Monitoring techniques for improved pregnancy rates during clomiphene ovulation induction

Is There Still a Place for Surgery in Patients with PCOS? A Review

OBJECTIVE

The surgical management of polycystic ovary syndrome (PCOS) represents an unclear option compared to medical therapy, and it is necessary to deepen the role of minimally invasive surgery, represented by laparoscopic ovarian drilling (LOD) and transvaginal hydrolaparoscopy (THL), for the treatment of PCOS in infertile women resistant to drug therapy and to establish its success in terms of ovulation and pregnancy rates.

METHODS

A search was performed in the main electronic databases (MEDLINE, EMBASE, Web of Science, PubMed, and the Cochrane Library) from 1994 to October 2022 in order to evaluate the role of surgery in patients with PCOS resistant to pharmacological treatment. Only original scientific articles in English were included.

RESULTS

Seventeen studies were analyzed in this review. In all analyzed studies, more than 50% of the population underwent spontaneous ovulation after surgical treatment without great differences between the two surgical techniques (LOD and THL). More than 40% of patients delivered, with a higher rate after LOD, although eight ectopic pregnancies and sixty-three miscarriages were reported. A lower risk of adhesion formation after THL has been reported. No clear data regarding the effect of surgery on the regularization of the menstrual cycle has been described. A reduction in LH and AMH serum levels as well as the LH/FSH ratio compared to preoperative levels for both surgical techniques has been described.

CONCLUSIONS

Despite the scarcity and heterogeneity of data, surgical therapy could be considered an effective and safe approach in the management of PCOS patients with resistance to pharmacological treatment who desire to become pregnant.

Clomiphene citrate increases nitric oxide, interleukin-10 and reduces matrix metalloproteinase-9 in women with polycystic ovary syndrome

OBJECTIVES

Matrix metalloproteinase-9, Nitric oxide and inflammation plays a role in the pathogenesis of poly cystic ovary syndrome (PCOS). Even though these parameters are altered in PCOS, the effect of clomiphene citrate on them has not been studied till date. The present study was done to assess the effect of clomiphene citrate on matrix metalloproteinase-9, nitric oxide and interleukin-10 levels in women with PCOS.

STUDY DESIGN

72 women diagnosed with PCOS were enrolled in the study. Matrix metalloproteinase-9, nitric oxide and interleukin-10 levels were compared at baseline and after three weeks following Clomiphene citrate treatment.

RESULTS

Clomiphene citrate increases both nitric oxide (p = 0.03) and interleukin-10 (p < 0.001) levels and reduces matrix metalloproteinase-9 levels (p < 0.001) in women with PCOS. It also improves the ovulation rate (52.8%) and clinical pregnancy rate (19.4%) in PCOS. Also there was a significant reduction in matrix metalloproteinase-9 levels in both the ovulatory (p < 0.001) and conceived groups (p = 0.024) compared to non ovulatory and non conceived group. There was no difference in nitric oxide and interleukin-10 levels in ovulatory and conceived groups compared to non ovulatory and non conceived group.

CONCLUSION

We conclude that clomiphene citrate increases the levels of nitric oxide and interleukin-10 and decreases the matrix metalloproteinase - 9 levels and improves the ovulation rate and clinical pregnancy rate in PCOS.

Randomized controlled trial comparing laparoscopic ovarian diathermy with clomiphene citrate as a first-line method of ovulation induction in women with polycystic ovary syndrome

BACKGROUND

Laparoscopic ovarian diathermy (LOD) is currently accepted as a successful second-line treatment for ovulation induction (OI) in clomiphene citrate (CC)-resistant women with polycystic ovary syndrome (PCOS). The aim of this study was to test the hypothesis that LOD may be superior to CC as a first-line treatment.

METHODS

The study included 72 anovulatory women with PCOS who were randomized to LOD (n = 36) or CC (n = 36). Women who remained anovulatory after LOD were offered CC. Similarly, women receiving CC who failed to ovulate or conceive were offered LOD. Pregnancy rates were compared between the two groups using chi(2) and odds ratio with 95% confidence interval (OR, 95% CI).

