Effect of clomiphene citrate upon amount and duration of human menopausal gonadotropin therapy

Polycystic ovary syndrome and infertility: an update

Polycystic ovarian syndrome is the most well-known endocrine condition among women of this generation (PCOS). Symptoms of hyperandrogenism, irregular menstrual periods, and insulin resistance are all traits associated with PCOS. In women with PCOS, the chance of having problems including infertility, insulin resistance, and type 2 diabetes increases. The PCOS board hopes to reduce body weight and insulin levels, restore fertility, control excessive hair growth on the body or scalp, re-establish the regular feminine cycle, and avoid misunderstandings. Insulin sensitizers have been one of the most common metabolic modulators, but their effectiveness has been sporadic. Insulin resistance, followed by thiazolidinediones, is central to the pathophysiology of PCOS, with metformin having nearly similar efficacy. In the management of PCOS, statins and incretins are newer therapies with obvious metabolic targets. Vitamin D, acarbose, and myoinositol are just a few of the reciprocal and optional clinical treatments that have been proved to be useful in the treatment of PCOS. The number of viable methods for dealing with PCOS-related infertility has increased as well. Despite the fact that clomiphene citrate (CC) has long been the gold standard for ovulation induction in the event of ovulatory infertility, aromatase inhibitors can induce ovulation with results that are nearly identical to or better than those reported with CC, aromatase inhibitors can cause ovulation with results that are nearly identical to or better than those reported with CC. Ovarian incitement conventions that intelligently utilize gonadotropins, gonadotropin-delivering hormone rivals, the approach of ovarian boring, and assisted conceptive advancements with in vitro oocyte development indicate an expanding level of therapeutic progress.

Use of clomiphene citrate in infertile women: a committee opinion

This committee opinion describes the use of clomiphene citrate, including indications, use, monitoring, and side effects. There is also a discussion of adjuvants and alternatives to clomiphene citrate therapy.

Minimal stimulation protocol for use with intrauterine insemination in the treatment of infertility

OBJECTIVE

To determine whether minimal stimulation with clomiphene and one injection of 150 IU of human menopausal gonadotrophin (hMG) provides pregnancy rates comparable with those in a conventional full hMG stimulation protocol for infertile patients undergoing intrauterine insemination (IUI).

METHODS

A prospective study was carried out at the Infertility Clinic of a teaching institute and tertiary care referral center in Chandigarh, India. Two hundred couples with either unexplained infertility or ovulatory dysfunction cases who ovulated with clomiphene citrate (CC) but failed to conceive were offered ovarian stimulation with CC and hMG along with IUI for 420 cycles. Pregnancy rate, medication and monitoring cost were compared between minimal and conventional stimulation protocols.

RESULTS

There was no difference in the couples of the two stimulation protocols regarding their age, duration and type of infertility as well as cause of infertility. Number of ampoules of hMG and monitoring costs were significantly higher in the full hMG stimulation cases whereas pregnancy rate was comparable in both protocols.

CONCLUSION

Minimal stimulation appears to be an effective protocol in cases of unexplained infertility undergoing intrauterine insemination. Reduced cost and minimal monitoring is appealing to patients and the clinician.

Ovulation induction

In the woman with anovulation and polycystic ovarian syndrome, there are many options for ovulation induction. Treatment should be individualized, but clomiphene citrate is an excellent first-line agent. In the woman resistant to clomiphene citrate, combination therapy often results in pregnancy. Some women with PCOS only respond to gonadotropin therapy. These women are at a higher risk for multiple pregnancy and ovarian hyperstimulation syndrome. In the woman with anovulation and hypothalamic amenorrhea, the options for ovulation induction are limited. The luteal phase must be supported. The hypothalamus is unable to support the corpus luteum or early pregnancy.

Female and male human embryo growth rates are similar before the eight-cell stage

OBJECTIVE

Our purpose was to assess the possible relationship between human embryo growth rates and sexual differentiation.

STUDY DESIGN

We analyzed 142 conceptional in vitro fertilization and embryo transfer cycles undertaken in 137 women (151 embryos transferred) in which each embryo transferred led to a gestational sac. Embryos were sorted into three groups according to the number of blastomeres assessed just before embryo transfers < or = 3, 4, and > or = 5 blastomeres.

RESULTS

Percentages of girls and boys remained roughly unaltered irrespective of the number of blastomeres observed just before embryo transfer: < or = 3 blastomeres, 45% and 55%; 4 blastomeres, 44% and 56%; and > or = 5 blastomeres, 45% and 55%, respectively (statistical power 90% at the 5% significance level).

