumer organizations with multidisciplinary experts and women with PCOS directly involved at all stages. A (AGREE) II-compliant processes were followed, with extensive evidence synthesis. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was applied across evidence quality, desirable and undesirable consequences, feasibility, acceptability, cost, implementation and ultimately recommendation strength. The guideline was peer-reviewed by special interest groups across our partner and collaborating societies and consumer organizations, was independently assessed against AGREE II criteria and underwent methodological review. This guideline was approved by all members of the GDG and has been approved by the NHMRC.

MAIN RESULTS AND THE ROLE OF CHANCE

The quality of evidence (QOE) for the EBRs in the assessment and management of infertility in PCOS included very low (n = 1), low (n = 9) and moderate (n = 4) quality with no EBRs based on high-quality evidence. The guideline provides 14 EBRs, 10 clinical consensus recommendations (CCRs) and 20 clinical practice points on the assessment and management of infertility in PCOS. Key changes in this guideline include emphasizing evidence-based fertility therapy, including cheaper and safer fertility management.

LIMITATIONS, REASONS FOR CAUTION

Overall evidence is generally of low to moderate quality, requiring significantly greater research in this neglected, yet common condition. Regional health systems vary and a process for adaptation of this guideline is provided.

WIDER IMPLICATIONS OF THE FINDINGS

The international guideline for the assessment and management of infertility in PCOS provides clinicians with clear advice on best practice based on the best available evidence, expert multidisciplinary input and consumer preferences. Research recommendations have been generated and a comprehensive multifaceted dissemination and translation program supports the guideline with an integrated evaluation program.

STUDY FUNDING/COMPETING INTEREST(S)

The guideline was primarily funded by the Australian National Health and Medical Research Council of Australia (NHMRC) supported by a partnership with ESHRE and the American Society for Reproductive Medicine (ASRM). GDG members did not receive payment. Travel expenses were covered by the sponsoring organizations. Disclosures of conflicts of interest were declared at the outset and updated throughout the guideline process, aligned with NHMRC guideline processes. Dr Costello has declared shares in Virtus Health and past sponsorship from Merck Serono for conference presentations. Prof. Norman has declared a minor shareholder interest in the IVF unit Fertility SA, travel support from Merck and grants from Ferring. Prof. Norman also has scientific advisory board duties for Ferring. The remaining authors have no conflicts of interest to declare.

This article was not externally peer-reviewed by Human Reproduction Open.

The role of anti-Müllerian hormone in predicting clomiphene citrate resistance in women with polycystic ovarian syndrome

Clomiphene citrate (CC) is the agent of first choice in polycystic ovarian syndrome; however, anovulation problem does not resolve in a quarter of them. Thus, we investigated the value of anti-Müllerian hormone (AMH) in the prediction of ovarian response to CC in women with the polycystic ovarian syndrome (PCOS). This prospective cohort study included 90 anovulatory women with PCOS who were given 50 mg/d CC. The patients who ovulated occupied the group of responders and the patients who did not ovulate in three cycles included in the CC-resistant group. AMH levels of both groups were compared. p < .05 was considered statistically significant. Patients who ovulated had significantly lower serum AMH concentrations compared with the resistant group (p = .001). After analyzing the ROC curve, serum AMH concentration was found to be a useful predictor of CC resistance with the sensitivity of 66% and the specificity of 89%, when the threshold AMH concentration was >12.38 ng/ml in PCOS patients. In the present study, we revealed that the higher the AMH level the poorer the CC response would be in PCOS patients, therefore we recommend measuring the AMH levels of all PCOS patients before planning any ovulation induction treatment to achieve the desired success.

Letrozole for patients with polycystic ovary syndrome: A retrospective study

This retrospective study investigated the efficacy and safety of letrozole for patients with polycystic ovary syndrome (PCOS).Totally, 136 cases of infertility women with PCOS were analyzed. Of those, 68 patients received letrozole, and were assigned to Letrozole group. The other 68 cases received clomiphene, and were assigned to clomiphene group. Patients in both groups were treated up to 5 treatment cycles. The primary endpoint included infant outcomes. The secondary endpoints consisted of the number of women in conception, pregnancy, pregnancy loss, and ovulation. In addition, any kinds of adverse events were also recorded.Cases in the Letrozole group did not show better outcomes neither in primary endpoint (live birth, P = .11; birth weight, P = .95; infant gender, P = .85), nor in secondary endpoints (the number of women in conception, P = .07; pregnancy, P = .12; pregnancy loss, P = .47; pregnancy loss in first trimester, P = .70; and ovulation, P = .09), compared with cases in the clomiphene group. Moreover, no adverse events differ significantly between 2 groups.This study demonstrated that the efficacy of letrozole is not superior to the clomiphene in patients with PCOS.

Recent advances in oncofertility care worldwide and in Japan

BACKGROUND

Oncofertility is a crucial facet of cancer supportive care. The publication of guidelines for the cryopreservation of oocytes and ovarian tissue is becoming increasingly prevalent in Japan and an updated overview is necessary.

METHODS

In order to provide an updated overview of oncofertility care, original research and review articles were searched from the PubMed database and compared in order to present clinical care in Japan.

