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

The role of progesterone and the progesterone receptor in human reproduction and cancer

Insufficient progesterone, effect possibly more on immune factors rather than adequate endometrial development, can be an easy remedial cause of infertility by simply supplementing the luteal phase with either vaginal or intramuscular or oral (dydrogesterone) progesterone. Progesterone will also help to reduce miscarriage rates when follicle maturing drugs are used for those with regular menses but follicular maturation defects, or women with recurrent miscarriages. One mechanism of action seems to be related to production of an immunomodulatory protein, the progesterone-induced blocking factor either in the cytoplasm or in the circulation. PIBF inhibits cytotoxicity of natural killer cells. Cancer cells may 'borrow' the same mechanism to escape NK cell immunosurveillance.

Luteal phase defect: part of the infertility zeitgeist or relic from the past?

Luteal phase defect (LPD) or short luteal phase is a controversial entity that has been variously defined over the years. There are a number of potential causes for LPD all of which are associated with inadequate progesterone secretion throughout the luteal phase which impairs endometrial development and is thus thought to cause infertility. However, the relationship between LPD and infertility is complex, with LPD found in both fertile and infertile women. Attempts have been made at treating LPD with a number of regimens including progesterone supplementation and ovulation induction using clomiphene citrate, however, problems with study design have prevented conclusive evidence for the efficacy of these treatments being drawn. Practically, with the more interventionalist and aggressive approaches to managing couples with unexplained infertility, LPD may have become an irrelevant entity.

Adverse effects of fertility drugs

Ovulation-induction agents are commonly used in the treatment of infertility in patients with or without ovulatory disturbances. These agents include clomifene, bromocriptine, gonadotrophin preparations and gonadotrophin-releasing hormone (GnRH) and its analogues. Each agent is associated with its own specific adverse effects. Although many of these adverse effects are benign and self-limited, some, in particular those effects associated with gonadotrophins, may be life-threatening. Commonly noted adverse effects encountered with the use of pharmacological agents to treat infertility include the following. Clomifene has been associated with hot flushes, multiple gestation, visual disturbances, cervical mucus abnormalities and luteal phase deficiency. Similarly, most of the adverse symptoms associated with bromocriptine are short-lived, such as nausea and postural hypotension. On the other hand, gonadotrophin therapy, even when used appropriately, may lead to the ovarian hyperstimulation syndrome (which is occasionally life-threatening) and a high incidence of multiple gestation. Pulsatile GnRH therapy maybe accompanied by similar adverse effects to those of gonadotrophins, but with a far lower incidence. With regards to the long term safety of these medications, the relationship between fertility drugs and epithelial ovarian cancer is controversial, and causality has yet to be proven. Indeed, a working knowledge of the many adverse effects associated with these medications is essential to any physician prescribing ovulation induction agents, in order to ensure maximum patient safety, compliance and understanding.

Luteal phase deficiency: effect of treatment on pregnancy rates

Luteal phase deficiency is thought to be a cause of female infertility. Nevertheless, little agreement exists concerning either its diagnosis or its treatment. To address the latter question, we reviewed the English literature and examined the effect of treatment on pregnancy rates. One randomized controlled trial found a statistically insignificant benefit of treatment with progesterone suppositories or oral dehydroprogesterone versus no treatment (relative risk 1.9; 95% confidence interval 0.4 to 8.1). Three other comparative studies also showed no statistically significant benefit. Case-series reports (before-after studies) claiming benefit failed to account for the effect of regression to the mean. The benefit of treatment for luteal phase deficiency has not been established. Uniform case definitions and randomized controlled trials of adequate power are needed to resolve this problem.

Error in histologic dating of secretory endometrium: variance component analysis

OBJECTIVE

To characterize the extent and sources of imprecision in histologic dating of the endometrial biopsy.

DESIGN

Duplicate endometrial biopsies from 25 women were dated by five evaluators on two separate occasions to evaluate the overall precision of the measure. Using variance component analysis, estimates of intrauterine, intraevaluator, and interevaluator variability were determined.

SETTING

Samples were obtained during outpatient fertility testing. Evaluators were colleagues at the same institution.

PATIENTS, PARTICIPANTS

Women presenting with infertility undergoing routine evaluation.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Variability in histologic dating of the endometrium.

RESULTS

Inconsistencies between evaluators accounted for 65% of the observed variability, whereas 27% was because of inconsistencies in duplicate readings by the same evaluator. Regional differences in the uterus accounted for only 8% of the total variability.

CONCLUSIONS

The overall error from these sources have the potential to result in a substantial false-positive rate for diagnosis of luteal phase defect.