CONCLUSIONS

This indicates that embryo growth rates before the eight-cell stage are not related to the sex of the live-born infant, thereby dissuading the use of embryo growth rates in the appraisal of sex likelihood in regular in vitro fertilization-embryo transfer.

Pregnancy rates using CC/hMG or hMG alone

OBJECTIVE

The purpose of our study was to determine which of the two drug regimens is more successful in achieving conception in the infertile couple.

SUBJECTS

One hundred and sixty women with primary infertility were included in this study. Group A, consisted of 102 patients were treated with clomiphene citrate (CC) and human menopausal gonadotrophin (hMG). Group B, consisted of 58 patients were treated with hMG alone.

METHODS

This retrospective study was performed between April 1993 and March 1996, to compare the pregnancy rates in women using two drug regimens with ultrasound scan and serum E2 to monitor ovulation induction.

RESULTS

The pregnancy rate per patient in Group A was significantly higher than in Group B (46% vs 25.9%) as was the pregnancy rate per treatment cycle (31.3% vs 15.8%) pregnancy loss was lower in Group A than in Group B (17% vs 33.3%). The incidence of multiple pregnancy was 8.5% in Group A, and 13.3% in Group B. While the incidence of ovarian hyperstimulation syndrome was 3% in Group A, and 6.9% in Group B.

CONCLUSIONS

We concluded that the use of CC + hMG in an assisted conception programme gives a better pregnancy rate 46% than in the hMG alone 25.9%. These data with the use of U/S scan and serum E2 clearly showed that the use of CC + hMG is a successful and safe method for the treatment of infertile patients.

Minimal stimulation achieves pregnancy rates comparable to human menopausal gonadotropins in the treatment of infertility

OBJECTIVE

To examine the effectiveness of a novel clomiphene citrate (CC) and hMG combination protocol ("minimal stimulation") for controlled ovarian hyperstimulation. Minimal stimulation consists of administering 100 mg/d CC for 5 days followed by a single dose of 150 IU hMG. The results of this analysis are compared with those of an hMG-alone protocol. In vitro fertilization-embryo transfer and donor insemination patients are excluded from this analysis.

DESIGN

Retrospective review of minimal stimulation and hMG cycles from January 1, 1989 to December 31, 1992.

SETTING

Tertiary care center reproductive endocrinology and infertility clinic.

PATIENTS

Two hundred thirty-two women who underwent 549 treatment cycles.

MAIN OUTCOME MEASURES

Clinical and multiple pregnancy rates (PRs) and medication costs.

RESULTS

Sixty-one women received 106 cycles of minimal stimulation and 183 received 443 cycles of hMG. Although subject groups were not assigned randomly, multivariate analysis detected no significant differences between the treatment groups. The total ampules of hMG required differed significantly (2.0 for minimal stimulation versus 16.8 +/- 8.5 [mean +/- SD] for hMG). Pregnancy rates and multiple gestation rates were similar. Medication expense of minimal stimulation is 21% that of the hMG protocol.

CONCLUSIONS

Minimal stimulation is as effective as hMG in the population examined. The comparable PRs and decreased medication costs of minimal stimulation justifies further evaluation of its role in the treatment of infertility.

Clinical uses of antiestrogens

An antiestrogen is a compound that blocks the action of estrogen. Most synthetic antiestrogens have agonistic or antagonistic activity depending on the tissue and the endogenous estrogen mileu. The triphenylethylene derivatives, clomiphene and tamoxifen, are the antiestrogens in greatest clinical use. Their biologic effects, clinical indications, and risks are reviewed. Novel antiestrogens which are beginning to be studied clinically include the benzothiophene derivative, raloxifene and the "pure" antiestrogens such as ICI 182,780. New clinical indications for existing compounds as well as the development of novel antiestrogens may lead to better treatment options for endocrine-dependent conditions.