RESULTS

In Western countries, various methods for ovarian stimulation, such as the combined use of aromatase inhibitors and random-start protocols, have been reported. Although ovarian tissue cryopreservation, mainly performed via the slow-freezing method, also has yielded >100 live births, the optimal indications and procedures for the auto-transplantation of cryopreserved tissue have been under investigation. In Japan, however, vitrification is prevalent for ovarian tissue cryopreservation, although its efficacy has not yet been established. The quality of network systems for providing oncofertility care in Japan varies greatly, based on the region.

CONCLUSION

There remain many issues in the optimization of oncofertility care in Japan. Along with the regional oncofertility networks, the creation of "oncofertility navigators" from healthcare providers who are familiar with oncofertility, such as nurses, psychologists, and embryologists, could be useful for supplementing oncofertility care coordination, overcoming the issues in individual regions.

Mild ovarian stimulation with letrozole plus fixed dose human menopausal gonadotropin prior to IVF/ICSI for infertile non-obese women with polycystic ovarian syndrome being pre-treated with metformin: a pilot study

BACKGROUND

Letrozole is widely employed as ovulation induction agent in women with PCOS, but its use in mild stimulation (MS) protocols for IVF is limited. Aim of the present study was to evaluate the feasibility of a MS protocol with letrozole plus hMG in non-obese PCOS women undergoing IVF after a metformin pre-treatment.

METHODS

We retrospectively evaluated the data of 125 non-obese PCOS undergoing MS with letrozole plus hMG, 150 IU as starting dose, (group 1, N = 80) compared to those undergoing a conventional IVF stimulation protocols (CS) (group 2, N = 45) prior to IVF. All patients had received metformin extended release 1200-2000 mg daily for three to six months before IVF. GnRH antagonist was administered in both groups when the leading follicles reached 14 mm.

RESULTS

Both groups were comparable for age, BMI and ovarian reserve markers. Both groups showed lower than expected AFC and AMH values as a consequence of metformin pre-treatment. Letrozole-treated patients required a significantly lower amount of gonadotropins units (p < 0.0001), and showed significantly lower day 5, day 8 and hCG day E2 levels compared to patients undergoing the CS protocol (p < 0.0001, p < 0.0001 and p = 0.001 respectively). The oocyte yield, in terms of total (6, IQR 3, vs 6, IQR 4 respectively,) and MII oocytes (5, IQR 3, vs 5, IQR 3, respectively) number, did not differ among groups; the number of total (3, IQR 2, vs 3, IQR 1 respectively) and good quality embryos (2, IQR1 vs 2, IQR 1,5 respectively) obtained was comparable as well in the two groups. The number of fresh transfers was significantly higher in group 1 compared to group 2 (80% vs 60%, p = 0.016). A trend for higher cumulative clinical pregnancy rate was found in women undergoing MS compared to CS (42.5%vs 24,4%, p = 0.044), but the study was not powered to detect this difference.

CONCLUSIONS

The present study suggests that the use of letrozole as adjuvant treatment to MS protocols for IVF may be an effective alternative to CS protocols for non-obese PCOS patients pre-treated with metformin, as it provides comparable IVF outcome without requiring high FSH dose, and avoiding supraphysiological estradiol levels.

Deficiency of Gpr1 improves steroid hormone abnormality in hyperandrogenized mice

BACKGROUND

Polycystic ovary syndrome (PCOS) is a complex genetic disease with multifarious phenotypes. Many researches use dehydroepiandrosterone (DHEA) to induce PCOS in pubertal mouse models. The aim of this study was to investigate the role of GPR1 in dehydroepiandrosterone (DHEA)-induced hyperandrogenized mice.

METHODS

Prepubertal C57BL/6 mice (25 days of age) and Gpr1-deficient mice were each divided into two groups and injected daily with sesame oil with or without DHEA (6 mg/100 g) for 21 consecutive days. Hematoxylin and eosin (H&E) staining was performed to determine the characteristics of the DHEA-treated ovaries. Real-time PCR was used to examine steroid synthesis enzymes gene expression. Granulosa cell was cultured to explore the mechanism of DHEA-induced, GPR1-mediated estradiol secretion.

RESULTS

DHEA treatment induced some aspects of PCOS in wild-type mice, such as increased body weight, elevated serum testosterone, increased number of small, cystic, atretic follicles, and absence of corpus luteum in ovaries. However, Gpr1 deficiency significantly attenuated the DHEA-induced weight gain and ovarian phenotype, improving steroidogenesis in ovaries and estradiol synthesis in cultured granulosa cells, partially through mTOR signaling.

CONCLUSIONS

In conclusion, Gpr1 deficiency leads to the improvement of steroid synthesis in mice hyperandrogenized with DHEA, indicating that GPR1 may be a therapeutic target for DHEA-induced hyperandrogenism.

Aromatase inhibitors (letrozole) for subfertile women with polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is the most common cause of infrequent periods (oligomenorrhoea) and absence of periods (amenorrhoea). It affects about 4% to 8% of women worldwide and often leads to anovulatory subfertility. Aromatase inhibitors (AIs) are a class of drugs that were introduced for ovulation induction in 2001. Since about 2001 clinical trials have reached differing conclusions as to whether the AI letrozole is at least as effective as the first-line treatment clomiphene citrate (CC).