RESULTS

After randomization, six women conceived before starting treatment and another patient postponed treatment. The remaining 65 women received the treatment (33 underwent LOD and 32 received CC). After the primary treatment, more pregnancies (44%) occurred in women receiving CC than in those undergoing LOD (27%), although the difference did not reach statistical significance [P = 0.13, OR 2.1 (0.7 - 5.8)]. After adding the second treatment, the pregnancy rate was still higher, but to a less extent, in the CC group [63% versus 52%, P = 0.2, OR 1.6 (0.6 - 4.2)].

CONCLUSIONS

LOD is not superior to CC as a first-line method of OI in women with PCOS. The trial is registered with ClinicalTrials.gov with an identifier number NCT00220545.

Oral agents for ovulation induction--clomiphene citrate versus aromatase inhibitors

The purpose of this review is to compare clomiphene citrate (CC) with aromatase inhibitors (AI) as the first-line therapy for WHO Group II (eu-oestrogenic) infertility. For the past 45 years CC has been the first-line therapy, as it is a simple, cheap treatment, almost devoid of side effects, and yields ovulation in 73%, pregnancy in 36% and a singleton live birth rate of 25%. The gap between ovulation and pregnancy rates has mainly been attributed to its anti-oestrogen effects on endometrium. AI block oestrogen production, not oestrogen receptors, and would therefore be expected to produce superior conception rates and less multiple pregnancies. AI have yet to undergo further large, robust clinical trials in order to fulfill this promise as a feasible alternative to CC in this role, but some preliminary trials have shown at least equality and some superiority.

Comparison of the efficacy of the aromatase inhibitor letrozole and clomiphen citrate gonadotropins in controlled ovarian hyperstimulation: a prospective, simply randomized, clinical trial

OBJECTIVE

To study the efficacy of the aromatase inhibitor letrozole in controlled ovarian hyperstimulation (COH).

MATERIAL AND METHODS

In this prospective simply randomized clinical trial, one hundred forty patients with unexplained infertility undergoing intrauterine insemination (IUI) therapy were randomized to receive either letrozole or clomiphene citrate (CC)-gonadotropin. The patients were selected among patients referred to one university hospital and one private infertility clinic. A letrozole dose of 5 mg/day (n = 70) was given on days 3-7 of the menstrual cycles. Clomiphen citrate a dose of 100 mg/day was given like letrozole but combined with human menopausal gonadotropin (hMG) dose of 75 IU/ml administered every day starting on day 6. Ovulation was triggered with urinary hCG (10,000 IU) when the leading follicle(s) reached 18 mm in diameter. A single IUI was performed 36 hours later. The luteal phase was supplemented with micronized progesterone vaginally. Ovarian stimulation response (E2 levels and number of follicles) was primary outcome.

RESULTS

There were no differences in demographic characteristics between groups. The number of mature follicles (1.8 +/- 0.7 vs. 2.46 +/- 2.3; P = 0.042) and serum E2 level on the day of hCG (310 +/- 135.4 vs. 1,670.7 +/- 1021.8 pg/ml, respectively; P < 0.0001) were significantly lower in letrozole group. A significantly higher endometrial thickness was observed at the time of hCG administration in patients that received letrozole (9.7 +/- 1.6 mm vs. 7.8 +/- 2 mm; P < 0.001). Clinical pregnancy rates also were significantly higher in letrozole group (32.8% vs. 14.3%, respectively; P < 0.01).

CONCLUSION

The aromatase inhibitor letrozole appears to constitute a good alternative to CC-gonadotropin in patients with unexplained infertility undergoing COH cycles combined with IUI therapy.

Use of an aromatase inhibitor in patients with polycystic ovary syndrome: a prospective randomized trial

OBJECTIVE

To compare the use of an aromatase inhibitor (letrozole) with the use of clomiphene citrate (CC).

DESIGN

Prospective randomized study.

SETTING

An infertility clinic in a university hospital.