The role of superovulation with menotropins in ovulatory infertility: a review

The risks of menotropin therapy (ovarian hyperstimulation syndrome, multiple gestation, adnexal torsion) are well known and have been previously described. Superovulation should not be considered for the indications described herein until more traditional therapies for infertility have been tried and found unsuccessful and sufficient time has elapsed for conception to occur. The cost of superovulation is high: the medications are expensive, frequent E2 monitoring and US studies are costly, and pregnancy complications relating to the higher rate of pregnancy loss and multiple gestation may add substantially to the overall cost. Yet, compared with IVF and GIFT, superovulation cycles combined with IUI cost between one third to one sixth that of an IVF cycle. Protocols involving combined CC/hMG/hCG, which reduce the total number of ampules of Pergonal needed per cycle and still provide multiple follicular development, may further reduce costs. There is a growing consensus that superovulation-IUI protocols should be attempted before GIFT and IVF in couples with normal pelvic viscera. There is little doubt that IVF and GIFT cycles are more costly, stressful, and complex. No comparative data have clearly shown IVF and GIFT to be superior to superovulation protocols in ovulatory women with normal pelvic anatomy. In the only study examining this issue published to date, Kaplan et al. retrospectively analyzed all GIFT and superovulation/IUI cycles at a single university center and found GIFT to be three times more efficient. However, the inherent limitations of a nonrandomized, nonprospective study of this kind are obvious as these authors have suggested. Therefore, it may be wise to consider the use of superovulation before assisted reproductive technologies until this issue is settled. It would be interesting to determine if the high PRs reported for couples with unexplained infertility or mild endometriosis in IVF and GIFT cycles in some centers not incorporating superovulation/IUI protocols would hold up if such an approach was routinely followed. Despite the increasing acceptance of superovulation protocols, we must be aware that many of the studies suggesting a role of hMG in treating ovulatory infertile women with normal pelvic anatomy suffer from deficiencies in experimental design. In a payor-driven system, such as in the United States, the difficulties in designing and carrying out scientifically sound clinical studies examining infertility therapies are obvious. The lack of federal or outside funding for the study of infertility issues contributes to the problem. It is our hope that better designed studies examining the role of superovulation in the treatment of ovulatory infertile women with normal pelvic anatomy will be forthcoming.

Risk factors and prognostic variables in the ovarian hyperstimulation syndrome

This study was undertaken to clarify discriminative roles of multiple epidemiologic, hormonal, and biophysical variables for causation of ovarian hyperstimulation syndrome. Three hundred ninety-six patients with anovulatory infertility had ovulation induction with human menopausal gonadotropin throughout 1822 treatment cycles; 54 cycles (3%) were complicated by ovarian hyperstimulation syndrome. Early follicular serum estradiol and prolactin levels were higher in this group than in controls: 75.5 versus 46.2 pg/ml and 18.5 versus 11.7 ng/ml, respectively (p less than 0.01). On the day of human chorionic gonadotropin administration (day 0) the mean serum estradiol level was 1047 +/- 381 in the group with ovarian hyperstimulation syndrome and 719 +/- 339 pg/ml in controls (p less than 0.0001). In all follicular sizes and in all grades of ovarian hyperstimulation syndrome there was a tendency for more recruited follicles, with significantly more small follicles (12 to 14 mm) present on day 0 in all grades of ovarian hyperstimulation syndrome than in controls. Stepwise logistic regression performed on 22 variables identified a high-risk group for this syndrome; the major features are illustrated by young, lean patients who, after relatively few ampules of human menopausal gonadotropin, develop high estradiol levels and multiple small follicles.

Improved pregnancy rate with monitoring of gonadotropin therapy by three modalities

The frequency of complications during gonadotropin therapy was reduced after the introduction of rapid estrogen assays. However, pregnancy rates remained low especially in normoestrogenic women. One hundred forty-three infertile normoestrogenic women were treated with human menopausal gonadotropin-human chorionic gonadotropin for 661 cycles. Almost all cycles were ovulatory. Whereas 53.7% of the patients conceived when drug administration was monitored by cervical score and serum estradiol levels only, 72.1% became pregnant when treatment was monitored by these modalities and real-time ultrasonography of the ovaries (p less than 0.05). Mean serum estradiol levels were significantly higher when ultrasonography was used to monitor response, but complications such as multiple births and ovarian enlargement did not occur more often. The data suggest that "true" ovulation occurs more often when ovarian imaging is used to determine drug dosage. Because of the higher pregnancy rate achieved by combined clinical (cervical score), biochemical (serum estradiol), and sonographic methods of monitoring, this approach should replace less extensive techniques.

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.

Progressive dosages of clomiphene in hypothalamic anovulation

A group of 89 sterile patients with hypothalamic anovulation were subjected to progressive dosages of clomiphene citrate according to a predesigned program. In order to analyze our results, we divided our patients into seven groups, according to the largest dosage of clomiphene citrate received. Clinical features were revised in relation to the ovulatory dose of clomiphene. Significant differences between groups regarding weight, menstrual pattern, age at menarche, and hirsutism were not found. Obesity increased the dose required for ovulation when it was less than 900 mg/cycle, but had no effect at higher doses. The ovulation rate, pregnancies, prenatal wastage, and side effects of treatment were analyzed; and it was found that the scheme for ovulation induction used, without expensive and sophisticated ovarian monitoring resources, improved ovulation and pregnancy rates with few and unimportant deleterious side effects.