OBJECTIVES

To evaluate the effectiveness and safety of aromatase inhibitors for subfertile women with anovulatory PCOS for ovulation induction followed by timed intercourse or intrauterine insemination (IUI).

SEARCH METHODS

We searched the following sources from inception to November 2017 to identify relevant randomised controlled trials (RCTs): the Cochrane Gynaecology and Fertility Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO, Pubmed, LILACS, Web of Knowledge, the World Health Organization (WHO) clinical trials register and Clinicaltrials.gov. We also searched the references of relevant articles. We did not restrict the searches by language or publication status.

SELECTION CRITERIA

We included all RCTs of AIs used alone or with other medical therapies for ovulation induction in women of reproductive age with anovulatory PCOS.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted the data and assessed risks of bias. We pooled studies where appropriate using a fixed-effect model to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for most outcomes, and risk differences (RDs) for ovarian hyperstimulation syndrome (OHSS). The primary outcomes were live birth and OHSS. Secondary outcomes were clinical pregnancy, miscarriage and multiple pregnancy. We assessed the quality of the evidence for each comparison using GRADE methods.

MAIN RESULTS

This is a substantive update of a previous review. We identified 16 additional studies for the 2018 update. We include 42 RCTs (7935 women). The aromatase inhibitor letrozole was used in all studies.Letrozole compared to clomiphene citrate (CC) with or without adjuncts followed by timed intercourseLive birth rates were higher with letrozole (with or without adjuncts) compared to clomiphene citrate (with our without adjuncts) followed by timed intercourse (OR 1.68, 95% CI 1.42 to 1.99; 2954 participants; 13 studies; I² = 0%; number needed to treat for an additional beneficial outcome (NNTB) = 10; moderate-quality evidence). There is high-quality evidence that OHSS rates are similar with letrozole or clomiphene citrate (0.5% in both arms: risk difference (RD) -0.00, 95% CI -0.01 to 0.00; 2536 participants; 12 studies; I² = 0%; high-quality evidence). There is evidence for a higher pregnancy rate in favour of letrozole (OR 1.56, 95% CI 1.37 to 1.78; 4629 participants; 25 studies; I² = 1%; NNTB = 10; moderate-quality evidence). There is little or no difference between treatment groups in the rate of miscarriage by pregnancy (20% with CC versus 19% with letrozole; OR 0.94, 95% CI 0.70 to 1.26; 1210 participants; 18 studies; I² = 0%; high-quality evidence) and multiple pregnancy rate (1.7% with CC versus 1.3% with letrozole; OR 0.69, 95% CI 0.41 to 1.16; 3579 participants; 17 studies; I² = 0%; high-quality evidence). However, a funnel plot showed mild asymmetry, indicating that some studies in favour of clomiphene might be missing.Letrozole compared to laparoscopic ovarian drillingThere is low-quality evidence that live birth rates are similar with letrozole or laparoscopic ovarian drilling (OR 1.38, 95% CI 0.95 to 2.02; 548 participants; 3 studies; I² = 23%; low-quality evidence). There is insufficient evidence for a difference in OHSS rates (RD 0.00, 95% CI -0.01 to 0.01; 260 participants; 1 study; low-quality evidence). There is low-quality evidence that pregnancy rates are similar (OR 1.28, 95% CI 0.94 to 1.74; 774 participants; 5 studies; I² = 0%; moderate-quality evidence). There is insufficient evidence for a difference in miscarriage rate by pregnancy (OR 0.66, 95% CI 0.30 to 1.43; 240 participants; 5 studies; I² = 0%; moderate-quality evidence), or multiple pregnancies (OR 3.00, 95% CI 0.12 to 74.90; 548 participants; 3 studies; I² = 0%; low-quality evidence).Additional comparisons were made for Letrozole versus placebo, Selective oestrogen receptor modulators (SERMS) followed by intrauterine insemination (IUI), follicle stimulating hormone (FSH), Anastrozole, as well as dosage and administration protocols. There is insufficient evidence for a difference in either group of treatment due to a limited number of studies. Hence more research is necessary.

AUTHORS' CONCLUSIONS

Letrozole appears to improve live birth and pregnancy rates in subfertile women with anovulatory polycystic ovary syndrome, compared to clomiphene citrate. There is high-quality evidence that OHSS rates are similar with letrozole or clomiphene citrate. There is high-quality evidence of no difference in miscarriage rates or multiple pregnancy rates. There is low-quality evidence of no difference in live birth and pregnancy rates between letrozole and laparoscopic ovarian drilling, although there were few relevant studies. For the 2018 update, we added good-quality trials, upgrading the quality of the evidence.

Double-blind randomized controlled trial of letrozole versus clomiphene citrate in subfertile women with polycystic ovarian syndrome

STUDY QUESTION

Would letrozole as a primary ovulation induction agent generate better pregnancy rates than clomiphene citrate (CC) in subfertile women with anovulatory polycystic ovarian syndrome (PCOS)?

SUMMARY ANSWER

Participants receiving letrozole as a primary treatment achieved a significantly (P = 0.022) higher clinical pregnancy rate per patient (61.2%) compared to CC (43.0%).

WHAT IS KNOWN ALREADY

According to a recent Cochrane systematic review (2014), letrozole appears to improve live-birth (LB) and pregnancy rates in anovulatory women with PCOS, compared to CC. However, the review concluded that the quality of evidence was low due to poor reporting of study methods and possible publication bias.

