Cycle abnormalities in infertile women with regular menstrual cycles: effects of clomiphene citrate treatment

The definition of unexplained infertility: A systematic review

BACKGROUND

There is no consensus on tests required to either diagnose unexplained infertility or use for research inclusion criteria. This leads to heterogeneity and bias affecting meta-analysis and best practice advice.

OBJECTIVES

This systematic review analyses the variability of inclusion criteria applied to couples with unexplained infertility. We propose standardised criteria for use both in future research studies and clinical diagnosis.

SEARCH STRATEGY

CINAHL and MEDLINE online databases were searched up to November 2022 for all published studies recruiting couples with unexplained infertility, available in full text in the English language.

DATA COLLECTION AND ANALYSIS

Data were collected in an Excel spreadsheet. Results were analysed per category and methodology or reference range.

MAIN RESULTS

Of 375 relevant studies, only 258 defined their inclusion criteria. The most commonly applied inclusion criteria were semen analysis, tubal patency and assessment of ovulation in 220 (85%), 232 (90%), 205 (79.5%) respectively. Only 87/220 (39.5%) studies reporting semen analysis used the World Health Organization (WHO) limits. Tubal patency was accepted if bilateral in 145/232 (62.5%) and if unilateral in 24/232 (10.3%). Ovulation was assessed using mid-luteal serum progesterone in 115/205 (56.1%) and by a history of regular cycles in 87/205 (42.4%). Other criteria, including uterine cavity assessment and hormone profile, were applied in less than 50% of included studies.

CONCLUSIONS

This review highlights the heterogeneity among studied populations with unexplained infertility. Development and application of internationally accepted criteria will improve the quality of research and future clinical care.

Follicular growth, endometrial thickness, and serum estradiol levels in spontaneous and clomiphene citrate-induced cycles

OBJECTIVES

To evaluate follicular growth, endometrial thickness, and serum estradiol levels in spontaneous cycles and cycles induced by clomiphene citrate (CC).

METHODS

A 2-year prospective study of spontaneous cycle followed by a CC-induced cycle to compare paired data. Twenty couples with unexplained infertility were recruited from the Infertility Clinic of the Jawaharlal Institute of Postgraduate Medical Education and Research. An oral dose of 150 mg of CC was administered on days 5 through 9 of the CC-induced cycle. Each woman was evaluated using transvaginal sonography and serum estradiol level estimation from day 10 of the menstrual cycle until ovulation. Results were analyzed using the paired t-test.

RESULTS

The leading follicular diameter was significantly larger, endometrial thickness was significantly decreased, and serum estradiol levels were significantly higher in the follicular phase of CC-induced cycles.

CONCLUSIONS

Clomiphene citrate-induced cycles showed different follicular, endometrial growth patterns, and serum estradiol levels compared with spontaneous cycles.

Diagnosis of subtle ovulation disorders in subfertile women with regular menstrual cycles: cost-effective clinical practice?

Serial monitoring by plasma progesterone measurement is advised in the literature for fertility work-up, to detect ovulation disturbances in women presenting with regular menstrual cycles. Three strategies to diagnose such 'subtle ovulation disorders' (SOD, defined as anovulation, inadequately timed ovulation or ovulation of a follicle of reduced size in regularly cycling women) were evaluated, in order to investigate costs of such a diagnosis. On the basis of a 'maximal', an 'ultrasound-only', and a 'preselection' strategy, total medical costs and costs including non-medical costs were calculated for each SOD diagnosis. A 'maximal' diagnostic strategy resulted in a total medical cost of ECU 9057 per diagnosis (including non-medical costs ECU 12,787); an 'ultrasound-only' strategy in ECU 4520 (ECU 6791) per diagnosis. By use of a 'preselection' strategy, 4.25% of the women were found to have an SOD, at a cost of ECU 3036 (ECU 6868) for each diagnosis. As the real significance of SOD diagnosis for the prognosis of the patient to become pregnant without treatment remains unclear, and as no randomized trials on treatment effectiveness have as yet been undertaken, it is questionable whether this approach is worthwhile.

Ovarian function in relation to the outcome of in vitro fertilization (IVF) treatment in regularly menstruating women with tubal infertility

STUDY DESIGN

Ovarian endocrine function was evaluated in 53 regularly menstruating women, 27 to 38 years of age, who failed to conceive at least 2 years following reconstructive surgery for tubal infertility. Thirty apparently healthy women, 24 to 40 years of age with proven fertility, served as controls. Blood samples were obtained daily on cycle days 2-4 and 22-26 to assess FSH, E2, and P4 results.

RESULTS

There was a tendency for women with more advanced tubal damage to be subjected to more extensive surgery. Based on extent of reconstructive surgery, the patients were divided into three groups. Group A (n = 29) had less extensive surgery, limited to the fallopian tubes, group B (n = 14) included patients with extended adhesiolysis, and group C (n = 10) comprised patients that had the most extensive reconstructive procedures involving ovarian surgery. Significantly highest FSH levels were found in group C (P < 0.001) compared to groups A and B in the early follicular phase. During the luteal phase, E2 levels were lower in groups B (P < 0.01) and C (P < 0.001) compared to group A. P4 levels were lower in group C compared to groups A and B.

CONCLUSION

When the patients underwent IVF treatment higher grades of tubal damage, more extensive surgery and hormonal signs of ovarian insufficiency were highly related to treatment failure.

Alcoholic hypogonadism: hormonal response to clomiphene

To investigate the androgen, weak androgen, estrogen, and gonadotrophin response to clomiphene in alcoholics, we determined in 63 male patients (25 with and 38 without liver cirrhosis) serum testosterone, sexual hormone binding protein (SHBG), dehidroepiandrosterone, androstenedione, LH, FSH, prolactin, and estradiol levels, on the first and the sixth day after admission, and after a course of 8 days of clomiphene 200 mg/day. The same test was performed on 15 healthy volunteers. Cirrhotic patients showed decreased basal testosterone levels and a loss of the circadian rhythm with recovery after clomiphene. Although basal testosterone levels in noncirrhotic alcoholics did not differ from those of the controls, there was a significant improvement after withdrawal. SHBG levels were higher in both groups of alcoholics than in controls, pointing to a worse degree of hypogonadism, because only the free hormone is active. Before the clomiphene test, serum LH and FSH levels were nonsignificantly higher in both groups of alcoholics than in the control group. After clomiphene both LH and FSH increased. Androstenedione and estradiol showed a (parallelism) similar behavior in alcoholic and in cirrhotic groups, showing in both cases higher levels than in the control group, and an increase after clomiphene, perhaps reflecting peripheral conversion of androgens to estrogens. Because clomiphene has no effect on the adrenal cortex, the increase of androstenedione after clomiphene points to its testicular origin (directly or after testosterone conversion) and not to an adrenal one. The highest serum estradiol levels were observed in cirrhotics with ascites or gynecomastia. We have not found any relation between serum hormone levels and alcohol intake nor with nutritional status.