PATIENT(S)

Seventy-four consecutive infertile patients with polycystic ovary syndrome were recruited. Thirty-eight patients were randomized to the letrozole group (99 cycles), and the remaining patients were recruited to the CC group (95 cycles).

INTERVENTION(S)

The aromatase inhibitor letrozole (2.5 mg/d) and CC (100 mg/d) were administered orally on days 3-7 of menses.

MAIN OUTCOME MEASURE(S)

Number of follicles, endometrial thickness, E(2) levels on hCG day, and pregnancy rates among both groups.

RESULT(S)

Ovulation occurred in 65.7% (65/99) of letrozole cycles and in 74.7% (71/95) of CC cycles. The median (minimum-maximum) number of follicles sized >15 mm in diameter on the day of hCG administration were 1 (0-4) and 1 (0-5) in the letrozole and CC groups, respectively. On the day of hCG administration, median serum E(2) concentrations in the letrozole and CC groups were statistically significantly different: 189 pg/mL (18-1,581 pg/mL) and 386 pg/mL (27-6,190 pg/mL), respectively. The median serum E(2) concentrations per follicle sized >15 mm in diameter on the day of hCG also statistically significantly differed between the letrozole and CC groups: 160 pg/mL (18-808 pg/mL) and 281 pg/mL (27-2,615 pg/mL), respectively. The median endometrial thickness on the day of hCG did not significantly differ between the CC and letrozole groups; it was 8 mm. Pregnancy was achieved in nine cycles (9.1%) of the letrozole group and in seven cycles (7.4%) of the CC group, which also was not a statistically significant difference.

CONCLUSION(S)

The aromatase inhibitor letrozole may be an acceptable alternative to CC as an ovulation-induction drug in patients with PCOS.

Role of aromatase inhibitor in ovulation induction in patients with poor response to clomiphene citrate

AIM

To examine the efficacy of aromatase inhibitor in the induction of ovulation.

METHODS

This prospective clinical trial in patients with infertility and poor response to clomiphene citrate (CC) was undertaken in a tertiary referral infertility clinic. Thirty-five infertile patients, who were treated by clomiphene citrate for several cycles and referred to the infertility clinic, were the target population. Initially, the response of CC was assessed by same dose of CC that the patient had in her last cycle. The patients who did not respond adequately were treated by aromatase inhibitor 2.5-5 mg/day from day 3-7 of the menstrual cycle. The main outcome measures were the number of mature follicles, ovulation rate, endometrial thickness and pregnancy rate.

RESULTS

Twenty-seven (90%) patients developed mature follicles by day 12. The majority (77.77%) developed single follicle. Except for one cycle of one patient, the follicles of all patients were ruptured in all cycles and seven (25.94%) got pregnant.

CONCLUSION

The aromatase inhibitor letrozole is effective for ovulation induction in anovulatory infertility in patients that failed to ovulate by CC.

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.

Ultra-short metformin pretreatment for clomiphene citrate-resistant polycystic ovary syndrome

OBJECTIVE

To evaluate the effect of ultra-short (12 days) metformin pretreatment in clomiphene-citrate (CC) resistant polycystic ovary syndrome (PCOS).

METHOD

Eighty women with CC-resistant PCOS were randomly allocated to metformin pretreatment or usual treatment. Forty women received 1500 mg metformin daily for 12 days, followed by clomiphene 150 mg daily for 5 days along with metformin. Forty women (control group) received the same dose of clomiphene but no metformin pretreatment.

RESULTS

In the metformin group, 17 (42.5%) women ovulated, and 6 (15%) conceived. In the control group, 5 (12.5%) women ovulated but none conceived. Compared with the control group, the metformin group had significantly higher ovulation (P = 0.03) and pregnancy rates (P = 0.026).

CONCLUSION

Twelve days of metformin pretreatment improves ovulation and pregnancy rates in women with CC-resistant PCOS.

