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Singh S, Prakash U. Study of Folliculometry After Spontaneous and Clomiphene Citrate-Induced Ovulation in Infertile Women. Cureus 2023; 15:e42234. [PMID: 37605698 PMCID: PMC10440010 DOI: 10.7759/cureus.42234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2023] [Indexed: 08/23/2023] Open
Abstract
Background Ovulatory disruption is the primary reversible cause of infertility, which affects 12-24% of couples. The FDA's first-line recommendation for ovulation induction in such cases is clomiphene citrate. Serial ultrasonography can be used to evaluate follicular development. Methodology The current study is a two-year prospective cohort study conducted at a tertiary care centre. One hundred patients with either primary or secondary infertility and no pelvic pathology were involved in the study and split into two groups: Group I included ovulatory women whose infertility was caused by a factor other than ovulatory disorder, and Group II comprised anovulatory women. Folliculometry was performed using transvaginal sonography; Group I had a spontaneous cycle, whereas Group II received clomiphene citrate (CC) to induce ovulation. The ovulation rate, pregnancy rate, multiple pregnancy rate, and rate of ovarian hyperstimulation (OHSS) were all studied. Results Seventy-two percent of the patients had primary infertility, and most appeared after 3-6 years of infertility. 62% of the patients were between the ages of 21 and 30 years. 50% of cases had ovulatory dysfunction, and polycystic ovarian disease (PCOD) was the most frequent cause of anovulation (24%). The leading follicular diameter was substantially bigger (22-26 mm) in the CC-triggered cycle compared to the spontaneous cycle (16-21 mm). In both spontaneous and induced cycles, the endometrial thickness displayed a linear development pattern during the pre-ovulatory phase and plateaued during the luteal phase. With CC, there was a 68% ovulation rate, a 32% pregnancy rate, a 12.5% multiple pregnancy rate, and a 2% incidence of OHSS. Conclusion Clomiphene citrate increases the rate of ovulation and pregnancy in females having ovulatory disorders.
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Affiliation(s)
- Smita Singh
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Patna, Patna, IND
| | - Uday Prakash
- Orthopedics and Traumatology, Darbhanga Medical College, Darbhanga, IND
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Liang Y, Guo Q, Wu XH, Zhang LN, Ge J, Xu ML, Feng ZL, Wu XQ. Does the additional use of clomiphene citrate or letrozole for in vitro fertilization deserve more attention? BMC Pregnancy Childbirth 2021; 21:275. [PMID: 33794797 PMCID: PMC8017864 DOI: 10.1186/s12884-021-03668-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 02/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adding clomiphene citrate (CC) and/or letrozole (LE) to in vitro fertilization (IVF) cycles for mild ovarian stimulation is a general approach. Although lots of researches have demonstrated partial benefits of the strategy, all-around effects of oral medications remained deficient. This paper aims to assess whether an addition of oral medication will result in considerable outcomes on T-Gn (total dose of gonadotropin), Gn days, total retrieved ova, high quality embryos, blastocyst number, ovarian hyperstimulation syndrome (OHSS) rate, clinical pregnancy rate and cumulative pregnancy rate, even if it was not conventional mild/minimal stimulations. RESULTS Participants were categorized to three diverse populations as high responders, normal responders and poor responders according to basal antral follicle count. T-Gn in patients treated with CC/LE distinctly decreased from 2496.96 IU/d to 1827.68 IU/d, from 2860.28 IU/d to 2119.99 IU/d, and from 3182.15 IU/d to 1802.84 IU/d, respectively. For high ovary responders and normal responders, the OHSS incidence rate also declined from 29.2 to 4.3% (P < 0.001) and from 1.1 to 0.0% (P = 0.090). Other, there was no statistical difference with respect to the T-retrieved ova (total retrieved ova), high quality embryos, cultured blastocyst and blastocyst number in high responders. For normal responders and poor ovary responders, T-Gn, Gn days, T-retrieved ova, high quality embryos, cultured blastocyst and blastocysts number in oral medications group all apparently decreased. Clinical pregnancy rate per fresh cycle of poor responders with prior oral medications was significantly decreased (25.7% vs. 50.8%, P = 0.005), and no significant differences in high responders and normal responders were expressed (52.5% vs. 44.2%, P = 0.310; 51.9% vs. 42.4%, P = 0.163) between two groups of participants. The numbers of cumulative pregnancy rates were lower in the conventional group compared to the add group for high (75.90% versus 81.03%, P = 0.279), normal (62.69% versus 71.36%, P = 0.016) and poor (39.74% versus 68.21%, P < 0.001) responders. CONCLUSIONS The addition of CC/LE to the ovulation induction during IVF has certain efficacy in terms of low cost, low OHSS incidence. CC/LE deserves more recommendations as a responsible strategy in high responders due to advantageous pregnancy outcomes. For normal responders, the strategy needs to be considered with more comprehensive factors.
