Characteristics of gonadotropin response, follicular development, and endometrial growth and maturation across consecutive cycles of clomiphene citrate treatment**Presented in part at the 41st Meeting of the Society for Gynecologic Investigation, Chicago, Illinois, March 22 to 26, 1994.††Supported by a grant from the Clinical Investigations Division, National Naval Medical Center, Bethesda, Maryland.‡‡The opinions and assertions expressed herein are those of the authors and are not to be construed as official or as representing the view of the Department of the Navy, the Department of Army, the Department of the Air Force, or the Department of Defense

Down regulatory response of reproductive potentials in stress-induced rats supplemented with clomifene citrate: The fate of infertility

This study was designed to physiologically investigate the fate of stress related infertility conditions to focus on the regulatory response of reproductive potentials in stress-induced female Wistar rats supplemented with clomifene citrate. 42 apparently healthy female Wistar rats weighing about 120-160 g were used in the study. The animals were randomly distributed into 3 groups after acclimatization for 2 weeks. Group 1 served as the control pregnant rats not induced by restraint, mirrored and intruder stressors, group 2 consisted of rats treated with 0.013 mg/g of clomifene citrate drug and exposed to three different stressors while group 3 represented pregnant rats exposed to different stressors but not treated with clomifene citrate. At the end of 3weeks, the rats were euthanized via cervical dislocation. The uterus and ovary organs were carefully isolated, weighed and examined for histological changes. The reproductive capacities studied were gestation period, mean pup weight, litter size and survival rate respectively. Data collected is expressed in Mean±SEM and one way ANOVA statistics was used for comparison of means while Fisher's LSD was employed for post hoc test and the level of significance is determined at p-value < 0.05. Results from our study revealed that restraint and intruder stressors following supplementation with clomifene citrate produced similar stress response in the gestation length, pub-weights, litter size and percentage of survival. Stress of different nature altered the histoarchitecture of the ovary and the uteri of rats exposed to restraint or intruder stressor. Meanwhile, Clomifene citrate administration produced effect on ovulation and pregnancy outcome of stressed pregnant rats and the survival ratio of the offspring.

Polycystic ovary syndrome and infertility: an update

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

Optimal lead follicle size for human chorionic gonadotropin trigger in clomiphene citrate and intrauterine insemination cycles: an analysis of 1,676 treatment cycles

OBJECTIVE

To identify the optimal lead follicle size for hCG trigger in clomiphene citrate (CC)-intrauterine insemination (IUI) cycles.

DESIGN

Retrospective cohort study.

SETTING

University-affiliated center.

PATIENT(S)

Patients <40 years of age with ovulatory dysfunction or unexplained infertility undergoing their first CC-IUI cycle.

INTERVENTION(S)

Ovulation induction, hCG trigger, and IUI.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate (CPR) was the primary outcome and was plotted against lead follicle size in increments of 1 mm. Odds ratios with 95% confidence intervals for associations between lead follicle size and CPR were calculated from a multivariable logistic regression model. A receiver operating characteristic (ROC) curve was generated for CPR as a function of lead follicle size.

RESULT(S)

1,676 cycles were included. The overall CPR was 13.8% (232/1,676). There was no difference in baseline demographics or ovulation induction parameters of patients who did or did not conceive. The odds of clinical pregnancy were 2.3 and 2.2 times higher with lead follicle sizes of 21.1-22.0 mm and >22.0 mm, respectively, compared with the referent category of 19.1-20.0 mm. Lead follicle size was an independent predictor of CPR, even after accounting for confounders. A lead follicle size of 22.1 mm corresponded to a sensitivity and specificity of 80.1% and 90.4% for clinical pregnancy, respectively, with an area under the ROC curve of 0.89.

CONCLUSION(S)

hCG administration at a lead follicle size of 21.1-22.0 mm is associated with higher odds of clinical pregnancy in patients undergoing their first CC-IUI cycles for ovulatory dysfunction or unexplained infertility.