Clomiphene citrate--end of an era? A mini-review

The purpose of this review is to examine whether the time has come to replace clomiphene citrate (CC) as the first line therapy for WHO group II (eu-oestrogenic) infertility, the majority of which is associated with polycystic ovary syndrome. CC has been the first line therapy for these cases for the last 40 years. It is a simple, cheap treatment, almost devoid of side effects which yields a single live birth rate of approximately 25% of starters. Non-response to CC and the gap between ovulation and pregnancy rates have variously been attributed to its anti-estrogen effects, and high LH and androgen concentrations. Three possible contenders for the replacement of CC as first-line treatment are scrutinized: metformin, aromatase inhibitors and low-dose FSH. Each has their advantages and disadvantages, but none of them, while showing much potential promise, has been proven, as yet, to be a feasible replacement for CC in this role. For CC, it may not yet be the end of an era but it may be the beginning of the end.

Laparoscopic evaluation following failure to achieve pregnancy after ovulation induction with clomiphene citrate

OBJECTIVE

To assess the value of laparoscopic evaluation of the pelvis after failure to achieve pregnancy with clomiphene citrate-induced ovulation and to determine whether predictors for significant pelvic pathology can be isolated.

DESIGN

Retrospective study.

SETTING

Tertiary care academic medical center.

PATIENT(S)

Ninety-two patients failing to conceive after four ovulatory cycles with clomiphene citrate with a normal hysterosalpingogram who underwent laparoscopic evaluation of the pelvis.

INTERVENTION(S)

Laparoscopy.

MAIN OUTCOME MEASURE(S)

Presence of pelvic pathology and predictors of pelvic disease.

RESULT(S)

Of the 92 patients studied, 32 patients (34.8%) had a "positive" laparoscopy (i.e., stages III and IV endometriosis, an endometrioma, pelvic adhesions, and/or tubal disease), 27 patients (29.3%) had stage I or II endometriosis, and 30 patients (32.6%) had a normal pelvis. The predictors for intrapelvic disease were a history of dyspareunia, no prior use of oral contraceptive pills, and no prior use of any form of contraception. Almost 40% of women with predictors had a "positive" laparoscopy, compared with only 12.5% of patients without predictors; however, the majority of patients (91.3%) had at least one predictor.

CONCLUSION(S)

More than one third of the patients failing to conceive after four ovulatory cycles of clomiphene citrate had significant intrapelvic pathology. Although predictors for intrapelvic disease were isolated, their high prevalence reduced their predictive value.

A randomized double-blind comparison of the effects of clomiphene citrate and the aromatase inhibitor letrozole on ovulatory function in normal women

OBJECTIVE

To evaluate the ovarian follicular dynamics of cycle modification with the aromatase inhibitor letrozole compared with clomiphene citrate in normal ovulatory women.

DESIGN

Randomized double-blind controlled trial.

SETTING

Tertiary care hospital.

PATIENT(S)

Nineteen ovulatory female volunteers, ages 18-35 years.

INTERVENTION(S)

Subjects were monitored in one control cycle. Subjects then received either letrozole 2.5 mg daily or clomiphene citrate 50 mg daily on days 5-9 after menses.

MAIN OUTCOME MEASURE(S)

Number of mature follicles, endometrial thickness and endometrial pattern at ovulation, and follicular profiles of LH, FSH, and E(2).

RESULT(S)

The number of mature follicles at the LH surge in natural cycles was 1.0 with an exaggerated response seen for treatment both with clomiphene and letrozole. There was no difference in the endometrial thickness at midcycle during either the natural cycles or the medicated cycles. LH surges and spontaneous ovulation were documented in all natural and medicated cycles. When measured daily, follicular profiles of LH and FSH are similar between the groups in both the natural and medicated cycles. In the medicated cycles, clomiphene results in a significant increase in E(2) levels, while E(2) levels in letrozole-stimulated cycles appeared lower than in natural cycles.

CONCLUSION(S)

Transient inhibition of aromatase activity in the early follicular phase with the aromatase inhibitor letrozole results in stimulation of ovarian folliculogenesis similar to that seen with clomiphene citrate with no apparent adverse effect on endometrial thickness or pattern at midcycle.