Sequential use of clomiphene citrate, human menopausal gonadotropin, and human chorionic gonadotropin in human in vitro fertilization. II. Study of luteal phase adequacy following aspiration of the preovulatory follicles

The 88 patients included in the in vitro fertilization program during 113 cycles were submitted to superovulation by sequential use of clomiphene citrate, human menopausal gonadotropin, and human chorionic gonadotropin. No correlation was found between estradiol and progesterone levels during the luteal phase and estradiol on the days preceding administration of human chorionic gonadotropin. Nineteen biopsies of the endometrium were carried out. The importance of the increase of estradiol between the day before and the day of administration of human chorionic gonadotropin is positively correlated with the quality of the endometrium.

Outcome of an octuplet pregnancy

An octuplet pregnancy with survival of all liveborn babies in a woman treated with gonadotropins is described and problems related to ovulation induction and the management of very multiple pregnancy are discussed.

Sequential clomiphene citrate-menotropin therapy for induction or enhancement of ovulation

Either to induce ovulation in anovulatory infertility patients or to enhance ovulation in patients with mild endometriosis or luteal phase inadequacy, we utilized a sequential regimen of low-dose clomiphene citrate (CC) followed by human menopausal gonadotropin (hMG) injections on alternate days; duration and dosage of menotropin therapy was individualized by using serum estradiol levels for monitoring until the time of administration of human chorionic gonadotropins. Previous therapeutic efforts without menotropins had been unsuccessful in all patients. One third of 70 treated patients conceived during 156 treatment cycles. The pregnancy rate was 44% in anovulatory patients (n = 34), and 26% in patients with ovulation dysfunction (n = 23). Pregnancy rates declined with patient's age. Four of the 23 patients that conceived had a spontaneous abortion (17%). The multiple gestation rate was 10.5%. A relative inhibition of cervical mucus development was noted and shown to be caused by CC. Hyperstimulation occurred in three patients. The discussed CC-hMG regimen approaches the effectiveness of standard hMG therapy; but compared with standard hMG therapy, it has significant economic advantages and seems to have a markedly lower rate of multiple gestation. However, like standard hMG therapy, CC-hMG therapy requires careful monitoring specifically, because hyperstimulation may occur.

Observations on the combination of clomiphene citrate-human menopausal gonadotropin-human chorionic gonadotropin in the management of anovulation

To study the effects of the addition of clomiphene citrate to human menopausal gonadotropin (hMG) and human chorionic gonadotropin (hCG), 23 cycles of clomiphene citrate-hMG-hCG (CHH) were administered to 10 anovulatory women. Of these 10 women, 5 also received 15 cycles of hMG-hCG (HH). Although there was a significant increase in the ovulation rate in the CHH group (p less than 0.01), there was no difference in the pregnancy rate (p less than 0.05). Patients in the CHH group required significantly less hMG for ovulation induction than the HH group (p less than 0.01). Patients receiving CHH who had low serum levels of follicle-stimulating hormone required significantly more hMG than those with normal values. The luteinizing hormone releasing hormone test may predict those patients who will require less hMG during CHH therapy. The relative safety of the CHH treatment is discussed.

The use of gonadotropins for induction of ovulation

There has been impressive progress in the treatment of anovulation with gonadotropins in the last two decades. At the present time most patients can be helped. The treatment is expensive and complicated. To obtain good results with the fewest complications, patients should be closely monitored by measuring urinary or plasma estrogen levels, and treatment should be given only in centers where the estrogen assay is readily available. Severe hyperstimulation is avoidable, but the high rate of multiple gestations remains unavoidable. Possibly with sonographic monitoring of follicular development this problem will be solved.

A comparison of clinical and laboratory methods in monitoring human menopausal gonadotropin therapy

Twenty infertile, anovulatory women were treated with human menopausal gonadotropin (hMG) for a total of 61 treatment cycles. Cervical scores (all cycles) and vaginal maturation indices (23 cycles) were compared with serum concentrations of total immunoreactive estrogens to determine their clinical efficacy in monitoring hMG treatment. All courses of therapy were judged to have induced ovulation. Singleton pregnancies occurred in nine patients, and one patient conceived twice. All pregnancies were uncomplicated. There was good clinical correlation between cervical score and increasing estrogen levels in approximately one-third of the cycles. Most of these good correlations occurred in patients with low estrogen status. Very poor correlation was found with vaginal cytologic changes. Therefore, in conjunction with serum estrogen determinations, the cervical score is a safe and less expensive means of monitoring hMG therapy in selected patients.