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Affiliation(s)
- Ying Liang
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province, China.
| | - Qing Guo
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province, China
| | - Xiao-Hua Wu
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province, China
| | - Li-Nan Zhang
- Department of Pathology and Pathophysiology, Hebei Medicine University, Shijiazhuang, Hebei, China
| | - Jun Ge
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province, China
| | - Mei-Ling Xu
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province, China
| | - Zheng-Li Feng
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province, China
| | - Xiao-Qian Wu
- Department of Reproduction Medicine, The Fourth Hospital of Shijiazhuang, Hebei Medicine University, Hebei, Hebei Province, China
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Farhud DD, Zokaei S, Keykhaei M, Hedayati M, Zarif Yeganeh M. In-Vitro Fertilization Impact on the Risk of Breast Cancer: A Review Article. IRANIAN JOURNAL OF PUBLIC HEALTH 2021; 50:438-447. [PMID: 34178791 PMCID: PMC8214614 DOI: 10.18502/ijph.v50i3.5583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Due to the increasing prevalence of infertility, the number of referrals to infertility treatment centers has also increased. Nowadays, assisted reproductive technology (ART), including in vitro fertilization (IVF), is a treatment for infertility or genetic problems. Considering the possible consequences of this method among women undergoing in vitro fertilization (IVF) and kids conceived by IVF, extensive research has been conducted in this regard. Methods Overall, 100 articles were entered into the study, and relevant articles were searched and extracted from PubMed, Springer, and Google Scholar databases. In IVF procedure, medications such as Clomiphene citrate and gonadotropins are used to stimulate and mature follicles and thus increase ovulation. Results There are conflicting opinions on this issue. Some findings report a slight increase in cancer risk for hormone-sensitive cancers including breast cancer. The long-term use of IVF medications can increase estrogen hormones and cause excessive expression of genes, resulting in an increased risk of breast cancer, which is one of the most frequent cancers among women. Conclusion There are some risks to be aware of, which followed the hypothesis that long IVF treatment process may lead to breast cancer among IVF candidates. Furthermore, the risk of breast cancer may be increased in those women with a positive family history and related inherited genes. Therefore, women candidates for IVF should be informed of the probable implications of the reproductive therapy techniques.
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Affiliation(s)
- Dariush D Farhud
- School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.,Department of Basic Sciences, Iranian Academy of Medical Sciences, Tehran, Iran
| | - Shaghayegh Zokaei
- School of Advanced Medical Sciences, Tehran Medical Branch, Islamic Azad University, Tehran, Iran
| | - Mohammad Keykhaei
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Hedayati
- Cellular and Molecular Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Marjan Zarif Yeganeh
- Cellular and Molecular Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Olaniyi KS, Oniyide AA, Adeyanju OA, Ojulari LS, Omoaghe AO, Olaiya OE. Low dose spironolactone-mediated androgen-adiponectin modulation alleviates endocrine-metabolic disturbances in letrozole-induced PCOS. Toxicol Appl Pharmacol 2021; 411:115381. [PMID: 33359182 DOI: 10.1016/j.taap.2020.115381] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 12/09/2020] [Accepted: 12/17/2020] [Indexed: 12/11/2022]
Abstract
Polycystic ovarian syndrome (PCOS), is a multifactorial endocrine disorder in women of reproductive age. It usually associates with metabolic disorders (MDs), which aggravates the risk of infertility, cardiometabolic events and associated comorbidities in women with PCOS. Adiponectin, a circulating protein produced by adipocytes, which has been suggested to inversely correlate with MDs. Spironolactone, a non-selective mineralocorticoid receptor (MR) antagonist, has been in wide clinical use for several decades. Herein, we investigated the effects of low dose spironolactone (LDS) and the role of adiponectin in endocrine-metabolic disturbances in experimentally-induced PCOS rats. Eighteen female Wistar rats (160-180 g) were randomly allotted into 3 groups and treated with vehicle (p.o.), letrozole (LET; 1 mg/kg) and LET + LDS (0.25 mg/kg), once daily for 21 days, respectively. The results showed that LET-treated animals had features of PCOS, characterized by elevated plasma testosterone and prolactin, increased body weight gain and ovarian weight as well as disrupted ovarian cytoarchitecture and degenerated follicles. Additionally, elevated fasting blood glucose, 1 h-postload glucose and plasma insulin, impaired glucose tolerance, insulin resistance, reduced insulin sensitivity, increased plasma and ovarian lipid profile, plasma lipid peroxidation, TNF-α, IL-6 and decreased plasma glutathione peroxidase and glutathione content were observed. These alterations were associated with decreased circulating adiponectin and were reversed when treated with LDS. The present results suggest that LDS ameliorates endocrine-metabolic disturbances and inflammation-related comorbidities associated with LET-induced PCOS by modulating circulating androgen-adiponectin status.
