Transabdominal ultrasonographic evaluation of endometrial thickness in clomiphene citrate-stimulated cycles in relation to conception

Does progesterone supplementation improve pregnancy rates in clomiphene citrate and intrauterine insemination treatment cycles?

AIM

To investigate the effect of empiric use of luteal phase progesterone supplementation to improve endometrial receptivity in women undergoing treatment with clomiphene citrate in combination with intrauterine insemination (CC-IUI).

DESIGN

Retrospective cohort analysis.

SETTING

University fertility center.

PATIENTS

426 CC-IUI cycles from 292 patients with unexplained infertility.

INTERVENTIONS

Patients were treated with micronized intravaginal progesterone 100 mg twice daily beginning approximately three days after CC-IUI.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy per initiated cycle as defined by presence of fetal heart rate on ultrasound.

RESULTS

Clinical pregnancy rate was higher in patients receiving luteal phase support compared to patients not receiving luteal phase support (odds ratio: 2.04; 95% confidence interval: 1.01-4.14) after adjusting for all factors in the analysis using a multivariate logistic regression model. Age at the start of the cycle, BMI and CC dose were not shown to have an effect on clinical pregnancy rates. Patients with endometrial lining (EML) thickness 6-8 mm and >8 mm had increased clinical pregnancy rates compared to EML <6 mm independent of luteal phase progesterone use. Patients who appear to receive the greatest benefit of progesterone supplementation are in the 6-8 mm EML cohort.

CONCLUSIONS

Luteal phase progesterone supplementation in CC-IUI cycles can improve endometrial receptivity as judged by the improved clinical pregnancy rates as the primary outcome.

Clomiphene citrate or aromatase inhibitors combined with gonadotropins for superovulation in women undergoing intrauterine insemination: a prospective randomised trial

The objective of this study was to test the use of letrozole in combination with follicle-stimulating hormone (FSH) vs clomiphene citrate (CC) with FSH for ovarian hyperstimulation prior to intrauterine insemination (IUI). A prospective randomised trial in which 280 women with unexplained infertility were randomised to 100 mg of CC (141 patients, 219 cycles) or 5 mg of letrozole daily (139 patients, 215 cycles) for 5 days starting on day 3 of menses both combined with gonadotropins for ovarian stimulation prior to IUI. The primary outcome measures were the number of growing and mature follicles, the concentrations of serum E2 (pg/ml) and progesterone (ng/ml), and the endometrial thickness (mm). The secondary outcome measure was the occurrence of pregnancy and miscarriage. The total number of follicles was significantly greater in the CC group (4.1 +/- 0.46 vs 2.6 +/- 0.43). There was no significant difference in endometrial thickness between the two groups. Pregnancy occurred in 33 out of 139 patients (215 cycles) in the letrozole group (23.7% and 15.3%, respectively) and 37 out of 141 patients (219 cycles) (26.2% and 16.8%, respectively) in the CC group; the differences were not statistically significant. The allied use of either CC or letrozole, during ovarian stimulation to reduce the dose of gonadotropins prior to IUI is justified. This approach will reduce the cost of stimulation protocols without effect on the treatment outcome and letrozole has no advantage over CC in this respect.

Ovulatory status and follicular response predict success of clomiphene citrate-intrauterine insemination

OBJECTIVE

To test the hypothesis that anovulatory women would have good pregnancy rates (PRs), regardless of single or multiple follicular development, in response to clomiphene citrate (CC), whereas ovulatory women would have good PRs only when achieving multifollicular responses to CC.

DESIGN

Retrospective chart review.

SETTING

University-based infertility center.

PATIENT(S)

Two hundred and fifty-four women underwent 585 CC-IUI treatment cycles over a 3-year period.

INTERVENTION

Treatment with CC-IUI.

MAIN OUTCOME MEASURE(S)

Various factors were examined as predictors of clinical pregnancy rate (CPR) and live-birth rate (LBR) per cycle with the use of logistic regression.

