Pathophysiology of reproductive failure after clomiphene-induced ovulation

The luteal phase after ovarian stimulation

Evaluation of the luteal phase after ovarian stimulation presents several difficulties. Until today, it has not been proved that in cycles stimulated with clomiphene citrate/human menopausal gonadotrophins, luteal supplementation with progesterone significantly increases implantation rate. On the contrary, it is accepted that in cycles stimulated with GnRH agonists/gonadotrophins, support of the luteal phase is essential for the achievement of pregnancy. In GnRH antagonist cycles luteal supplementation, although widely practised, is not at present supported by randomized controlled trials. Finally, it appears that the combination of gonadotrophin stimulation with human chorionic gonadotrophin results in an inadequate luteal phase with or without the use of either agonists or antagonists.

Endometrial biopsy during induction of ovulation with clomiphene citrate in polycystic ovary syndrome

BACKGROUND

The dichotomy between ovulation rates and pregnancy rates for women with polycystic ovary syndrome (PCOS) treated with clomiphene citrate (CC) prompted the present study to determine the effect of CC on endometrial maturity.

METHODS

Retrospective case-control study of anovulatory women with PCOS (n = 119) on their third ovulatory cycle of CC and controls, 238 healthy regularly ovulating women whose partners had abnormal sperm, all of whom had an endometrial biopsy in the late luteal phase.

RESULTS

Endometrial histology classified according to the classical Noyes criteria revealed out-of-phase endometrium in 19/119 (16%) of the CC group compared with 7/238 (3%) in controls (p < 0.0001). Duration of the luteal phase was not influenced by histological age of the endometrium. Endometrial biopsy performed during 138 conception cycles extracted from the database did not increase the miscarriage rate significantly (23.9%).

CONCLUSIONS

CC treatment significantly increases the prevalence of out-of-phase endometrium and this could explain, in part, the large difference between ovulation and pregnancy rates. There was no correlation between the results of the endometrial biopsy and the duration of the luteal phase. Performing an endometrial biopsy during a conception cycle does not seem to have a significant negative effect on the outcome of pregnancy.

Toxicological overview of cigarette smoking on angiogenesis

Angiogenesis is the process of generating new capillary blood vessels. It occurs under tight regulation in the female reproductive system, during wound healing and during embryogenesis. Angiogenesis also plays an important role in the pregnancy-associated changes in the reproductive tract. Cigarette smoke inhibits processes that may hinder normal process of angiogenesis resulting in abnormal blood supply to tissues, decreased repair and remodeling. This report summarizes the evidences of the causal association between tobacco smoking and disruption of angiogenesis. Application of small amount of nicotine on day 5 old chorioallantoic membranes (CAMs) did not disrupt the process of angiogenesis, while application of mainstream smokes (MSS) solutions to CAMs caused varying levels of disruption on normal process of angiogenesis and adversely affect capillary plexus formation, diameters of secondary and tertiary vessels. We have also observed that at equivalent doses, sidestream smoke (SSS) can significantly be more potent than MSS and can alter the normal process of angiogenesis more drastically than MSS. It suggests that SSS either contains a toxicant(s) not present in MSS or that the toxicant(s) that produces these effects is present in higher concentration in SSS than in MSS. Therefore, it is undisputed that smoking can interfere the normal process of angiogenesis, which is a vital process to maintain pregnancy and development of fetus. Smoking during pregnancy is harmful to fetal development and is associated with an increased risk of miscarriage, perinatal death and sudden infant death syndrome. Smoking-cessation programs remain a crucial strategy for preventing poor birth outcomes and decreasing the social and financial costs of smoking during pregnancy.

Polycystic ovary syndrome and ovulation induction

Before initiating treatment to induce ovulation in cases of PCOS, an appropriate evaluation of the patient and her partner, based on individual considerations, is important to optimize outcome. For obese patients with PCOS, weight-loss measures should be pursued before pharmacologic treatment is initiated. For most patients, the pharmacologic agent of choice to induce ovulation is clomiphene citrate, alone or in combination with a glucocorticoid. Treatment with metformin, alone or in combination with clomiphene citrate, may also be beneficial. For patients not responsive to clomiphene citrate, injectable gonadotropin treatment is usually warranted, although, depending on individual circumstances, laparoscopic ovarian drilling may be appropriate.