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Affiliation(s)
- Kehinde S Olaniyi
- Department of Physiology, College of Medicine and Health Sciences, Afe Babalola University, Ado-Ekiti 360101, Nigeria.
| | - Adesola A Oniyide
- Department of Physiology, College of Medicine and Health Sciences, Afe Babalola University, Ado-Ekiti 360101, Nigeria
| | - Oluwaseun A Adeyanju
- Department of Physiology, College of Medicine and Health Sciences, Afe Babalola University, Ado-Ekiti 360101, Nigeria.
| | - Lekan S Ojulari
- Department of Physiology, College of Medicine and Health Sciences, Afe Babalola University, Ado-Ekiti 360101, Nigeria
| | - Adams O Omoaghe
- Department of Physiology, College of Medicine and Health Sciences, Afe Babalola University, Ado-Ekiti 360101, Nigeria
| | - Oluranti E Olaiya
- Department of Physiology, College of Medicine and Health Sciences, Afe Babalola University, Ado-Ekiti 360101, Nigeria
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Optimized Background Regimen for Treatment of Active Tuberculosis with the Next-Generation Benzothiazinone Macozinone (PBTZ169). Antimicrob Agents Chemother 2018; 62:AAC.00840-18. [PMID: 30126954 DOI: 10.1128/aac.00840-18] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 08/10/2018] [Indexed: 11/20/2022] Open
Abstract
The efficacy of the standardized four-drug regimen (comprising isoniazid, rifampin, pyrazinamide, and ethambutol) for the treatment of tuberculosis (TB) is menaced by the emergence of multidrug-resistant (MDR) and extensively drug-resistant (XDR) strains of Mycobacterium tuberculosis Intensive efforts have been made to develop new antibiotics or to repurpose old drugs, and several of these are currently being evaluated in clinical trials for their antitubercular activity. Among the new candidate drugs is macozinone (MCZ), the piperazine-containing benzothiazinone PBTZ169, which is currently being evaluated in phase I/II clinical trials. Here, we determined the in vitro and in vivo activity of MCZ in combination with a range of anti-TB drugs in order to design a new regimen against active TB. Two-drug combinations with MCZ were tested against M. tuberculosis using checkerboard and CFU enumeration after drug exposure assays. MCZ was observed to have no interactions with all first- and second-line anti-TB drugs. At the MIC of each drug, MCZ with either bedaquiline (BDQ), clofazimine (CLO), delamanid (DMD), or sutezolid (STZ) reduced the bacterial burden by 2 logs compared to that achieved with the drugs alone, indicating synergism. MCZ also displayed synergism with clomiphene (CLM), a potential inhibitor of the undecaprenyl pyrophosphate synthase (UppS) in mycobacteria. For all the other drugs tested in combination with MCZ, no synergistic activity was observed. Neither antagonism nor increased cytotoxicity was found for most combinations, suggesting that MCZ could be added to different TB treatment regimens without any significant adverse effects.
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Abstract
Polycystic ovary syndrome (PCOS) is a common endocrine disorder in women, and it is the main cause of infertility in women of reproductive age due to anovulation. PCOS also increases the risk of diseases such as cardiovascular disease and type 2 diabetes in women with this disorder. The mechanism of pathogenesis is not clear, as it may be related to heredity, the environment and internal embryonic factors; thus, the treatment strategies remain unclear. This review summarizes current treatments for PCOS worldwide. Lifestyle modification (LSM) is considered the first-line treatment, regardless of fertility status, without the addition of metformin. Oral contraceptive (OC) pills should be used as a first-line treatment for long-term management for patients with no reproductive requirements. For patients with fertility requirements, ovulation therapy is an effective treatment. For refractory ovulation disorders, patients can choose from among the latest treatments, including ovarian hippocampal signal path block theory, the theory of leptin, inositol treatment, bilateral ovarian drilling to stimulate ovulation and assisted reproductive technology. Because current treatments cannot cure PCOS, lifelong administration is still the mainstream method of management; however, the optimal treatment plan needs further research and exploration.