STUDY DESIGN, SIZE, DURATION

This double-blind randomized controlled trial (RCT) included 159 participants between April 2007 and June 2014. Subjects were randomly allocated to either CC (n = 79) or letrozole (n = 80) in a 1:1 ratio. Both drugs were encapsulated to look identical. Randomization was performed in mixed blocks and stratified by patients’ BMI (<30 and 30–35 kg/m²).

PARTICIPANTS/MATERIALS, SETTING, METHODS

The trial included subfertile women diagnosed with PCOS. Treatment started with one tablet (CC 50 mg, letrozole 2.5 mg) increasing to two in non-responders and continuing until pregnancy or for up to six ovulatory cycles. Non-responders were crossed over to the other treatment after a 6-week break. Cycles were initially monitored with ultrasound follicle tracking then mid-luteal serum progesterone measurement in subsequent cycles.

MAIN RESULTS AND THE ROLE OF CHANCE

Amongst the 159 participants included in the intention-to-treat analysis, four women conceived before treatment and six were lost-to-follow-up. The remaining 149 participants (74 on CC and 75 on letrozole) completed at least the first treatment. Women receiving letrozole achieved a significantly (P = 0.022; absolute difference [95% confidence interval] 18% [3–33%]) higher pregnancy rate (61.%) than those on CC (43%). The median number of treatment cycles received until pregnancy was significantly (log rank P = 0.038) smaller with letrozole (4[3–5] cycles) compared to CC (6[4–7] cycles). LB rates were not statistically (P = 0.089) different between the two groups, although there was a trend towards higher rates on letrozole (48.8%) compared to CC (35.4%). After the crossover, pregnancy and LB rates on letrozole (n = 45; 28.9 and 24.4%, respectively) were not statistically (P = 0.539 and P = 0.601) different from CC (n = 31; 22.6 and 19.4%).

LIMITATIONS, REASONS FOR CAUTION

One possible limitation of this trial may be the exclusion of PCOS women with BMI > 35 kg/m², which would limit the applicability of the results in this subgroup of PCOS. However, this group of women are generally excluded from treatment in the majority of fertility centres, especially in Europe, due to the associated challenges and risks.

WIDER IMPLICATIONS OF THE FINDINGS

The results of this trial are consistent with the recent Cochrane systematic review. However, with its robust design, the current RCT provides more valid and compelling evidence for the superiority of letrozole over CC as a primary ovulation induction agent in PCOS women with 40% increase in pregnancy rates and with a shorter time-to-pregnancy. Furthermore, the participants in this RCT are a good representation of subfertile PCOS population receiving fertility treatment in Europe and worldwide. The results are therefore globally generalizable for clinical practice.

STUDY FUNDING/COMPETING INTEREST(S)

This RCT was mainly funded by the R&D Funding Scheme of Derby Hospitals NHS Foundation Trust. The study also received funds from School of Medicine, University of Nottingham. The Trust R&D department was involved in the development of the protocol and the running of the trial. The trial was sponsored and monitored by the University of Nottingham. The authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

www.Clinicaltrials.gov: NCT00478504.

TRIAL REGISTRATION DATE

Registration was verified on 23/05/2007.

DATE OF FIRST PATIENT'S ENROLMENT

25/04/2007.

PCOS and pregnancy: a review of available therapies to improve the outcome of pregnancy in women with polycystic ovary syndrome

INTRODUCTION

Polycystic ovary syndrome (PCOS) is a common cause of female infertility affecting multiple aspects of a women's health.

AREAS COVERED

The aim of this review is to summarize the existing evidence on the treatment of PCOS patients and to examine the actual available therapies to overcome the problem of infertility and improve the outcome of pregnancy. We analyse different treatment strategies such as lifestyle modification, bariatric surgery, insulin sensitizing agents, inositol, clomiphene citrate (CC), aromatase inhibitors, gonadotrophins, laparoscopic ovarian drilling, and assisted reproductive techniques (ART).

EXPERT COMMENTARY

Lifestyle modification is the best initial management for obese PCOS patients seeking pregnancy and insulin sensitizing agents seem to have an important role in treating insulin resistance. Up to now, CC maintains a central role in the induction of ovulation and it has been confirmed as the first-line treatment; the use of gonadotrophins is considered the second-line in CC resistant patients; laparoscopic ovarian drilling is an alternative to gonadotrophins in patients who need laparoscopy for another reason. However, in anovulatory patients, ART represents the only possible alternative to obtain pregnancy. Larger and well-designed studies are needed to clarify the best way to improve the outcome of pregnancy in PCOS women.

Letrozole versus clomiphene citrate in polycystic ovary syndrome: a meta-analysis of randomized controlled trials

PURPOSE

Polycystic ovary syndrome (PCOS) is a common endocrine disturbance affecting women in the reproductive age group. The present study aimed to compare the effects of letrozole (LE) and clomiphene citrate (CC) for ovulation induction in women with PCOS.

METHODS

The PUBMED, Web of Science, and EMBASE databases were screened systematically for randomized controlled trials (RCTs) published from database inception to July 2017.