Role of vascular endothelial growth factor in ovarian physiology and pathology

OBJECTIVE

To review the current literature on the role of vascular endothelial growth factor/vascular permeability factor (VEGF/VPF) in ovarian physiology and pathology.

DESIGN

A computerized search was conducted to identify relevant in vitro and in vivo studies published in English. MEDLINE, Current Contents, and the Index Medicus were searched for studies published before January 2000.

RESULT(S)

VEGF/VPF is an angiogenic factor and a potent mitogen for vascular endothelium. During reproductive life, VEGF/VPF plays a role in the cyclic growth of ovarian follicles and corpus luteum development and maintenance, mediating ovarian angiogenesis. VEGF/VPF expression and secretion are induced by both FSH and LH/hCG receptor-activated pathways.

CONCLUSION(S)

VEGF/VPF expression and production within the ovary are critical for normal reproductive function. Defects in angiogenesis may contribute to a variety of disorders including anovulation and infertility, pregnancy loss, ovarian hyperstimulation syndrome, and ovarian neoplasms.

Angiogenesis in the corpus luteum

The ovarian corpus luteum plays a critical role in reproduction because it is the primary source of circulating progesterone. After ovulation, as the corpus luteum forms from the wall of the ruptured follicle, it grows and vascularizes extremely rapidly. In fact, the rates of tissue growth and angiogenesis in the corpus luteum rival those of even the fastest growing tumors. Thus, the corpus luteum provides an outstanding model for studying the factors that regulate the angiogenic process, which is critical for normal tissue growth, development, and function. In agreement with data from other tissues, vascular endothelial growth factors (VEGF) seem to be a major angiogenic factor responsible for vascularization of the developing corpus luteum. Recent data suggest that luteal expression of VEGF occurs primarily in specific perivascular cells, including arteriolar smooth muscle and capillary pericytes, and is regulated primarily by oxygen levels. In addition, soon after ovulation, pericytes derived from the thecal compartment appear to be the first vascular cells to invade the developing luteal parenchyma. The granulosa-derived cells produce a factor that stimulates pericyte migration. Moreover, nitric oxide (NO), which is a potent vasodilator and can stimulate VEGF production and angiogenesis, is expressed in endothelial cells of luteal arterioles and capillaries, often in association with expression of VEGF by luteal perivascular cells. Thus, we have proposed a model for the initial process of luteal vascularization in which hypoxia plays a major role. In this model, which we believe will apply to other tissues as well, a paracrine loop exists between the vascular endothelial cells, which produce NO, and the peri-endothelial cells (vascular smooth muscle and pericytes), which produce VEGF, to ensure coordinate regulation of luteal vasodilation and angiogenesis.

Comparison of low-technology and high-technology monitoring of clomiphene citrate ovulation induction

OBJECTIVE

To determine whether newer monitoring techniques, including urinary detection of the LH surge and vaginal ultrasound, offer an advantage over basal body temperature (BBT) charts alone in achieving pregnancy using clomiphene citrate (CC).

DESIGN

Randomized clinical trial.

SETTING

Infertility patients in an academic research environment.

PATIENT(S)

Forty-five women undergoing ovulation induction with CC.

INTERVENTION(S)

The women were assigned randomly to receive either low- or high-technology ovulation monitoring for a total of 3 ovulatory cycles. Both groups were followed with BBT charts. The high-technology group also was monitored with urinary LH kits and vaginal ultrasound.

MAIN OUTCOME MEASURE(S)

Cycle fecundity rates for each technique were compared statistically with use of life-table analysis.

RESULT(S)

Forty-five patients were studied during a total of 134 cycles. The overall cycle fecundity rate was 8%, 10% (8 of 81 cycles) for the low-technology monitoring group and 6% (3 of 53 cycles) for the high-technology monitoring group. These rates were not statistically significant when evaluated by Fisher's exact test (P = .53) or when using life-table analysis and a log-rank test (P = .48).