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Affiliation(s)
- Peipei Jin
- a Department of Traditional Chinese Medicine , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China
| | - Yongyong Xie
- a Department of Traditional Chinese Medicine , The First Affiliated Hospital of Wenzhou Medical University , Wenzhou , China
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Yilmaz S, Yilmaz Sezer N, Gönenç İM, İlhan SE, Yilmaz E. Safety of clomiphene citrate: a literature review. Cytotechnology 2018; 70:489-495. [PMID: 29159661 PMCID: PMC5851961 DOI: 10.1007/s10616-017-0169-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 11/09/2017] [Indexed: 12/24/2022] Open
Abstract
Clomiphene citrate (CC) is a nonsteroidal compound and induces ovulation indirectly. The wide usage of the CC raises a question; is it safe or not? In the light of this question, this review aimed to highlight all researches and insights into the association between the use of CC and risk of genotoxicity, cytotoxicity, embryotoxicity, teratogenicity and risk of different cancer types. We conducted a MEDLINE/PubMed, Scopus, Web of Science, Google Scholar search. After a careful screening process of all authors, 32 of these articles were considered as appropriate, and reviewed. Our evaluations showed that CC has genotoxic, cytotoxic, embryotoxic and teratogenic properties. There is no association between the use of CC and risk of ovarian, breast, uterine, cervix, endometrium, lung, colorectal cancer, and lymphoma. However, risk increased especially after 6 cycles of use and especially in nulligravid women. The use of CC should be restricted to 6 cycles. Moreover, malignant melanoma and thyroid cancer risk was found to be higher among CC treated women in almost all studies. Further works should be conducted especially in animal models to assess its risk features.
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Affiliation(s)
- Serkan Yilmaz
- Ankara University Faculty of Health Sciences, 06340, Altındağ, Ankara, Turkey.
| | | | | | - Sibel Erkal İlhan
- Ankara University Faculty of Health Sciences, 06340, Altındağ, Ankara, Turkey
| | - Ebru Yilmaz
- Gazi University Vocational School of Health Services, Gölbaşı, Ankara, Turkey
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O’Rourke TK, Wosnitzer MS. Opioid-Induced Androgen Deficiency (OPIAD): Diagnosis, Management, and Literature Review. Curr Urol Rep 2016; 17:76. [DOI: 10.1007/s11934-016-0634-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Oktem M, Guler I, Erdem M, Erdem A, Bozkurt N, Karabacak O. Comparison of The Effectiveness of Clomiphene Citrate versus Letrozole in Mild IVF in Poor Prognosis Subfertile Women with Failed IVF Cycles. INTERNATIONAL JOURNAL OF FERTILITY & STERILITY 2015; 9:285-91. [PMID: 26644850 PMCID: PMC4671387 DOI: 10.22074/ijfs.2015.4542] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Accepted: 04/20/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND Our objective was to evaluate the effectiveness of clomiphene citrate (CC) vs. letrozole (L) plus human menopausal gonadotropin (hMG) in gonadotropin releasing hormone (GnRH) antagonist protocol in poor prognosis women with previous failed ovarian stimulation undergoing intracytoplasmic sperm injection (ICSI). MATERIALS AND METHODS This retrospective cohort study included cycles with CC and L plus hMG/GnRH antagonist protocols of 32 poor responders who had failed to have ideal follicles to be retrieved during oocyte pick-up (OPU) or embryo transfer (ET) at least for 2 previous in vitro fertilization (IVF) cycles with microdose flare protocol or GnRH antagonist protocol from January 2006 to December 2009. Main outcome measures were implantation, clinical pregnancy and live birth rates per cycle. Duration of stimulation, mean gonadotropin dose used, endometrial thickness, number of mature follicles, serum estradiol (E2) and progesterone (P) levels on the day of human chorionic gonadotropin (hCG) administration, number of retrieved oocytes and fertilization rates were also evaluated. RESULTS A total number of 42 cycles of 32 severe poor responders were evaluated. Total gonadotropin consumption was significantly lower (1491 ± 873 vs. 2808 ± 1581 IU, P=0.005) and mean E2 level on the day of hCG injection were significantly higher in CC group than L group (443.3 ± 255.2 vs. 255.4 ± 285.2 pg/mL, P=0.03). ET, overall pregnancy and live birth rates per cycle were significantly higher in CC than L protocol (27.2 vs. 15%, 13.6 vs. 0% and 4.5 vs. 0%, respectively, P<0.05). CONCLUSION Severe poor responders who had previously failed to respond to microdose or GnRH antagonist protocols may benefit from CC plus hMG/GnRH antagonist protocol despite high cancellation rate.