RESULTS

Eleven RCTs involving 2255 patients were included, and data were independently extracted and analyzed using 95% risk ratios (RRs) and confidence intervals (CIs) based on a random- or fixed-effect model (as appropriate). Meta-analyses of nine RCTs comparing LE and CC ovulation induction, followed by timed intercourse, indicated that the former significantly increased the ovulation rate (RR = 1.18; 95% CI 1.03-1.36, P = 0.01), pregnancy rate (RR = 1.34; 95% CI 1.09-1.64, P = 0.006), and live birth rate (RR = 1.55; 95% CI 1.28-1.88, P < 0.00001). However, LE and CC did not differ significantly in terms of the multiple pregnancy and abortion rates. Furthermore, LE for ovulation induction significantly improved the pregnancy rate after IUI.

CONCLUSION

LE is superior to CC for ovulation induction in patients with PCOS.

Polycystic ovary syndrome throughout a woman's life

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among reproductive-aged women and the main cause of infertility due to anovulation. However, this syndrome spans the lives of women affecting them from in-utero life until death, leading to several health risks that can impair quality of life and increase morbidity and mortality rates. Fetal programming may represent the beginning of the condition characterized by hyperandrogenism and insulin resistance which leads to a series of medical consequences in adolescence, adulthood, and old age. Menstrual and fertility problems evolve into metabolic complications as age advances. An early and precise diagnosis is important for an adequate management of PCOS, especially at the extreme ends of the reproductive lifespan. However, many different phenotypes are included under the same condition, being important to look at these different phenotypes separately, as they may require different treatments and have different consequences. In this way, PCOS exhibits a great metabolic complexity and its diagnosis needs to be revised once again and adapted to recent data obtained by new technologies. According to the current medical literature, lifestyle therapy constitutes the first step in the management, especially when excess body weight is associated. Pharmacotherapy is frequently used to treat the most predominant manifestations in each age group, such as irregular menses and hirsutism in adolescence, fertility problems in adulthood, and metabolic problems and risk of cancer in old age. Close surveillance is mandatory in each stage of life to avoid health risks which may also affect the offspring, since fetal and post-natal complications seem to be increased in PCOS women.

A successful live birth with in vitro fertilization and thawed embryo transfer after conservative treatment of recurrent endometrial cancer

Estrogen-dependent early stage endometrial cancer is relatively common in young women of reproductive age. The standard treatment is hysterectomy and bilateral salpingo-oophorectomy (BSO), even in early stage well-differentiated endometrial cancer patients. This surgical option results in permanent loss of fertility. There have been some reports of live births using in vitro fertilization after conservative management of endometrial cancer with high-dose progestin for the purpose of fertility preservation. However, most were not recurrent cases and pregnancy was achieved through conventional in vitro fertilization, which usually raises serum estradiol levels and may lead to the recurrence of endometrial cancer. To date, it is hard to find a case that can be referred for any possible different approach needed for the patients who experience recurrence. Here we report a successful live birth with in vitro fertilization using letrozole to maintain physiological levels of estradiol, and subsequent thawed embryo transfer after elective cryopreservation of embryos in a patient with recurrent endometrial cancer. There has been no evidence of disease recurrence at one year after delivery.

Effect of Casein Phosphopeptide-amorphous Calcium Phosphate and Calcium Sodium Phosphosilicate on Artificial Carious Lesions: An in vitro Study

Aim

To compare new remineralizing agents calcium sodium phosphosilicate paste and casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) paste with that of fluoridated toothpaste in remineralization of early carious lesions using scanning electron microscopy and energy-dispersive X-ray (SEM-EDX) analysis.

Materials and methods

Sixty sound extracted premolars were collected and placed in demineralizing solution for 4 days to produce artificial carious lesions. All specimens were evaluated for any loss of mineral content using SEM-EDX analysis. Samples were randomly assigned to three groups: Group I: Fluoridated toothpaste (control), group II: CPP-ACP paste, and group III: Calcium sodium phosphosilicate paste. Specimens were then treated with above-mentioned remineralizing agents and again measured for mineral content using SEM-EDX analysis.

Results

Group III (calcium sodium phosphosilicate paste) showed highest significant difference followed in descending order by group II (CPP-ACP paste) and group I (fluoridated toothpaste).

Conclusion

Calcium sodium phosphosilicate paste showed maximum remineralizing potential compared with CPP-ACP and fluoridated toothpastes.

How to cite this article

Chaudhary I, Tripathi AM, Yadav G, Saha S. Effect of Casein Phosphopeptide-amorphous Calcium Phosphate and Calcium Sodium Phosphosilicate on Artificial Carious Lesions: An in vitro Study. Int J Clin Pediatr Dent 2017;10(3):261-266.

Effect of Resin Infiltration on Artificial Caries: An in vitro Evaluation of Resin Penetration and Microhardness

Aim

To evaluate the effectiveness of resin infiltration on artificial caries lesion by assessing the depth of resin penetration and the change in microhardness of lesion postinfiltration.

Materials and methods

Totally 45 human extracted premolars were used to create an artificial demineralized lesion in enamel using demineralizing solution. A total of 15 samples (group I) were infiltrated with resin. The depth of resin penetration was studied using scanning electron microscope (SEM). Other half (n = 30) of samples was equally divided into three subgroups and Vickers hardness number (VHN) values were obtained to measure the surface microhardness as group 11 a—before demineralization, 11 b—after demineralization, IIc—postresin infiltration.