RESULT(S)

Overall, the CPR was 11.1%, and the LBR was 8.7%. Of 65 clinical pregnancies, 81.5% resulted in live births (singletons, 67.7%; twins, 13.8%). There were no higher-order deliveries. In anovulatory women, the CPR and LBR were 15.7% and 13.6%, respectively. In ovulatory women, the CPR and LBR were 8.8% and 6.3%, respectively. As the number of large follicles increased from one to two, the LBR increased from 6.8% to 10.5%. Regarding the interaction of follicles with ovulatory status, anovulatory women had nearly double the CPR and LBR compared to those in ovulatory women, irrespective of the number of large follicles.

CONCLUSION(S)

Treatment with CC-IUI is more successful in anovulatory women than in ovulatory women. The multiple follicular response in both ovulatory and anovulatory women increases PRs.

Embryo transfer and luteal support in natural cycles

Embryo transfer policy and luteal supplementation was reviewed, comparing literature data and the results from the Maribor IVF Centre. A retrospective analysis of 1024 cycles in patients undergoing IVF, intracytoplasmic sperm injection (ICSI) or testicular sperm aspiration in unstimulated cycles was carried out using four different approaches for cycle monitoring. This showed that the most successful protocol for monitoring was administration of human chorionic gonadotrophin (HCG) when serum oestradiol was >0.49 nmol/l and follicle diameter was at least 15 mm. The implantation rate per transferred embryo was higher when a blastocyst was transferred (42.8%) rather than a day-2 embryo (23.5%) in the same monitoring protocol. Analysis of the influence of patient age on the success of oocyte retrieval, oocyte fertilization, embryo transfer rate and delivery rate demonstrates that patient age does not influence the rate of positive oocyte retrieval or fertilization rate as much as it influences pregnancy rate per embryo transfer. The delivery rate per cycle was dramatically influenced by age in patients over 38 years. There is no clear evidence in the literature as to whether luteal phase support is necessary in natural cycles for IVF/ICSI. Comparing the data, a higher pregnancy rate was observed if HCG was administered after embryo transfer.

Follicular growth, endometrial thickness, and serum estradiol levels in spontaneous and clomiphene citrate-induced cycles

OBJECTIVES

To evaluate follicular growth, endometrial thickness, and serum estradiol levels in spontaneous cycles and cycles induced by clomiphene citrate (CC).

METHODS

A 2-year prospective study of spontaneous cycle followed by a CC-induced cycle to compare paired data. Twenty couples with unexplained infertility were recruited from the Infertility Clinic of the Jawaharlal Institute of Postgraduate Medical Education and Research. An oral dose of 150 mg of CC was administered on days 5 through 9 of the CC-induced cycle. Each woman was evaluated using transvaginal sonography and serum estradiol level estimation from day 10 of the menstrual cycle until ovulation. Results were analyzed using the paired t-test.

RESULTS

The leading follicular diameter was significantly larger, endometrial thickness was significantly decreased, and serum estradiol levels were significantly higher in the follicular phase of CC-induced cycles.

CONCLUSIONS

Clomiphene citrate-induced cycles showed different follicular, endometrial growth patterns, and serum estradiol levels compared with spontaneous cycles.

Effect of clomiphene citrate on endometrium thickness and echogenic patterns

OBJECTIVE

To study the effect of clomiphene citrate (CC) on the thickness and echogenic pattern of the endometrium using vaginal sonography.

METHOD

In this experimental prospective study, CC was given to 31 women with unexplained infertility. Thickness and echo patterns of the endometrium, as well as estradiol (E2) and progesterone (P) levels, were compared in women taking CC and in control patients during both the late proliferative and midsecretory phases of the menstrual cycle.

RESULTS

Endometrial thickness was significantly thinner in women taking CC (P<0.03) than in controls during the late proliferative phase but there was no significant difference during the midsecretory phase. The endometrial echogenic patterns of women taking CC who had conceived revealed endometrial thicknesses of grade III and grade IV on midsecretory days, but these findings were not significantly different from those of women who had not conceived (P=0.3). Serum E2 level was higher in women taking CC than in the controls on both late proliferative and midsecretory days (P<0.05).

CONCLUSION

CC affects endometrium thickness on late proliferative days but not on midsecretory days, and does not alter the echogenic pattern of the endometrium.