Endometrial thickness after ovarian stimulation with gonadotropin, clomiphene, or letrozole for unexplained infertility, and association with treatment outcomes

OBJECTIVE

To study the association of endometrial thickness (EMT) with live birth rates (LBR) in ovarian stimulation with intrauterine insemination (OS-IUI) treatments for unexplained infertility.

DESIGN

Prospective cohort analysis of the Reproductive Medicine Network's Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) randomized controlled trial.

SETTING

Multicenter randomized controlled trial.

PATIENTS

A total of 868 couples with unexplained infertility (n=2,459 cycles).

INTERVENTIONS

OS-IUI treatment cycles (n = 2,459) as part of the AMIGOS clinical trial.

MAIN OUTCOME MEASURES

Live birth rates; unadjusted and adjusted risk ratios (RR) for live birth by EMT category, calculated using generalized estimating equations.

RESULTS

The overall mean EMT on day of human chorionic gonadotropin administration in cycles with a live birth was significantly greater than in those without. Compared to the referent EMT group of 9 to 12 mm, the unadjusted RR for live birth for the EMT groups of ≤5 and 6-8 were 0.48 and 0.92, respectively. The test for trend indicated evidence of decreasing LBR with decreasing EMT. After adjustment for ovarian stimulation medication, a linear trend was no longer supported. Stratified analyses revealed no differences in associations by treatment group.

CONCLUSIONS

In OS-IUI for unexplained infertility, higher LBR are observed with increasing EMT; however, EMT is not significantly associated with LBR when adjusted for OS treatment type. Appreciable LBR are seen at all EMT, even those of ≤5 mm, suggesting that OS-IUI cycles should not be canceled for thin endometrium.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01044862.

Comparison of clomiphene and letrozole for superovulation in patients with unexplained infertility undergoing intrauterine insemination: A systematic review and meta-analysis

BACKGROUND

With the medical advancement some studies put forward that letrozole (LE), a specific aromatase inhibitor with the function of reducing oestrogen synthesis, has recently been applied as a potentially better alternative compared with clomiphene citrate (CC), owing to that it has a superior efficacy as compared with CC in patients of unexplained infertility undergoing intrauterine insemination (IUI). However, there is no one study can clear and definite whether LE can replace the CC as first line drug.

OBJECTIVE

Our objective is to compare the LE with CC in the induction of ovulation in patients with unexplained infertility IUI.

METHOD

Searching databases consist of all kinds of searching tools, such as Medline, The Cochrane Library, Embase, PubMed, etc. All the include studies should meet our demand of this meta-analysis: RESULT:: Based on the current meta-analysis, we rigorously consider that LE has a likelihood to improve dominant follicles (MD= -0.56, I= 100%, P= .04; MD= -0.39, I= 73%, P = .0003, respectively) and reduces the miscarriage rate (RR= 0.61, I= 0%, P = .03). There is no significant differences between the 2 groups in The total rate of pregnancy, pregnancy rate per cycle, multiple pregnancy and endometrial thickness. (RR= 1.06, I= 11%, P = .38; RR= 1.09, I= 7%, P = .32; RR= 0.79, I= 0%, P = .46; respectively) CONCLUSION:: Combined with the results of current systematic review and meta-analysis through subgroup analysis and sensitivity analysis, we can be cautious: in general, compared with CC, LE is an effective treatment in the IUI cycle, has a likelihood to improve dominant follicles and reduces the miscarriage rate.

Clomiphene citrate before and after withdrawal bleeding for induction of ovulation in women with polycystic ovary syndrome: Randomized cross-over trial

AIM

To compare the ovarian response to early versus late clomiphene citrate (CC) in women with polycystic ovary syndrome (PCOS).

METHODS

This cross-over randomized controlled clinical trial included 90 infertile amenorrheic women with PCOS. After inducing withdrawal bleeding, patients were randomly divided into two equal groups to receive ovulation induction with CC 100 mg/day for 5 days. Group I started treatment the next day after finishing medroxyprogesterone acetate course for a menstrual cycle, and after a washout period of another menstrual cycle, the treatment was shifted to start on day 2 of withdrawal bleeding. Group II received a reversed protocol: late then early treatment. Women were followed up on transvaginal ultrasonography to monitor follicular growth, endometrial thickness and evidence of ovulation. Human chorionic gonadotropin 10 000 IU was given i.m. to trigger ovulation when at least one mature follicle measured ≥18 mm at day 14.