CONCLUSION(S)

These data suggest that, for initial attempts at ovulation induction with CC in unselected patients, high-technology monitoring of ovulation offers no increase in fecundity over low-technology monitoring.

The effect of clomiphene citrate treatment on cervical mucus and plasma estradiol and progesterone levels

OBJECTIVES

To study the relationship between cervical mucus (CM) quality, postcoital test (PCT) results and plasma estradiol (E2) in clomiphene citrate (CC)-treated women. A subsidiary aim was to study the relationship between CM quality and plasma progesterone (P).

DESIGN

Untreated women were compared with oligo-ovulatory patients given CC.

SETTING

Infertility Clinic, Fazakerley Hospital, United Kingdom.

PATIENTS, PARTICIPANTS

Fifty-one untreated patients and 31 women given CC.

INTERVENTIONS

The treated women were given 50 mg/d CC from days 2 to 6 of their cycle.

MAIN OUTCOME MEASURES

A CM assessment, a PCT, plasma E2, and P were performed at the anticipated time of ovulation based on at least two previous basal body temperature charts and menstrual patterns.

RESULTS

In untreated women there was a very strong tendency for CM quality to improve with rising plasma E2 levels and to worsen with rising plasma P levels. There was a significant association between CM quality and PCT results. Similar results were found in CC-treated women, except that plasma E2 was very significantly higher and there was a significant inverse relationship between plasma E2 and CM quality.

CONCLUSION

High plasma E2 in the periovulatory phase in CC-treated women is a marker for increased sensitivity to and continuing action of the antiestrogen. This impairs the quality of the CM.

A prospective, randomised, cross-over study comparing the effects of clomiphene citrate and cyclofenil on endometrial morphology in the luteal phase of normal, fertile women

OBJECTIVE

To examine the effect of two anti-oestrogens, clomiphene citrate and cyclofenil, on endometrial morphology in the luteal phase.

DESIGN

A prospective, randomised, cross-over study.

SETTING

Jessop Hospital for Women, Sheffield, UK.

SUBJECTS

10 women who were previously fertile and regularly cycling.

INTERVENTION

The administration of clomiphene citrate or cyclofenil in the treatment cycles. A LH timed endometrial biopsy was taken on day LH + 6.

MAIN OUTCOME MEASURES

Histological dating and morphometric analysis of the endometrial sample.

RESULTS

Only one out of 10 subjects had abnormal endometrium. There was no difference in the results between cycles treated with clomiphene citrate and cyclofenil.

CONCLUSIONS

Clomiphene citrate or cyclofenil does not have a major adverse effect on endometrial morphology in the luteal phase of normal fertile subjects. The possible adverse effects of anti-oestrogens on endometrium may have been previously overestimated.

Luteal insufficiency: correlation between endometrial dating and integrated progesterone output in clomiphene citrate-induced cycles

Midluteal phase endometrium was histologically dated with midcycle luteinizing hormone surge time in 29 cycles from 10 parous women during untreated cycles (control) and treatment with clomiphene citrate 50 mg and 150 mg daily on days 5 through 9. Integrated progesterone output for 7 days after luteinizing hormone surge calculated from the daily plasma progesterone levels was 66.6 +/- 9.8 ng/ml in the control group compared with 117.5 +/- 18.6 ng/ml for clomiphene citrate 50 mg treatment and 152.1 +/- 11 ng/ml for clomiphene citrate 150 mg treatment (p less than or equal to 0.05). Only one cycle (clomiphene citrate 150 mg) had an out-of-phase endometrium and a significantly reduced integrated progesterone output of 28 ng/ml. All other cycles showed synchronous endometrial maturation. We conclude that luteal insufficiency as a result of clomiphene citrate treatment in ovulatory women is infrequent and is more likely to be a result of functional outcome of a relative lack of luteal phase progesterone output.