Metformin therapy improves ovulatory rates, cervical scores, and pregnancy rates in clomiphene citrate-resistant women with polycystic ovary syndrome

OBJECTIVE

To evaluate the effect of metformin therapy on hyperandrogenism, insulin resistance, cervical scores, ovulation, and pregnancy rates in clomiphene citrate-resistant women with polycystic ovary syndrome (PCOS).

DESIGN

Prospective, randomized, double-blind, placebo-controlled study.

SETTING

Infertility clinic of a tertiary referral center.

PATIENT(S)

Fifty-six women with clomiphene citrate-resistant PCOS.

INTERVENTION(S)

Two cycles of oral metformin therapy (850 mg, twice daily) in group I and placebo therapy (twice daily) in group II. Clomiphene citrate (100 mg/day) on cycle days 3-7 of the second cycle in both groups.

MAIN OUTCOME MEASURE(S)

Insulin, T, DHEAS, FSH, LH, body mass index (BMI), waist-to-hip ratio, endometrial thickness, cervical score, ovulation, and pregnancy rates in clomiphene-induced cycles after metformin therapy.

RESULT(S)

Metformin therapy resulted in a significant decrease in total T, LH level, LH/FSH ratio, insulin resistance, and mean BMI. No difference in waist-to-hip ratio, DHEAS level, and fasting insulin level was observed. Clomiphene citrate induction resulted in higher ovulation rates and thicker endometrium in the metformin group than in the placebo group. There was higher cumulative pregnancy rate in the metformin group; however, there was no significant difference in the pregnancy rate between the two groups.

CONCLUSION(S)

Metformin therapy not only decreases hyperandrogenism and insulin resistance but also improves ovulation rates, cervical scores, and pregnancy rates in clomiphene citrate-resistant women with PCOS.

Growth hormone response to clonidine in anovulatory infertile women resistant to clomiphene citrate stimulation

OBJECTIVE

To evaluate the GH response to the clonidine test in a group of infertile women and to determine their ovulatory response to clomiphene citrate (CC) stimulation.

DESIGN

Prospective study.

SETTING

Reproductive endocrinology unit.

PATIENT(S)

Thirty-three anovulatory infertile women (age range, 25-36 years) and 9 healthy controls with normal ovulation.

INTERVENTION(S)

In the early follicular phase, 0.3 mg of clonidine was administered between 8:30 and 9:00 A.M. and blood samples were collected for 120 minutes thereafter for measurement of serum GH levels. Plasma levels of insulin and glucose were measured after a 75-g glucose load, and CC was given at a dosage of 50-250 mg/d for ovulation-induction.

MAIN OUTCOME MEASURE(S)

Serum concentrations of GH, insulin-like growth factor I, insulin, and insulin-like growth factor binding protein-1.

RESULT(S)

On the basis of their ovulatory response to CC, 15 patients were considered nonresponsive (group 1) and 18 patients were considered responsive (group 2). Baseline levels of GH, insulin-like growth factor I, and insulin-like growth factor binding protein-1 were similar in the two groups of patients and the controls. The GH response to clonidine was significantly greater in group 2 and in the controls than in group 1. Concentrations of insulin and glucose after the glucose load were not different among the three groups.

CONCLUSION(S)

Women who were resistant to CC had a reduced GH response to clonidine. These data suggest that adequate GH secretory capacity is important for CC action.

Polycystic ovary syndrome

Polycystic ovary syndrome is a syndrome and not a disease. It reflects multiple potential etiologies and variable clinical presentations that are reviewed in this article. In addition to menstrual dysfunction and hyperandrogenism, women with polycystic ovary syndrome also may have hypothalamic-pituitary abnormalities, polycystic ovaries on pelvic ultrasonography, infertility, obesity, and insulin resistance. A familial pattern occurs in some cases, suggesting a genetic component to the disorder. The three major pathophysiologic hypotheses that have been proposed to explain the clinical findings of the disorder as well as treatment options are reviewed in this article.