RESULTS

In all cases, early induction protocol resulted in significantly higher proportion of ovulating patients, thicker endometrium and higher number of follicles 14-17 mm in diameter, ≥ 18 mm in diameter and total number of follicles (P < 0.001 for all comparisons).

CONCLUSION

In women with PCOS, early initiation of CC before withdrawal bleeding or during the last days of the luteal phase can achieve a better ovulatory response.

Comparison of pregnancy rates in PCOS patients undergoing clomiphene citrate and IUI treatment with different leading follicular sizes

PURPOSE

The objective of the study was to compare the pregnancy rates in PCOS patients undergoing clomiphene citrate (CC) and intrauterine insemination (IUI) treatment with different leading follicular sizes.

METHODS

A total of 358 infertile women with PCOS who underwent 563 clomiphene citrate and IUI treatment cycles were included in this prospective study. Treatment cycles were divided into three groups according to leading follicular size on the day of hCG administration: Group I: follicular size 17-18 mm (n = 177), Group II: 19-22 mm (n = 321), and Group III : >22 mm (n = 65). Pregnancy rates were evaluated. Treatment outcomes of the groups were further analyzed related to endometrial thickness measurement on the day of hCG. For this purpose, cycles were placed into three subgroups as follows: endometrial thickness <7, 8-9, and >9 mm.

RESULTS

There was no statistically significant difference in clinical pregnancy rate per cycle between the groups (8.5, 10, and 9.2 % for Group I, II, and III, respectively, p = 0.86). In further analyses related to endometrial thickness, no significant difference was also found in pregnancy rate among the groups.

CONCLUSION

This results suggest that pregnancy rate is not related to leading follicle size on the day of hCG administration in PCOS patients treated with CC and IUI. In addition, pregnancy rate in women with different follicular sizes is not influenced by the endometrial thickness.

The association between follicular size at the time of spontaneous rupture and pregnancy rates in clomiphene citrate treated PCOS patients in coit cycles

OBJECTIVE

To investigate the follicular size at spontaneous rupture on pregnancy rate in patients with polycystic ovary syndrome (PCOS) undergoing clomiphene citrate (CC) ovulation.

DESIGN

Cross-sectional study.

PATIENTS AND METHODS

One hundred and four women with ovulatory cycles after use of CC followed by ultrasound to determine the follicle size at the time of rupture, which was subsequently correlated with the occurrence of pregnancy or not in coit cycles.

RESULTS

In the group of follicular rupture at a mean diameter ≤25 mm (n = 54), pregnancy rate was 35.1% and when follicular rupture occurred at a mean diameter >25 mm (n = 50), it was 34% (p > 0.05). When different diameters at follicular rupture were randomly correlated with the pregnancy rate, there was no significant difference.

CONCLUSION

Our data suggest that the occurrence of pregnancy after ovulation induction with CC in women with PCOS is not associated with follicle size at the time of rupture.

Letrozole stimulation in endometrial preparation for cryopreserved-thawed embryo transfer in women with polycystic ovarian syndrome: a pilot study

OBJECTIVE

To study the efficiency of letrozole, an aromatase inhibitor, in endometrial preparation for cryopreserved-thawed embryo transfer (FET) in women with polycystic ovarian syndrome (PCOS).

DESIGN

Retrospective observational study.

PATIENTS

One hundred and twenty patients with PCOS who met the inclusion criteria for the study.

MEASUREMENTS

We assessed in vitro fertilization outcomes in one hundred and twenty patients with PCOS (148 cycles) who were prepared for and underwent FET between June 2011 and December 2012. Patients were prepared for FET using artificial hormone cycles induced with oestrogen and progesterone supplementation (n = 76), letrozole stimulation (n = 40) or hMG stimulation (n = 32).