Results

Mean depth of penetration in group I was 516.8 urn. There was statistically significant increase in VHN values of demineralized lesion postresin infiltration (independent Student’s t-test, p < 0.001).

Conclusion

Penetration depth of the resin infiltrant was deep enough to render beneficial effects, while significant increase in microhardness was observed postresin infiltration.

Clinical significance

Infiltrant used can be considered as a valid treatment option for noncavitated lesions.

How to cite this article

Prajapati D, Nayak R, Pai D, Upadhya N, Bhaskar VK, Kamath P. Effect of Resin Infiltration on Artificial Caries: An in vitro Evaluation of Resin Penetration and Microhardness. Int J Clin Pediatr Dent 2017;10(3):250-256.

Emerging Understanding of Emotional Intelligence of Teenagers

Aim

Emotional intelligence (EI) is the ability to use emotions effectively and productively. It is becoming increasingly clear that these skills are one of the primary foundations for better performance of students in classrooms and in the society as well and EI provides the basis for competencies important "in almost every job." So we accessed the EI of teenagers as a guide of their academic score.

Study design

We analyzed the correlation of academic score to the EI of teenagers in regular schools and part-time unconventional coaching institute using the Bar-On Emotional Quotient questionnaire.

Results and conclusion

The results of our study showed that empathy and self-actualization were highly developed in students of regular conventional school than those attending part-time unconventional coaching institute. The academic score had a significantly positive correlation with empathy, whereas a significantly negative correlation with interpersonal relations. Empathy, interpersonal relation, and impulsive control were significantly higher in females than males. Therefore by inculcating and working toward development of EI in the young generation, we can hope to achieve a more positive environment.

How to cite this article

Sekhri P, Sandhu M, Sachdev V. Emerging Understanding of Emotional Intelligence of Teenagers. Int J Clin Pediatr Dent 2017;10(3):289-292.

Comparison of Dermatoglyphic Pattern among Cleft and Noncleft Children: A Cross-sectional Study

Background

Oral clefts are among the common congenital birth defects with a broad phenotypic gamut. Since the epidermal ridges of the fingers and palms as well as the facial structures like lip, alveolus, and palate are formed from the same embryonic tissues during the same embryonic period, the genetic and environmental factors responsible for causing cleft lip and palate might also affect dermatoglyphic patterns.

Aim

Thus, study was undertaken to compare the dermato-glyphic pattern of children with orofacial clefts and normal children and to determine the correlation of dermatoglyphics with orofacial clefts.

Materials and methods

Total study sample consisted of 120 children in the age group of 3 to 16 years being divided into study and control groups. Dermatoglyphic data obtained from both control and study groups were then subjected to statistical analysis.

Results

Statistically no significant difference was found in the dermatoglyphic pattern and atd angle for both the groups.

Conclusion

It was observed that dermatoglyphics in orofacial clefts may not be distinctive. Further, large-scale studies are recommended to confirm the same.

How to cite this article

Mayall SS, Chaudhary S, Kaur H, Manuja N, Ravishankar T, Sinha AA. Comparison of Derma-toglyphic Pattern among Cleft and Noncleft Children: A Cross-sectional Study. Int J Clin Pediatr Dent 2017;10(3):245-249.

Comparison of clomiphene citrate and letrozole for ovulation induction in women with polycystic ovary syndrome: a prospective randomized trial

To compare the therapeutic efficacy of clomiphene citrate (CC) and letrozole (LE) on ovulation, pregnancy, and live birth in women with polycystic ovary syndrome (PCOS); and to ensure if LE can replace CC as the first-line therapy for ovulation induction in these women. This is a prospectively, randomized, controlled trial in the tertiary hospital. Two-hundred and sixty-eight anovulatory PCOS patients were treated by CC or CC plus metformin and LE or LE plus metformin for three continuous cycles or conception; their ovulation rates, pregnancy rates, and live birth rates were calculated and compared. No significant difference was noted among the four groups regarding to the baseline data of clinical manifestations, serum sex hormone levels, and serum insulin levels. A total of 240 patients completed the therapies. The ovulation rate was significantly higher in the group LE than the group CC; however, no significant difference was noted between the groups LE and CC, CC, and CC + MET, or LE and LE + MET in the pregnancy rate, abortion rate, and live birth rate. No birth defect was found in the total of 63 newborns. CC regimen was still recommended to be the first-line therapy of ovulation induction for PCOS.

Ovulation induction and controlled ovarian stimulation using letrozole gonadotropin combination: A single center retrospective cohort study

OBJECTIVE

To assess the effect of letrozole in combination with low dose gonadotropins for ovulation induction in anovulatory infertility from polycystic ovary syndrome (PCOS) and controlled ovarian stimulation for endometriosis, and unexplained infertility patients.

STUDY DESIGN

Retrospective cohort study in a setting of private Reproductive Endocrinology and Infertility Clinic affiliated with the University. Three hundred couples (650 cycles) requiring OI/COS for PCOS (92 patients, 195 cycles), endometriosis (89 patients, 217 cycles), and unexplained infertility (119 patients, 238 cycles). Patients received 2.5mg or 5mg letrozole for 5days (D3-D7) and recombinant follicle-stimulating hormone on alternating D3-D7 and human menopausal gonadotropin-highly purified alternating D5-D10 until growth of ideally 2 mature follicles. Ovulation was triggered with 10,000 IU of HCG. Maximum number of cycles per patient was four.