Surgical management of polycystic ovarian syndrome

The objective of this chapter is to review the role of surgical management of polycystic ovarian syndrome in infertile women. Pertinent studies and their references were identified through computer medline search. To date there is no standardization of the technique of laparoscopic ovarian drilling. However, it appears that the results are promising, with a high ovulation rate ranging between 70% and 90% and a pregnancy rate of 70%. Clomiphene citrate remains the first line of treatment to induce ovulation in infertile women with polycystic ovarian syndrome. Laparoscopic ovarian drilling can be offered to clomiphene-resistant women, especially to those who have also failed to respond to gonadotrophin treatment or who have experienced ovarian hyperstimulation syndrome. It appears that the pregnancy rate after ovarian drilling is comparable with that for gonadotrophin therapy. However, until more complete and long-term data are available, caution must be exercised when offering this type of treatment.

Ovulation triggering in clomiphene citrate-stimulated cycles: human chorionic gonadotropin versus a gonadotropin releasing hormone agonist

PURPOSE

To compare the use of human chorionic gonadotropin (hCG) to a gonadotropin releasing hormone (GnRH) agonist, nafarelin, in initiating ovulation and supporting the luteal phase after priming with clomiphene.

METHODS

In 26 infertile women 50 mg clomiphene citrate produced a preovulatory-size follicle. Then, 11 women were randomized to receive two 400-micrograms doses of nafarelin intranasally 16 h apart, and 15 women were injected intramuscularly with 5000 IU of hCG (luteal day 0 = LD0). Starting on LD6, 7 more 400-micrograms doses of nafarelin were repeated on an every 16-h schedule or a single 2500 IU dose of hCG was given, respectively. Serum levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), progesterone (P), and hCG were measured. On LD13, endometrium was evaluated with ultrasonography and biopsy in 19 nonpregnant women.

RESULTS

As judged by a threefold rise in serum LH, an LH surge was detected on LD1 in all 11 nafarelin patients, but in only 8 hCG patients (P = 0.01). LH and FSH levels were significantly higher on LD1, 7, and 8 and were significantly suppressed on LD13 in the nafarelin group. All patients had mid-luteal P levels greater than 10 ng/ml and luteal phases longer than 13 days. Significantly different luteal E2 or P levels were noted only on LD13, with lower values in the nafarelin group. Pregnancies were achieved in 3 of 11 nafarelin cycles and 2 of 15 hCG cycles. Luteal phase defects were also similar: 4 of 8 nafarelin patients and 7 of 11 hCG patients.

CONCLUSION

Nafarelin or hCG in conjunction with clomiphene can result in viable pregnancies, but is associated with low pregnancy rates and a high incidence of luteal phase defects.

Detection of premature luteinization with serum progesterone levels at the time of the postcoital test

Poor cervical mucus (CM) may be caused by a number of factors, including premature luteinization, local cervical effects, and inadequate folliculogenesis. In an attempt to distinguish between these causes of poor CM, we obtained progesterone (P) levels at the time of postcoital tests (PCTs) in infertile women during spontaneous or clomiphene citrate (CC)-stimulated cycles. The amount of CM, viscosity, ferning, spinnbarkeit, and cellularity were each scored from 0 to 3 points on the day after detection of the urinary luteinizing hormone surge (luteal day 1). The charts of 46 such patients were retrospectively reviewed. Eleven control patients with good CM scores (greater than 10) had low P levels (less than 2.5 ng/mL). Of the remaining 35 cycles, 19 were marked by low P levels, and 16 were accompanied by P levels of greater than 2.5 ng/mL. Overall, 94.4% of CC-stimulated cycles versus 64.3% of spontaneous cycles had abnormal CM scores (less than 9). On the basis of these inappropriately elevated P levels, premature luteinization can be cited as the cause of poor mucus quality. In fact, premature luteinization may be responsible for some of the purported antiestrogenic effects of CC. Therefore, it is appropriate to draw a P level at the time of a poor PCT, particularly in cycles stimulated by CC.