Outpatient gamete intrafallopian transfer: a clinical analysis of 710 cases

From February 1986 to June 1989 445 infertile couples were treated with a total of 710 treatment cycles involving laparoscopic gamete intrafallopian transfer (GIFT). The median age of the female partner was 33.5 years (range, 24 to 49 years) and the median duration of infertility was 4 years (range, 2 to 20 years). The final outcome of all 217 clinical pregnancies is known. There were 150 live births among which all but one baby survived, comprising 112 singleton births, 28 twin births, nine triplet births and one quadruplet birth. There were no still births, but there were two premature, multiple live births (one triplet, one quadruplet) among which no babies survived the neonatal period. Overall, 40 of the 152 potentially viable pregnancies were multiple (26.3%). Three of 206 potentially viable babies were born with congenital anomalies (1.5%). There were 50 clinical spontaneous abortions (24.8% of uterine pregnancies), one termination of pregnancy for Down's syndrome, and 14 ectopic pregnancies rate was 30.6% per laparoscopy and, among 740 initiated cycles, a live and surviving birth-per-initiated-cycle rate of 20.2%, or 33.7% to date per couple entering the programme. The 710 laparscopies resulted in two serious complications (0.3%), one of which required laparotomy. Eight other patients were admitted to hospital for rest and observation because of painful ovarian enlargement in the luteal phase. The total inpatient admission rate was 1.4%. Outpatient laparoscopic GIFT under general anaesthesia is a safe and effective procedure when conventional treatment for infertility has been unsuccessful.

Hormonal profiles following clomiphene citrate therapy in conception and nonconception cycles

The hormonal profiles following clomiphene citrate (CC) administration during a single cycle were compared in infertile women who conceived and in those who did not. Of 41 treated patients, ovulation was assumed to have occurred in 28 and was confirmed by clinical pregnancy in five. In the 28 women who presumably ovulated, two distinct patterns of hormonal secretion were observed. A normal response was exhibited by 17 patients (including the five who became pregnant). The other 11 patients exhibited an abnormal response, characterized by significantly higher luteinizing hormone (LH)/follicle-stimulating hormone (FSH) ratios than in the normal response group from day 9 until the occurrence of the LH peak (days 9 and 10, P less than 0.05; days 11 and 12, P less than 0.001), and significantly higher oestradiol (E2) levels throughout the cycle (P less than 0.01). In addition, in comparison with the normal response group their LH levels during the follicular phase were significantly higher (P less than 0.05) but their LH peaks at ovulation were significantly lower (P less than 0.02). Moreover, their progesterone levels, in contrast to those in the normal response group, began to increase prior to the LH peak and remained high during the early and mid-luteal phases. None of the women who exhibited this abnormal gonadotrophin response to CC therapy achieved a clinical pregnancy. Exposure to high LH levels in the follicular phase following CC therapy seems to reduce the rate of fertilization and/or to contribute to early embryonic loss.

Effects of systemic administration of indomethacin on ovulation, luteinization, and steroidogenesis in the rabbit ovary

Indomethacin blocks ovulation in human chorionic gonadotropin-stimulated rabbits. Experiments were done with an in vitro ovarian perfusion system to investigate whether indomethacin affects luteinization and steroidogenesis. Indomethacin (10 mg/kg) was administered in combination with human chorionic gonadotropin (100 IU) via a marginal ear vein, and a second dose of indomethacin was given 8 hours later. Control animals received vehicle in place of indomethacin. Laparotomy was performed 24 hours after the initial treatment. The presence of unruptured follicles and corpora lutea was recorded and the ovaries were perfused in vitro for 3 hours. Progesterone, prostaglandin F2 alpha, prostaglandin E2, and 6-keto-prostaglandin F1 alpha were measured in samples obtained at 0, 30, 60, 120, and 180 minutes from the circulating perfusion medium entering and exiting the ovary. At the end of the perfusion all ovaries (12 treated and 10 controls) were fixed for histologic analysis. Ovulation occurred in all control ovaries but in none of the indomethacin-treated ovaries. The mean number of unruptured follicles per ovary in the treated group was not significantly different from the number of corpora lutea plus unruptured follicles per ovary in the controls. Cells in both groups were qualitatively similar in ultrastructure; abundant lipid droplets, smooth endoplasmic reticulum, and mitochondria were seen. Secretion rates of progesterone and prostaglandin did not differ between the two groups during the 3-hour perfusion period. These results suggest that transformation of granulosa cells into fully functional luteal cells can occur in the absence of follicular rupture.