RESULTS

Main outcome measures were clinical pregnancy rates, multiple order pregnancy rates, miscarriage rates, number of follicles and endometrial thickness on the day of HCG administration. The cumulative incidence of pregnancy was estimated as 35% (95%CI: 29%-41%) overall and was highest in patients with PCOS (36.6%), followed by unexplained infertility (34.6%) and endometriosis (32.5%). The pregnancy rates per cycle in PCOS, endometriosis and unexplained infertility patients were 17%, 13.2% and 17.2% respectively, no statistically significant difference between the groups. There were three twin pregnancies in PCOS, and one in unexplained infertility group. Monofolliculogenesis was noted in 48% of patients.

CONCLUSION(S)

Letrozole-low dose gonadotropins combination appears to be effective across different causes of infertility for superovulation. The letrozole-low dose gonadotropin combination resulted in high rate of monofolliculogenesis, low occurrence of multiple gestations and no case of OHSS or cycle cancellation.

Clomiphene citrate is associated with favorable cycle characteristics but impaired outcomes of obese women with polycystic ovarian syndrome undergoing ovarian stimulation for in vitro fertilization

The aim of this study was to explore the effect of clomiphene citrate (CC) on the cycle characteristics and outcomes of obese women with polycystic ovarian syndrome (PCOS) undergoing ovarian stimulation for in vitro fertilization (IVF).This is a retrospective cohort study, and it was conducted at the tertiary-care academic medical center.This study included 174 obese PCOS patients undergoing IVF.In the study group (n = 90), CC and human menopausal gonadotropin (HMG) were administered simultaneously beginning on cycle day 3, while in control group (n = 84) HMG was used only. Both of the 2 groups used medroxyprogesterone acetate (MPA) for preventing premature luteinizing hormone (LH) surges. Ovulation was cotriggered by a GnRH agonist and hCG when dominant follicles matured.The primary outcome measure was the number of oocytes retrieved. Secondary outcomes included the number of top-quality embryos, maturation rate, fertilization rate, cleavage rate, incidence of premature LH surge, and OHSS.The study group received obviously lower total HMG dose [1650 (975-4800) vs 2025 (1350-3300) IU, P = 2.038E-4] but similar HMG duration. While the antral follicle count (AFC) is higher in study group, the number of oocytes retrieved and top-quality embryos are remarkably less [5 (0-30) vs 13 (0-42), P = 6.333E-5; 2 (0-14) vs 3.5 (0-15), P = .003; respectively]. The mature oocyte rate is higher in study group (P = .036). No significant differences were detected in fertilization rate and cleavage rate between 2 groups.CC has a positive influence on cycle characteristics, but might be correlated with the impaired IVF outcomes (less oocytes retrieved and top quality embryos, lower oocyte retrieval rate) in obese PCOS patients undergoing IVF, when HMG and MPA are used simultaneously.

Letrozole combined with low dose highly purified HMG for ovulation induction in clomiphene citrate-resistant infertile Chinese women with polycystic ovary syndrome: a prospective study

BACKGROUND AND AIM

There are still open questions about ovulation induction in clomiphene citrate-(CC)-resistant infertile women. Especially little is known about efficacy and safety of letrozole (LTZ) combined with low-dose highly purified human menopausal gonadotropin (Hp-HMG) in women with polycystic ovary syndrome (PCOS).

METHODS

Prospective, single-arm single-center trial in 200 infertile PCOS patients refractory for at least three CC-treatment cycles. Women with hyperandrogenism took Diane-35 for at least 3 months. All patients got LTZ on day 3 for 5 d in combination with Hp-HMG, starting with 75 IU from cycle day 7 and maintained for up to 3 d. The maximum dose was 150 IU. Primary end-points were ongoing and clinical pregnancy rate, secondary end-points mono-follicular development, ovulation rate, OHSS, multiple pregnancy and early pregnancy loss. Major safety end-point was the incidence of adverse events.

RESULTS

Within 395 cycles the ongoing pregnancy rate was 28.24%, for cycles 35.23%, for patients 68%. The rate of ovulation per cycle was 97.7%, percentage of mono-follicular development 70.9%. No severe OHSS, multiple pregnancy, local or systemic side effects were seen.

CONCLUSIONS

LTZ combined with low-dose Hp-HMG is an effective and safe choice for reducing hyperstimulation and increasing pregnancy rate in CC-resistant women with PCOS.

Committee Opinion No. 663: Aromatase Inhibitors in Gynecologic Practice

Aromatase inhibitors have been used for the treatment of breast cancer, ovulation induction, endometriosis, and other estrogen-modulated conditions. For women with breast cancer, bone mineral density screening is recommended with long-term aromatase inhibitor use because of risk of osteoporosis due to estrogen deficiency. Based on long-term adverse effects and complication safety data, when compared with tamoxifen, aromatase inhibitors are associated with a reduced incidence of thrombosis, endometrial cancer, and vaginal bleeding. For women with polycystic ovary syndrome and a body mass index greater than 30, letrozole should be considered as first-line therapy for ovulation induction because of the increased live birth rate compared with clomiphene citrate. Lifestyle changes that result in weight loss should be strongly encouraged. Aromatase inhibitors are a promising therapeutic option that may be helpful for the management of endometriosis-associated pain in combination therapy with progestins.