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Affiliation(s)
- Mesut Oktem
- Department of Obstetrics and Gynecology, Gazi University School of Medicine, Ankara, Turkey
| | - Ismail Guler
- Department of Obstetrics and Gynecology, Gazi University School of Medicine, Ankara, Turkey
| | - Mehmet Erdem
- Department of Obstetrics and Gynecology, Gazi University School of Medicine, Ankara, Turkey
| | - Ahmet Erdem
- Department of Obstetrics and Gynecology, Gazi University School of Medicine, Ankara, Turkey
| | - Nuray Bozkurt
- Department of Obstetrics and Gynecology, Gazi University School of Medicine, Ankara, Turkey
| | - Onur Karabacak
- Department of Obstetrics and Gynecology, Gazi University School of Medicine, Ankara, Turkey
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Abstract
The purpose of this paper is to provide a stepwise approach to treating the infertility/subfertility associated with polycystic ovary syndrome. Defining polycystic ovary syndrome in a patient requires first investigating other possible causes for polycystic ovary morphology, acne, hirsutism, obesity, and the metabolic derangements that often accompany polycystic ovary syndrome. Beginning with lifestyle modification and use of metformin, the progressive inclusion of more intensive therapies for induction of ovulation is described. Second-line treatments are discussed and the new findings from a large multicenter trial are discussed in the context of evidence-based treatment strategies for first-line agents. Finally, monofollicular development as a treatment goal and in vitro fertilization are discussed for those with recalcitrant disease.
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Affiliation(s)
- Joshua J Berger
- University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Birmingham, AL, USA
| | - G Wright Bates
- University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Birmingham, AL, USA
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Saha L, Kaur S, Saha PK. N-acetyl cysteine in clomiphene citrate resistant polycystic ovary syndrome: A review of reported outcomes. J Pharmacol Pharmacother 2013; 4:187-91. [PMID: 23960423 PMCID: PMC3746301 DOI: 10.4103/0976-500x.114597] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Clomiphene citrate (CC) has been the gold-standard drug for ovulation induction in polycystic ovary syndrome (PCOS), but still CC resistance is seen in approximately 15-40% in women with PCOS. N-acetyl cysteine (NAC), a safe and cheap drug available in the market many years ago as mucolytic agent, was found to have a role in infertility management. Recently, some reports discussed the possible beneficial effects of NAC on ovulation. The biological properties of the NAC make this drug a potential candidate for its use in the infertility treatment, especially in the PCOS in inducing or augmenting ovulation. An updated electronic search was performed through PUBMED, MEDLINE, and COCHRANE and focused on peer-reviewed, full text, randomized controlled trials, and observational cohort or case-control studies for role of NAC in CC-resistant PCOS. Thorough search through all the clinical studies showed mixed results. Studies with positive results showed improvement in induction of ovulation as compared to negative studies showing contrary results. More randomized clinical trials are still needed to establish its definitive role in CC-resistant PCOS.
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Affiliation(s)
- Lekha Saha
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Abstract
Polycystic ovarian syndrome (PCOS) is a disorder of androgen excess and ovarian dysfunction. Hirsutism and elevated free testosterone levels are the most consistent signs of the androgen excess. Irregular, infrequent, or absent menses and infertility are symptoms of ovulatory dysfunction. Obesity is also a feature of this syndrome and contributes to associated metabolic abnormalities. Lifestyle modification should be the first treatment and is effective in reducing the signs and symptoms. The ovulatory infertility associated with PCOS can be overcome in most cases with oral (clomiphene citrate or letrozole) or injectable (gonadotropins) agents. Surgical intervention is reserved for cases resistant to medical management.
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Affiliation(s)
- G Wright Bates
- Department of Obstetrics and Gynecology, University of Alabama School of Medicine, 619 19th Street South, Building 176F, Room 10390, Birmingham, AL 35249-7333, USA.
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Endometrial shedding effect on conception and live birth in women with polycystic ovary syndrome. Obstet Gynecol 2012; 119:902-8. [PMID: 22525900 DOI: 10.1097/aog.0b013e31824da35c] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To estimate whether progestin-induced endometrial shedding, before ovulation induction with clomiphene citrate, metformin, or a combination of both, affects ovulation, conception, and live birth rates in women with polycystic ovary syndrome (PCOS). METHODS A secondary analysis of the data from 626 women with PCOS from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Cooperative Reproductive Medicine Network trial was performed. Women had been randomized to up to six cycles of clomiphene citrate alone, metformin alone, or clomiphene citrate plus metformin. Women were assessed for occurrence of ovulation, conception, and live birth in relation to prior bleeding episodes (after either ovulation or exogenous progestin-induced withdrawal bleed). RESULTS Although ovulation rates were higher in cycles preceded by spontaneous endometrial shedding than after anovulatory cycles (with or without prior progestin withdrawal), both conception and live birth rates were significantly higher after anovulatory cycles without progestin-induced withdrawal bleeding (live births per cycle: spontaneous menses 2.2%; anovulatory with progestin withdrawal 1.6%; anovulatory without progestin withdrawal 5.3%; P<.001). The difference was more marked when rate was calculated per ovulation (live births per ovulation: spontaneous menses 3.0%; anovulatory with progestin withdrawal 5.4%; anovulatory without progestin withdrawal 19.7%; P<.001). CONCLUSION Conception and live birth rates are lower in women with PCOS after a spontaneous menses or progestin-induced withdrawal bleeding as compared with anovulatory cycles without progestin withdrawal. The common clinical practice of inducing endometrial shedding with progestin before ovarian stimulation may have an adverse effect on rates of conception and live birth in anovulatory women with PCOS. LEVEL OF EVIDENCE II.