Diagnosis and management of out-of-phase endometrial biopsies among patients receiving clomiphene citrate for ovulation induction

Eighty-seven patients who underwent a late secretory phase endometrial biopsy while taking clomiphene citrate (CC) for ovulation induction were studied. Of the endometrial biopsies, 21 (24%) showed an endometrium greater than 2 days out of phase (OOP) with respect to the subsequent menstrual cycle. All 87 patients were categorized by age, weight, CC dosage, and underlying disease entity. The patients then were evaluated by these categories in relation to the incidence of an OOP biopsy while taking CC. Patients with a diagnosis of hypothalamic amenorrhea were statistically more likely to have an OOP endometrium. No other subgroup showed an increased or decreased incidence of OOP biopsies. Conception and spontaneous abortion rates were similar among patients with in-phase biopsies and those with out-of-phase biopsies, which subsequently were corrected with further medical therapy. An aggressive approach to the diagnosis and treatment of luteal phase insufficiency in patients who receive CC for ovulation induction is recommended.

In vitro fertilization: the degree of endometrial insufficiency varies with the type of ovarian stimulation

Fifty-eight patients in an in vitro fertilization program who did not have embryo transfers had endometrial biopsies performed on the second day after ovulation. The patients had been stimulated with clomiphene citrate (CC) and human chorionic gonadotropin (hCG) (group I); with CC, human menopausal gonadotropin (hMG), and hCG (group II), or with hMG and hCG (group III). Only 17 patients (30%) showed a normal luteal phase histology. The remaining 41 patients (70%) showed variety of endometrial abnormalities. Patients stimulated with hMG and hCG (group III) had a normal luteal phase at a significantly higher rate (48% versus 16%). Women below the age of 35 had a significantly higher rate of normal luteal phase histology than women older than 35 years. The study establishes abnormal endometrial histology as a possible cause of the low pregnancy rate of in vitro fertilization. The degree of endometrial histologic abnormality varies considerably with the type of ovarian stimulation used.

Direct effects of clomiphene citrate on the steroidogenic capability of human granulosa cells

The effects of clomiphene citrate (CC), 17 beta-estradiol (E2), and human chorionic gonadotropin (hCG) on the accumulation of progesterone (P) and 20 alpha-hydroxy-4-pregnen-3-one (20 alpha-OHP) in cultured human granulosa cells (GC) were examined. In addition, the metabolism of [4-14C]pregnenolone and accumulation of [4-14C]P in response to CC and E2 were determined. The authors conclude the following: (1) the dose-dependent inhibition of P and 20 alpha-OHP production by CC in GC was not reproduced by E2, (2) hCG abolished these effects of CC, (3) these inhibitory actions of CC were not associated with altered 3 beta-hydroxysteroid dehydrogenase activity nor P catabolism indicating that, (4) these actions by CC on the GC occur at some step(s) during steroidogenesis preceding the formation of pregnenolone. These findings may explain, at least in part, the luteal deficiency experienced by women treated with CC, and they also provide a rationale for the use of hCG supplementation during ovulation induction with CC.

Histologic and hormonal documentation of the luteinized unruptured follicle syndrome

Histologic and hormonal documentation of a luteinized unruptured follicle that occurred during a spontaneous menstrual cycle in a rhesus monkey is presented. Frequent (every 2 hours) blood sampling to assess midcycle hormonal dynamics in the monkey with the luteinized unruptured follicle and in five monkeys with an ovulatory stigma revealed significant aberrations in the gonadotropin and steroid hormone profiles associated with a luteinized unruptured follicle. Although the midcycle 17 beta-estradiol surge was normal, the monkey with the luteinized unruptured follicle demonstrated (1) blunted midcycle bioassayable luteinizing hormone, immunoassayable luteinizing hormone, and follicle-stimulating hormone surges; (2) absence of disparity in the bioassayable luteinizing hormone: immunoassayable luteinizing hormone ratio during the gonadotropin surge; (3) absence of progesterone and 17 alpha-hydroxyprogesterone secretion during the gonadotropin surge; and (4) delayed and blunted rise in progesterone and 17 alpha-hydroxyprogesterone after the gonadotropin surge. These findings suggest that an impaired luteinizing hormone surge, perhaps mediated by insufficient midcycle progestin secretion, is one possible cause of the luteinized unruptured follicle syndrome.