Addition of exogenous estrogens to improve cervical mucus following clomiphene citrate medication. Patient selection

Medication with Clomiphene Citrate and its effects on the quality of cervical mucus and the addition of exogenous estrogens in order to suppress abnormal mucus secretion are controversial issues. We have prospectively studied a group of 19 anovulatory women who were treated with clomiphene citrate in order to characterize those patients most likely to respond to the addition of exogenous estrogens. On day 14 of the cycle, 17 beta estradiol and cervical score were measured and 1 mg estradiol benzoate was injected intramuscularly. Cervical scores were below 7 in 12 out of the 19 patients before estradiol benzoate administration. In these patients, 17 beta estradiol rose from 751 +/- 541 to 1321 +/- 648 pg/ml (p less than 0.03), and cervical scores rose from 3.75 +/- 2.1 to 7.1 +/- 3.7 (p less than 0.01), after estradiol benzoate administration. Patients with cervical scores of 8-12 did not improve significantly. In the 12 patients with cervical scores below 7, those (n = 6) with 17 beta estradiol below 600 pg/ml experienced a significant improvement in cervical score, in contrast to those (n = 6) with 17 beta estradiol above 600 pg/ml who had no improvement. The reduction in cervical mucus accomplished with clomiphene citrate can be further improved by adding exogenous estrogens, mainly in patients who have low 17 beta estradiol levels concomitant with low cervical score.

Anti-oestrogens: their clinical physiology and use in reproductive medicine

The anti-oestrogens are important both as therapeutic agents in reproductive medicine and as tools to investigate the physiology of the oestrogen receptor and hormonal control mechanisms. Clomiphene occupies the oestradiol receptor and, although initially stimulatory, has a net antagonistic effect as oestrogen receptors are not replenished. The major fertility-enhancing effect is to cause an increase in LH and FSH output by increasing the frequency of pulsatile output of these hormones. Many effects due to an anti-oestrogenic effect have been postulated; some, such as an adverse effect on cervical mucus, have been proven. The clinical use of the anti-oestrogens is outlined in Table 1. In well chosen patients a rewarding pregnancy rate is obtained with minimal intervention and few important side-effects. The challenge for the reproductive biologist is successfully to manage the patient who is clomiphene-resistant, either because of failure to ovulate or failure to conceive once ovulation is induced.

Prediction of ovulation with the use of oral and vaginal electrical measurements during treatment with clomiphene citrate

This study was undertaken to evaluate the usefulness of measuring salivary and vaginal electrical resistance in monitoring ovulation induced by clomiphene citrate (CC). Data from 28 cycles of 12 women treated with CC were compared with those of 18 cycles of 13 women who were ovulating spontaneously. Patterns of salivary readings in CC and spontaneous cycles were similar and showed a preovulatory peak 6.2 (mean) days before the luteinizing hormone peak. The trend in vaginal readings for CC cycles differed from that of spontaneous ovulations in that the values were depressed during and shortly after CC therapy. Occurrence of the periovulatory nadir and subsequent rise was common to both groups. The rise in vaginal readings CC cycles occurred within 24 hours of the luteinizing hormone peak in 88% of cases. Retrospective analysis showed that, based on this method, artificial insemination would have been timed appropriately in 25 of 27 cycles or in every cycle, depending on the protocol used. The results indicate that the method is equally useful for predicting and confirming ovulation in cycles in which CC was used to induce ovulation as it is in spontaneous cycles.

Improved sperm counts in mink males (Mustela vison) treated with clomiphene citrate

A group of 12 sterile, azoospermic mink males were treated with clomiphene citrate (10 mg/kg/day) for 10 days during the mating season; 50% of the males showed improved sperm counts already after 2 days of treatment and the maximum effect was seen 4-6 days after the start of the treatment. The other half of the group did not respond to the treatment and their sperm counts remained near zero during the whole experiment.

Detection of the ovulatory luteinizing hormone (LH) surge with a semiquantitative urinary LH assay

We examined blood concentrations of ovarian steroid hormones (E2, P) and serum LH concentrations to establish that the Ovu-STICK assay reliably reflects endocrine events in the periovulatory period. In all 16 cycles studied, which included 2 cycles in which the women received CC, the ovulatory surge of LH was detected with the use of the Ovu-STICK assay. In contrast, BBT monitoring correctly predicted the ovulatory event in only half the cycles.