Oral clomiphene citrate and vaginal progesterone suppositories in the treatment of luteal phase dysfunction: a comparative study

Oral clomiphene citrate (CC) and vaginal progesterone suppositories (PS) are common treatment modalities in luteal phase dysfunction (LPD). Little is known regarding the relative efficacy of these agents. To study the use of CC and PS in the management of LPD, a retrospective cohort study of patients presenting with infertility was undertaken. Sixty-five patients in whom LPD was diagnosed and corrected, as judged by endometrial biopsies, were studied; 35 were treated with PS and 30 with CC. Using Student's t-tests and chi-square analyses, the two treatment groups were demographically comparable. Using life-table analysis, no one therapeutic approach proved superior. Clomiphene citrate and PS are comparable treatment modalities in the setting of LPD given correction of endometrial lag.

The short luteal phase and infertility

The distribution of the length of the luteal phase was investigated in 187 women with regular, apparently ovulatory menstrual cycles of whom 95 had unexplained infertility and the other 92 comprised a group of healthy volunteer subjects. If the short luteal phase is associated with infertility it might be expected to occur more frequently in women with unexplained infertility. A short luteal phase (defined as a luteal phase lasting less than or equal to 11 days) was found in 9% of the infertile group and in 8% of the normal group showing that these cycles do not occur more frequently in women with infertility.

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.

Basal body temperature graph and the luteal phase defect

Basal body temperature (BBT) charts from three menstrual cycles of 20 normal women and 20 women with biopsy-proven luteal phase defect (LPD) were reviewed. Mean luteal phase length in the normal women was 13.4 days, and that of the women with LPD was 11.8 days (P less than 0.05). Six (30%) of the LPD patients had luteal phases of less than 11 days according to BBT, and five of these patients had severely out-of-phase endometrial biopsies. None of the normal patients had luteal phases of less than 11 days. There was no significant difference in the mean rate of postovulatory BBT rise between the two groups. It is suggested that the slope of postovulatory temperature shift is not helpful in the diagnosis of LPD but that evidence of a luteal phase of less than 11 days on BBT does indicate a high likelihood of LPD.

A graduated regimen of clomiphene citrate: its correlation to glycogen content of the endometrium and serum levels of estradiol and progesterone in infertile patients at the midluteal phase

The glycogen content, glycogen synthetase level, and glycogen phosphorylase level were studied in endometrial samples obtained from 14 infertile patients during the midluteal phase before and after clomiphene citrate (Clomid, Shionogi & Company, Ltd., Osaka, Japan) treatment, simultaneously with measurement of the serum concentrations of estradiol and progesterone. Increase in the endometrial glycogen content in the clomiphene cycle was accompanied by a corresponding increase of the dosage of clomiphene. Also, the midluteal concentrations of estradiol and progesterone in the clomiphene cycle were significantly higher (P less than 0.005 and P less than 0.005, respectively) than those in the nontreatment cycle. Clomiphene therapy at 50 mg/day resulted in pregnancy in three of ten patients, while clomiphene at 100 mg/day resulted in pregnancy in three of six patients. These results suggest a fair correlation between the dosage of clomiphene and the improvement of endometrial function in infertile patients following stimulated ovarian steroidogenesis.

Clomiphene citrate therapy for luteal phase defect

The incidence of luteal phase defects in 366 infertility patients was 12.7%. Life-table analysis was used for determination of the conception rate with clomiphene citrate therapy, and with this method, evidence was found for the presence of two subgroups with respect to response. The crude conception rate was 40.9%. In a group of patients with a luteal phase defect and no other infertility factors, those that conceived had a significantly larger mean biopsy delay than those who did not (6.28 days versus 4.32; P less than 0.02). In a group with a histologic delay of 5 days or more, the conception rate was 79%, while the rate was only 8.9% in those with a less severe deficit (P less than 0.001). Theoretic considerations for clomiphene citrate therapy are discussed.

Tamoxifen in the treatment of infertility associated with luteal phase deficiency

A group of 17 patients with suspected luteal phase deficiency was treated with tamoxifen. Tamoxifen therapy was found to lengthen the luteal phase in all patients and resulted in pregnancy in 6 of 17 patients. The integrated luteal phase progesterone (P) concentration in the nontreatment cycle of seven patients was significantly lower (P less than 0.01) than that of five normal women. Therapy with tamoxifen increased the P concentration to 186.0 +/- 24.4 ng/ml/cycle (mean +/- standard error of the mean), i.e., twice that of the control cycle. The mean estradiol (E2) concentration at the midcycle peak was about twice that observed during the nontreatment cycle. The glycogen content of the endometrial tissue at the midluteal phase in the tamoxifen cycle was significantly higher (P less than 0.025) than that of endometrial tissue in the nontreatment cycle, indicating improvement of the endometrial function.