Congenital adrenal hyperplasia and luteal dysfunction

A case of 21-hydroxylase deficiency diagnosed and first treated at the age of 3 years is presented. Although pubertal development was delayed, full reproductive function was attained, with menses occurring at 14-33-day intervals. Infertility evaluation at age 20 revealed elevated 17-hydroxyprogesterone (17Po) and androgen concentrations and reduced luteal phase progesterone levels consistent with inadequate luteal function. This was corrected with additional corticosteroid replacement. Normal pregnancy and delivery followed.

Ultrasonographic and clinical correlates of menotropin versus sequential clomiphene citrate: menotropin therapy for induction of ovulation

Forty-six women remaining infertile with clomiphene citrate (CC) with or without human chorionic gonadotropin (hCG) were treated by either human menopausal gonadotropin (hMG, 44 cycles) or CC + hMG (33 cycles) and monitored by serum estradiol (E2) and ultrasonography. Ovarian hyperstimulation syndrome (OHS) and pregnancy outcome were compared in both regimens. In the presence of dominant follicles (greater than or equal to 18 mm) alone or with a single secondary follicle (14 to 16 mm) at hCG administration, OHS did not develop. A significant increase in OHS was noted when three or more secondary follicles were observed. Overall pregnancy rates were similar in both regimens but significantly higher when hCG was injected before rather than after the E2 peak. The results suggest secondary follicles rather than dominant follicles are a valuable sign of possible OHS development; and CC + hMG should be considered in CC-failure patients.

Follicle growth curves and hormonal patterns in patients with the luteinized unruptured follicle syndrome

A prospective longitudinal and standardized study is presented, dealing with ultrasonographic and hormonal characteristics of the luteinized unruptured follicle (LUF) syndrome. Among 600 cycles monitored in 270 infertility patients, 40 cycles in 27 patients showed no evidence of follicle rupture, in spite of signs of luteinization, as reflected by basal body temperature recordings and progesterone determinations. In this study, 20 LUF cycles in 20 infertile patients were compared with 45 ovulatory cycles in 45 control women. During the follicular phase, no substantial difference in follicle growth was found, but after the luteinizing hormone peak, LUF follicles, instead of rupturing, showed a typical accelerated growth pattern. Both mean luteinizing hormone peak levels and midluteal progesterone levels were significantly lower in LUF cycles than in the control cycles. However, the duration of the luteal phase was not affected. Both central and local factors can be held responsible for the lack of follicle rupture. Ultrasound offers new possibilities as a noninvasive method in diagnosing the LUF syndrome.

Induction of luteal phase defect with clomiphene citrate

The effect of clomiphene citrate and progesterone on luteal function in infertile women was studied. Endometrial biopsies were performed in 103 women immediately prior to menstruation. Group 1 (n = 62) had secretory endometrium with a histologic lag time of greater than or equal to 48 hours with respect to the subsequent menses, that is, luteal phase defect. Group 2 (n = 10) had normal histologic characteristics of the secretory phase. Group 3 (n = 31) had anovulatory endometrium. The last group was subdivided into those with polycystic ovary syndrome (n = 9) and those without the characteristic gonadotropin pattern of polycystic ovary syndrome (n = 22). Clomiphene citrate at doses of 50 to 250 mg daily for 5 days was administered for induction of ovulation, timing of ovulation, or treatment of luteal phase defect. An endometrial biopsy was obtained after three ovulatory treatment cycles. Only one fourth of the women with prior luteal phase defect had normalization of the biopsy specimen with clomiphene citrate, while one half of those treated with progesterone had normal specimens. Half of the normally ovulating women had induction of a luteal phase defect with clomiphene citrate. Only women with polycystic ovary syndrome had consistently well-timed endometrial histologic features with clomiphene citrate therapy. Despite successful induction of ovulation, 16 of the other 22 previously anovulatory women had endometrial histologic findings compatible with luteal phase defect. Increasing the clomiphene citrate dosage was unsuccessful in improving endometrial maturation. These results suggest that the use of clomiphene citrate may be associated with a high rate of luteal phase defect induction, except among women with polycystic ovary syndrome. Clomiphene citrate, even at high doses, appears to be ineffective therapy for luteal phase defect.