RESULTS

There were no differences in demographic characteristics between the groups, except that the letrozole group had a higher incidence of embryo transfer failure in the past. The letrozole stimulation group had a significantly higher maximal endometrial thickness and significantly higher rates of clinical pregnancy per transfer, ongoing pregnancy per transfer and implantation, compared with the artificial and hMG stimulation groups. Differences in these parameters between the artificial and hMG stimulation groups were not significant.

CONCLUSION

Using letrozole stimulation in endometrial preparation for cryopreserved-thawed embryo transfer in patients with PCOS may be associated with better outcomes than using hormonal manipulation or hMG stimulation.

Does optimal follicular size in IUI cycles vary between clomiphene citrate and gonadotrophins treatments?

OBJECTIVE

To evaluate pregnancy-related leading follicles during ovulation induction and superovulation with clomiphene citrate (CC) or gonadotropin.

DESIGN

Retrospective cohort.

PATIENTS

Five hundred and forty-two women who underwent a total of 615 treatment cycles with CC or gonadotropin.

INTERVENTION

We evaluated the effects of CC and gonadotropin on the leading follicles, clinical pregnancy rates and miscarriage rate.

RESULTS

The number of follicles larger than 15 mm in the different protocols was comparable. In those treated with CC, the diameter of the dominant follicles before human chorionic gonadotropins (hCG) trigger in the conception cycles (20.4 ± 1.2 mm) was significantly larger than in the non-conception cycles (18.8 ± 1.9 mm). In women treated with gonadotropin, the diameter of the leading follicle in the conception cycles (18.5 ± 1.7 mm) was comparable to that in the non-conception cycles (18.2 ± 1.7 mm). The pregnancy-related diameter of the leading follicle in CC cycles (20.4 ± 1.2 mm) was significantly larger than that in gonadotropin cycles (18.8 ± 1.9 mm; p = 0.001; 95% CI, -2.2 to -0.9).

CONCLUSION

Pregnancy-related diameter of the leading follicle in CC cycles is significantly larger than that in gonadotropin cycles and the best time for hCG trigger in the CC cycle is when the leading follicle reaches 20 mm.

Use of clomiphene citrate in infertile women: a committee opinion

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

Minimal stimulation or clomiphene citrate as first-line therapy in women with polycystic ovary syndrome: a randomized controlled trial

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.

Laparoscopic ovarian diathermy after clomiphene failure in polycystic ovary syndrome: is it worthwhile? A randomized controlled trial

PURPOSE

Laparoscopic ovarian diathermy (LOD) represents a successful treatment option for women with clomiphene citrate (CC)-resistant polycystic ovary syndrome (PCOS). However, in case of CC failure PCOS, LOD offers several theoretical advantages. This study was conducted to compare the efficacy of LOD versus continuation of CC up to six further cycles in PCOS patients who failed to achieve pregnancy despite the previous successful CC induced ovulation.

METHODS

One hundred and seventy six infertile women with CC failure PCOS were selected in this randomized controlled trial. Patients (n = 87) underwent LOD with 6 months follow-up or received CC (n = 89) up to six cycles. Outcome measures were; clinical pregnancy rate, midcycle endometrial thickness, cycle length, miscarriage and live birth rates.

RESULTS

The clinical pregnancy rate per patient and the cumulative pregnancy rate after six cycles were comparable in both groups (39 vs. 33.7% and 47 vs. 39.2%, respectively). Four twin pregnancies occurred in CC group and none in LOD group and the difference was statistically significant (p < 0.05). No significant difference in midcycle endometrial thickness was observed (8.8 ± 1.2 mm vs. 7.7 ± 1.1 mm). Improvement in cycle length, miscarriage and live birth rates were comparable in both groups. No cases of ovarian hyperstimulation syndrome occurred in either group.

CONCLUSIONS

LOD during the 6 months follow-up period and CC for up to six further cycles are equally effective for achieving pregnancy in CC failure PCOS patients.