Effect of Dentin Disinfection with 2% Chlorhexidine Gluconate and 0.3% Iodine on Dentin Bond Strength: An in vitro Study

Objective

Cavity preparation is a surgical procedure that attempts to remove all infected dentin.¹ Bacteria left beneath the filling material is greatest threat to the pulp. To reduce the potential for residual caries development and sensitivity, an antibacterial solution with the ability to disinfect the prepared tooth surface would be of help.² So this study was conducted to evaluate and compare the effect of dentin disinfection with 2% chlorhexidine gluconate (Consepsis) and 0.3% iodine (Ora5) on shear bond strength (SBS) of self-etch adhesives to dentin.

Materials and methods

Buccal surfaces of 36 caries-free permanent third molars were ground to expose dentin. All specimens were mounted on acrylic block, divided randomly into three groups, namely group I (control), group II (Con-sepsis), and group III (Ora5). After the application of cavity disinfectant and bonding procedures as per manufacturer’s instructions, composite cylinders were built. Then SBS was measured using universal testing machine.

Results

Statistical analysis of the measurements were made using one-way analysis of variance (ANOVA), which showed that when cavity disinfectants (Consepsis and Ora5) were used there was significant reduction in SBS of composite to dentin when compared with that of control group.

Interpretation and conclusion

The results indicate that the use of commercially available cavity disinfectants, Consepsis containing 2% chlorhexidine gluconate and Ora5 containing 0.3% iodine and 0.15% potassium iodide with self-etch adhesive (Adper Prompt), would significantly lower SBS of composite to dentin.

How to cite this article

Suma NK, Shashibhushan KK, Reddy VVS. Effect of Dentin Disinfection with 2% Chlorhexidine Gluconate and 0.3% Iodine on Dentin Bond Strength: An in vitro Study. Int J Clin Pediatr Dent 2017;10(3):223-228.

Eruption Chronology in Children: A Cross-sectional Study

Aims and objectives

The purpose of this study is to determine the appropriate reference standard for eruption timing of primary teeth in infants and preschool children of Bhopal city and to determine the role of various factors affecting the eruption of primary dentition.

Materials and methods

A cross-sectional study was conducted among the infants and preschool children (4-36 months) attending the local government or private hospitals, and vaccination centers. Prior to the study, Institutional Ethical Committee clearance and informed written consent from the parents were obtained. The data were collected from full-term infants and preschool children of 4 to 36 months from Bhopal city. Oral examination was done under adequate natural light by a single examiner using mouth mirror and probe. Teeth present in the oral cavity were noted by using Federation Dentaire Internationale system of nomenclature in the preformed pro-forma. The teeth were considered as erupted, when any part of its crown had penetrated the gingiva and was visible in the oral cavity. Height, weight, birth weight, and other close-ended questions in questionnaire were asked from parents.

Results and conclusion

The data collected were statistically analyzed and it was observed that significant relation exists between tooth eruption and birth weight, feeding habits, socioeconomic status, and body mass index (BMI). Based on the findings, it may be concluded that Indian children experienced delayed eruption of primary teeth when compared with children of different countries and standard norms.

How to cite this article

Verma N, Bansal A, Tyagi P, Jain A, Tiwari U, Gupta R. Eruption Chronology in Children: A Cross-sectional Study. Int J Clin Pediatr Dent 2017;10(3):278-282.

Evaluation of Antimicrobial Efficacy of various Intracanal Medicaments in Primary Teeth: An in vivo Study

Introduction

Bacteria and their products play a primary etiological role in the initiation and perpetuation of pulpoperiapical pathosis. Intracanal medication is important for endodontic success as it eliminates microorganisms that persist after chemomechanical preparation.

Aim

To compare antimicrobial efficacy of calcium hydroxide powder, triple antibiotic paste, calcium hydroxide with 2% chlorhexidine solution, and triple antibiotic paste with 2% chlorhexidine solution.

Materials and methods

A total of 48 nonvital primary teeth were included in this study. After access opening first microbiological sample (s1) was collected by using absorbent paper point introducing into canal. Second microbilogical sample (s2) was taken following chemomechanical preparation and the teeth were divided into four groups: Group I: calcium hydroxide (CH) powder with distilled water; group II: CH with 2% chlorhexidine solution; group III: triple antibiotic powder with distilled water; group IV: triple antibiotic paste with 2% chlorhexidine solution. Then the canals were filled with any one group of the medicament and cavity was temporarily sealed with zinc oxide eugenol. After 1 week, a postmedication sample (s3) was collected. Then the canal was filled with Metapex, restored with glass ionomer cement.

Conclusion

From the experiments carried out in this study, with the limitations, an inference can be drawn that a combination of antimicrobial agent used as intracanal medicament is definitely better than single agent like Ca(OH)₂.

How to cite this article

Dutta B, Dhull KS, Das D, Samir PV, Verma RK, Singh N. Evaluation of Antimicrobial Efficacy of various Intracanal Medicaments in Primary Teeth: An in vivo Study. Int J Clin Pediatr Dent 2017;10(3):267-271.