Dehydrogesterone treatment of endometrial luteal phase deficiency after ovulation induced by clomiphene citrate and human chorionic gonadotropin

Twenty infertile patients being treated with clomiphene citrate (CC) and human chorionic gonadotropin (hCG) for induction of ovulation, with a defective endometrial secretory pattern despite normal plasma levels of progesterone, estradiol, and prolactin, were entered into treatment plans on a random basis involving the following: CC-hCG plus dehydrogesterone (group 1), and CC-hCG (group 2). Success rates were similar in both groups (20% and 30%, respectively), based on a corrected endometrial defect during the second treated cycle. It is concluded that progestational agents are of low therapeutic value in endometrial luteal phase deficiency induced by CC.

Influence of laparoscopic follicular aspiration under general anaesthesia on corpus luteum progesterone secretion in normal and clomiphene-stimulated cycles

In 32 patients with unstimulated normal cycles and 24 with cycles stimulated with clomiphene and human chorionic gonadotrophin (hCG) all visible follicles were punctured laparoscopically under general anaesthesia for the purpose of in vitro fertilization. In unstimulated cycles the time of surgery was between 24 and 32 h after the first luteinizing hormone (LH) increase in the urine; in the cycles stimulated with hCG (5000 i.u.) laparoscopy was between 35 and 37 h after injection. Blood samples for progesterone determination were taken about 7 days later. Progesterone levels were compared with those in a control group not subjected to surgery, in which the progesterone levels were determined 7 days after the LH increase. There was no statistically significant difference in the progesterone levels in the unstimulated subjects after laparoscopy compared with those in the control subjects but progesterone levels in the stimulated subjects were significantly higher (p less than 0.01). Durations of the luteal phases showed no significant differences thus laparoscopy under general anaesthesia does not impair luteal function.

Spontaneous abortion incidence in the treatment of infertility

Analysis of published series indicates that, irrespective of the method of data collection, close agreement exists on empirically derived incidences of spontaneous abortion in North American populations, provided that age, previous abortion history, and gravidity are controlled. The normal incidence of clinically apparent abortion among first pregnancies in women under age 30 years is in the range 8.3% to 11.0%. A comprehensive analysis of published series on pregnancies after infertility treatment indicates that only three therapeutic methods are attended by an abortion incidence that approaches this asymptote: ovulation induction with bromocriptine in hyperprolactinemic anovulation (11.8%; n = 1,233 pregnancies); artificial insemination with donor semen for azoospermia (11.4%; n = 326 first pregnancies); and operation for endometriosis (9.3%; n = 768 pregnancies). Abortion incidences accompanying other modes of therapy are higher. Because increased abortion incidence is not generally recognized as a specific reproductive difficulty in infertile couples, as are the other two: i.e., refractory infertility despite technically adequate therapy and ectopic pregnancy, plausible physiologic mechanisms for abortions in specific categories of disease or treatment type are described and discussed in detail. Moreover, abortion incidence is proposed to be a sensitive and objective parameter with which to assess distortions in human reproductive physiology, especially when competing methods of infertility treatment have overall pregnancy outcomes that are thought to be similar.

Ultrasonic evidence for luteinization of unruptured preovulatory follicles

Luteinization of an unruptured ovarian follicle has been reported as a cause of infertility and has heretofore been diagnosed only by direct visualization of the ovarian surface. Four patients who demonstrated defects in ovulation requiring therapy to induce ovulation and who were not achieving desired conception despite apparently adequate treatment were studied with serial pelvic ultrasonic examinations for 17 cycles. Luteinization, characterized by the loss of a clear demarcation of the follicular cyst wall and the presence of intrafollicular echoes, was suspected in each of these cycles by the absence of ultrasonic signs of ovulation--that is, a rapid decrease in follicular size and the appearance of free fluid in the cul-de-sac. Histologic confirmation of a persistent luteinized cyst is presented.