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Abu Hashim H, Bazeed M, Abd Elaal I. Minimal stimulation or clomiphene citrate as first-line therapy in women with polycystic ovary syndrome: a randomized controlled trial. Gynecol Endocrinol 2012; 28:87-90. [PMID: 21770837 DOI: 10.3109/09513590.2011.589924] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIM To compare the efficacy of minimal stimulation and clomiphene citrate (CC) as a first-line treatment for anovulatory infertility associated with polycystic ovary syndrome (PCOS). METHODS One hundred and thirteen women with PCOS were selected in this randomized controlled trial. Patients received minimal stimulation protocol consisted of 5 days CC (100 mg/day) then 150 IU of highly purified uFSH on cycle day 9 (n = 58, 159 cycles) or CC only (n = 55, 153 cycles) for up to three cycles. Outcome measures were: clinical pregnancy rate per cycle, number of growing and mature follicles, serum E2, endometrial thickness at the hCG day, serum P, ovulation and miscarriage rates. RESULTS There were no differences between both groups regarding the clinical pregnancy rate per cycle and per woman (8.8% vs. 7.8 % and 24.1% vs. 21.8%; p = 0.23, p = 0.36, respectively). One twin pregnancy occurred in each group. Miscarriage rate was comparable (14.3% vs. 16.7%; p = 0.38). No differences were found regarding the number of follicles, serum P, ovulation rate, E2 and endometrial thickness at the hCG day (7.8 ± 0.5 vs. 7.6 ± 0.6 mm; p = 0.52). CONCLUSIONS Ovulation induction with minimal stimulation is not more effective than CC alone for achieving pregnancy when used as initial treatment in PCOS patients.
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Affiliation(s)
- Hatem Abu Hashim
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
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Abstract
This review concerns the effects on vision and the eye of medications prescribed at three phases of treatment for women with early-stage breast cancer (BC): (1) adjuvant cytotoxic chemotherapy, (2) adjuvant endocrine therapy, and (3) symptomatic relief. The most common side effects of cytotoxic chemotherapy are epiphora and ocular surface irritation, which can be caused by any of several different regimens. Most notably, the taxane docetaxel can lead to epiphora by inducing canalicular stenosis. The selective-estrogen-receptor-modulator (SERM) tamoxifen, long the gold-standard adjuvant-endocrine-therapy for women with hormone-receptor-positive BC, increases the risk of posterior subcapsular cataract. Tamoxifen also affects the optic nerve head more often than previously thought, apparently by causing subclinical swelling within the first 2 years of use for women older than ∼50 years. Tamoxifen retinopathy is rare, but it can cause foveal cystoid spaces that are revealed with spectral-domain optical coherence tomography (OCT) and that may increase the risk for macular holes. Tamoxifen often alters the perceived color of flashed lights detected via short-wavelength-sensitive (SWS) cone response isolated psychophysically; these altered perceptions may reflect a neural-response sluggishness that becomes evident at ∼2 years of use. The aromatase inhibitor (AI) anastrozole affects perception similarly, but in an age-dependent manner suggesting that the change of estrogen activity towards lower levels is more important than the low estrogen activity itself. Based on analysis of OCT retinal thickness data, it is likely that anastrozole increases the tractional force between the vitreous and retina. Consequently, AI users, myopic AI users particularly, might be at increased risk for traction-related vision loss. Because bisphosphonates are sometimes prescribed to redress AI-induced bone loss, clinicians should be aware of their potential to cause scleritis and uveitis occasionally. We conclude by suggesting some avenues for future research into the visual and ocular effects of AIs, particularly as relates to assessment of cognitive function.
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Affiliation(s)
- Alvin Eisner
- Women's Health Research Unit, Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, Oregon 97239, USA.
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Bouwsma EVA, Gorny KR, Hesley GK, Jensen JR, Peterson LG, Stewart EA. Magnetic resonance-guided focused ultrasound surgery for leiomyoma-associated infertility. Fertil Steril 2011; 96:e9-e12. [PMID: 21570071 PMCID: PMC5333557 DOI: 10.1016/j.fertnstert.2011.04.056] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Revised: 04/09/2011] [Accepted: 04/12/2011] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To describe magnetic resonance-guided focused ultrasound surgery (FUS) as a treatment for a case of leiomyoma-associated infertility. DESIGN Case report from a randomized clinical trial. SETTING Academic medical center. PATIENT(S) A 37-year-old woman with known leiomyomas and a history of 18 months of home-inseminations from a known donor. INTERVENTION(S) Magnetic resonance-guided FUS treatment of uterine fibroids, where the dominant fibroid distorted the uterine cavity. MAIN OUTCOME MEASURE(S) Pregnancy. RESULT(S) A viable intrauterine pregnancy, with a full-term vaginal delivery, was conceived after a single clomiphene citrate and intrauterine insemination cycle. CONCLUSION(S) The role of FUS for enhancement of fertility in women with nonhysteroscopically resectable uterine fibroids distorting the uterine cavity should be investigated further.