A decade's experience with an individualized clomiphene treatment regimen including its effect on the postcoital test

During a 10-year period, 428 women received clomiphene citrate according to a graduated therapeutic regimen in which the dose of clomiphene and the laboratory studies were individualized according to each patient's history, examination and response. Of the 428 patients, 85.3% ovulated and 42.8% conceived. The great majority of those who conceived did so during the first three ovulatory cycles. There was no evidence that clomiphene therapy was associated with the induction of another cause of infertility. Overall, 88.2% of those with no other causes for infertility who ovulated also conceived. However, only 7.8% of those who had one or more factors in addition to anovulation became pregnant. There was no evidence that clomiphene adversely affected the postcoital test, as only 15% of the patients had poor cervical mucus. The low rate of complications of this treatment, 5.1% cyst formation as well as the 14% abortion rate and the 2.6% congenital anomaly rate and the excellent gestational outcome in those who conceived support the use of this treatment regimen.

Induction of ovulation with menotropins in women with polycystic ovary syndrome

Twenty-four women with ovulatory infertility as a result of surgically or biochemically documented polycystic ovary syndrome (PCO) who had failed to conceive during clomiphene citrate therapy underwent a closely supervised menotropin treatment to induce ovulation. Evidence of ovulation was obtained in all patients treated, and major side effects were limited. Fourteen women conceived after an average of 2.4 treatment cycles; twin pregnancies occurred in 36% and spontaneous abortions occurred in 21%. Initial treatment cycles tended to be less successful than the subsequent treatment cycles. Serum 17 beta-estradiol (E2) levels were significantly augmented in the last 3 days before administration of chorionic gonadotropins (hCG) in treatment cycles resulting in conception compared to E2 levels in those cycles which resulted in ovulation only. A second hCG administration to trigger ovulation had to be given in 27% of the treatment cycles and seemed to be an indication of a less promising treatment cycle. Treatment cycles resulting in twin gestations did not differ from those resulting in singleton gestations; specifically, the E2 response was not increased. In summary, under a closely monitored regimen, menotropin therapy can be used in women with nonovulatory infertility as a result of PCO with considerable effectiveness and relative safety once clomiphene citrate treatment has failed.

The function of the corpus luteum of pregnancy in ovulatory dysfunction and luteal phase deficiency

Relatively little knowledge exists of corpus luteum function in early pregnancy after the successful treatment of ovulatory dysfunction or luteal phase deficiency. To assess the activity of the corpus luteum of such patients, human chorionic gonadotropin (hCG) and 17-hydroxyprogesterone (17-OH-P) levels were determined in serum samples obtained from normal women (44 patients), women with ovulatory dysfunction (10 patients), and women with luteal phase deficiency (7 patients); all determinations were made during conceptive cycles, and sampling continued into the first trimester of pregnancy. There were no statistically significant abnormalities of hCG levels when infertility patients were compared with control patients. According to the premise that 17-OH-P levels reflect corpus luteal function, there appeared to be adequate function in pregnancies after progesterone treatment of luteal phase deficiency. In pregnancies following ovulation induction with clomiphene, the corpus luteum function, on the basis of 17-OH-P levels, was significantly increased in magnitude and duration. These results have clinical implications with regard to supplemental hormone therapy in early pregnancy.

Clomiphene citrate in the management of infertility associated with shortened luteal phases

Repetitively short luteal phases were found in eight infertile women. The short luteal phase was defined as 10 days or less from the presumed time of ovulation (as assessed by basal body temperature recording) to the onset of menses. Clomiphene citrate (Clomid) therapy resulted in pregnancy in two patients and lengthened the luteal phase in the other six. Ultimately, seven of eight patients conceived during Clomid therapy. Clomid therapy can lengthen the luteal phase in patients with luteal temperature elevation of 10 days or less. The occurrence of short luteal phases may be associated with infertility.