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Affiliation(s)
- Esther V A Bouwsma
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Mayo Clinic, Rochester, Minnesota, USA
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18
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An algorithm for treatment of infertile women with polycystic ovary syndrome. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2010. [DOI: 10.1016/j.mefs.2010.07.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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19
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Nyboe Andersen A, Balen AH, Platteau P, Pettersson G, Arce JC. Prestimulation parameters predicting live birth in anovulatory WHO Group II patients undergoing ovulation induction with gonadotrophins. Hum Reprod 2010; 25:1988-95. [PMID: 20522443 PMCID: PMC2907229 DOI: 10.1093/humrep/deq142] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The objective of this study was to identify baseline predictors of live birth in anovulatory patients undergoing ovulation induction, and based on these predictors, develop nomograms for estimation of the probability of live birth in a single cycle. METHODS Univariate and multivariate logistic regression were used for retrospective analysis of clinical, sonographic and endocrinological parameters collected prior to the start of ovarian stimulation in a cohort of anovulatory World Health Organization (WHO) Group II patients (n = 335), who were resistant to clomiphene citrate (CC) and therefore stimulated with gonadotrophins using a low-dose step-up protocol. RESULTS The univariate analysis identified age [OR = 0.91 (95% CI: 0.84-0.98), P = 0.015], duration of infertility [OR = 0.71 (95% CI: 0.56-0.91), P = 0.007], serum follicle stimulating hormone (FSH) concentration at the start of stimulation [OR = 0.83 (95% CI: 0.69-0.99), P = 0.034] and menstrual cycle pattern (P = 0.022) as significant predictors of live birth. Baseline concentrations of luteinizing hormone, androgens, glucose and insulin, as well as body mass index, were not predictors of live birth. In the multivariate analysis, duration of infertility, FSH and menstrual cycle pattern were independent predictors, and nomograms were designed with these three parameters for individual prediction of the probability of live birth. CONCLUSIONS The chances of live birth in women with WHO Group II anovulatory infertility resistant to CC undergoing ovulation induction with gonadotrophins is highly influenced by the menstrual cycle pattern. Increases in duration of infertility and concentration of FSH (within the normal range) before the start of stimulation have negative influences on the likelihood of achieving a live birth.
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Affiliation(s)
- A Nyboe Andersen
- The Fertility Clinic, Section 4071, Copenhagen University Hospital, Rigshospitalet, 2100 Copenhagen, Denmark.
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20
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Kurosawa T, Hiroi H, Momoeda M, Inoue S, Taketani Y. Clomiphene citrate elicits estrogen agonistic/antagonistic effects differentially via estrogen receptors alpha and beta. Endocr J 2010; 57:517-21. [PMID: 20379036 DOI: 10.1507/endocrj.k09e-368] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Clomiphene citrate (CC) is known to possess dual actions as an estrogen agonist and an estrogen antagonist. To see how the dual actions of CC are exerted through estrogen receptor alpha (ER alpha) and/or ER beta we developed a cell-based transcription assay system in which 293T cells were transfected with the luciferase reporter plasmid with estrogen responsive element and either human ER alpha or ER beta expression plasmid. CC at lower doses (10(-10) M and 10(-12) M), but not higher doses (10(-6) M and 10(-8) M) elicited estrogenic activity via ER alpha. However, CC at concentrations between 10(-6) M and 10(-12) M did not elicit any estrogenic activity via ER beta. In the presence of 17beta-estradiol (E2), CC behaved either as an agonist or as an antagonist via ER alpha depending on the concentrations of E2, i.e., antagonistic when combined with the higher E2 concentrations, agonistic with the lower E2 concentrations. On the other hand, via ER beta, CC acted as an estrogen antagonist regardless of the concentration of E2 added together. In conclusion, CC acts as an estrogen agonist/antagonist via ER alpha in a coexisting estrogen concentration-dependent way whereas it acts as an estrogen antagonist via ER beta whether or not estrogen is present.
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Affiliation(s)
- Takako Kurosawa
- Department of Obstetrics and Gynecology, University of Tokyo, Tokyo, Japan
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21
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Altinkaya SO, Talas BB, Gungor T, Gulerman C. Treatment of clomiphene citrate-related ovarian cysts in a prospective randomized study. A single center experience. J Obstet Gynaecol Res 2009; 35:940-5. [DOI: 10.1111/j.1447-0756.2009.01041.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Sunduz Ozlem Altinkaya
- Department of Infertility, Dr Zekai Tahir Burak Women's Health Care Education and Research Hospital, Ankara, Turkey.
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22
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Badawy A, Mosbah A, Tharwat A, Eid M. Extended letrozole therapy for ovulation induction in clomiphene-resistant women with polycystic ovary syndrome: a novel protocol. Fertil Steril 2009; 92:236-9. [PMID: 18706549 DOI: 10.1016/j.fertnstert.2008.04.065] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2008] [Revised: 03/29/2008] [Accepted: 04/26/2008] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the outcome of long letrozole therapy for induction of ovulation in patients with clomiphene-resistant polycystic ovary syndrome (PCOS). DESIGN Prospective randomized controlled study. SETTING University teaching hospital and a private practice. PATIENT(S) The study comprised 218 patients with clomiphene-resistant PCOS. INTERVENTION(S) Patients were randomly allocated to treatment with either long letrozole therapy (n = 108; 219 cycles) or short letrozole therapy (n = 110; 225 cycles). MAIN OUTCOME MEASURE(S) Number of growing and mature follicles, serum E(2) (pg/mL), serum P (ng/mL), endometrial thickness, occurrence of pregnancy and miscarriage. RESULT(S) The number of ovulating patients was greater in the long letrozole group (65.7% vs. 61.8%), but without statistical differences. The total numbers of follicles during stimulation was significantly greater in the long letrozole group (6.7 +/- 0.3 vs. 3.9 +/- 0.4). The numbers of follicles > or =14 mm and > or =18 mm were significantly greater in the long letrozole group. There was no significant difference in the pretreatment endometrial thickness or endometrial thickness at the time of hCG administration between the two groups. Pregnancy occurred in 28 of 225 cycles in the short group (12.4%) and 38 of 219 cycles (17.4%) in the long letrozole group, and the difference was statistically significant. CONCLUSION(S) The long letrozole protocol (10 days) can produce more mature follicles and subsequently more pregnancies than the short letrozole therapy (5 days).
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Hurst BS, Hickman JM, Matthews ML, Usadi RS, Marshburn PB. Novel clomiphene "stair-step" protocol reduces time to ovulation in women with polycystic ovarian syndrome. Am J Obstet Gynecol 2009; 200:510.e1-4. [PMID: 19114272 DOI: 10.1016/j.ajog.2008.10.031] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2008] [Revised: 09/03/2008] [Accepted: 10/07/2008] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective of the study was to determine the efficacy of a novel "stair-step" clomiphene protocol in women with polycystic ovarian syndrome (PCOS) who do not respond to 50 mg clomiphene. STUDY DESIGN This was a retrospective analysis at an academic fertility center. The stair-step protocol is performed as follows: 50 mg clomiphene for 5 days, ultrasonography on days 11-14. If unresponsive, immediately begin 100 mg clomiphene for 5 days and repeat ultrasound in 1 week. If still unresponsive, begin 150 mg clomiphene for 5 days and repeat the ultrasound in 1 week. Stair-step cycles were compared with published historical clomiphene outcomes for women who were nonresponsive. RESULTS The time to ovulation was 32-53 days less with the stair-step protocol compared with a traditional regimen. The dose-dependent ovulation rate was 64% at 100 mg with the stair-step protocol compared with 22% with a traditional regimen. CONCLUSION It is not necessary to induce menses before increasing clomiphene doses in nonresponsive PCOS patients.
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Affiliation(s)
- Bradley S Hurst
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Carolinas Medical Center, Charlotte, NC, USA
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24
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Antoine JM. [Quality of ovary stimulation outside IVF]. JOURNAL DE GYNECOLOGIE, OBSTETRIQUE ET BIOLOGIE DE LA REPRODUCTION 2008; 37 Suppl 1:S22-S25. [PMID: 18786465 DOI: 10.1016/s0368-2315(08)73847-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Ovarian stimulation outside IVF is a relatively little studied and codified technique, although in France it accounts for two-thirds of the ovarian stimulations practiced. However, guidelines have recently been published, including from the AFSSAPS, recommending a high-quality approach that includes training and continuing education for practitioners and an organization adapted to patient management structures; using pretreatment workups, analogous to those used for IVF; respecting indications, some of which have been clearly codified (hypogonadotrophic hypogonadism, polycystic ovaries (PCO), and isolated anovulation, noniatrogenic hyperprolactinemia, etc.). This method also requires informed consent from the couples treated as well as rigorous respect and follow-up of the stimulation protocols used.
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Affiliation(s)
- J-M Antoine
- Service de Gynécologie-Obstétrique et Médecine de la Reproduction, Hôpital Tenon, 4 rue de la Chine, Paris, France
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