Intrauterine insemination versus timed intercourse with clomiphene citrate in polycystic ovary syndrome: a randomized controlled trial

OBJECTIVE

To compare the efficacy of intrauterine insemination vs. timed intercourse with clomiphene citrate as a first-line treatment for anovulatory infertility associated with polycystic ovary syndrome.

DESIGN

A randomized controlled trial following the CONSORT criteria.

SETTING

A university hospital and a private practice setting.

PATIENTS

188 women (525 cycles) with polycystic ovary syndrome.

MAIN OUTCOME MEASURES

Women received three consecutive cycles of ovulation induction with clomiphene citrate and intrauterine insemination (n=93, 259 cycles) or three consecutive cycles of clomiphene citrate with timed intercourse (n=95, 266 cycles).

OUTCOME MEASURES

Clinical pregnancy rate per cycle, number of growing and mature follicles, serum estradiol, endometrial thickness at the hCG day, serum progesterone, ovulation, miscarriage and live birth rates.

RESULTS

There were no differences between the two groups regarding the clinical pregnancy rate per cycle or per woman (8.49 vs. 7.89% and 23.6 vs. 22.1%; p=0.26 and p=0.33, respectively). Two twin pregnancies occurred in each group. Miscarriage and live birth rates were comparable (18.1 vs. 19% and 19.35 vs. 17.89%; p=0.31 and p=0.33, respectively). No ectopic, higher-order pregnancies or cases of ovarian hyperstimulation syndrome occurred. No differences were found regarding the number of follicles, serum progesterone, ovulation rates, estradiol levels or endometrial thickness at the hCG day (7.7±0.4 vs. 7.5±0.6mm; p=0.54).

CONCLUSIONS

Ovulation induction with clomiphene citrate and timed intercourse is as effective as that with intrauterine insemination for achieving pregnancy in polycystic ovary syndrome and could represent the initial treatment option, being less invasive and less expensive than intrauterine insemination.

Combined metformin and clomiphene citrate versus highly purified FSH for ovulation induction in clomiphene-resistant PCOS women: a randomised controlled trial

AIM

To compare the effect of combined metformin-clomiphene citrate (CC) with highly purified urinary FSH (HP-uFSH) for ovulation induction in CC-resistant women with polycystic ovary syndrome (PCOS).

METHODS

One-hundred fifty-three anovulatory women with CC-resistant PCOS were selected in this randomised controlled trial. Patients received combined metformin-CC (n=75, 205 cycles) or HP-uFSH (n=78, 186 cycles) for three cycles. Outcome measures were; Ovulation rate, number of growing and mature follicles, serum E2, serum P, endometrial thickness, pregnancy and miscarriage rates.

RESULTS

The ovulation rate per cycle was significantly higher in the HP-uFSH group (83.8% vs. 62%, p=0.01). The number of follicles ≥ 12 mm ≥ 14 mm and ≥ 18 mm on the hCG day was significantly greater in the HP-uFSH group (p=0.01, p=0.02 and p=0.03, respectively). Pregnancy occurred in 23/205 cycles (11.2%) in combined metformin-CC group and 40/186 cycles (21.5%) in the HP-uFSH group; the difference was statistically significant (p=0.02). Two patients in the HP-uFSH group suffered mild OHSS.

CONCLUSIONS

Combined metformin-CC resulted in modest ovulation and pregnancy rates without side effects. It is logical to offer this first for CC-resistant PCOS women before resorting to more expensive alternatives especially in developing communities where economic aspects of therapy are important.

The association between follicular size on human chorionic gonadotropin day and pregnancy rate in clomiphene citrate treated polycystic ovary syndrome patients

OBJECTIVE

To examine leading follicle size on human chorionic gonadotropin (hCG) day and pregnancy rate in anovulatory polycystic ovary syndrome (PCOS) patients treated with clomiphene citrate (CC).

DESIGN

Retrospective cohort study.

SETTING

Fertility clinics in women's health centers.

PATIENTS

Data on 291 infertile women with PCOS and irregular cycles who underwent 685 CC treatment cycles were used. Only cycles with one or two follicles >14 mm were included. hCG was administered once the leading follicle reached the size of 17-24 mm.

MAIN OUTCOME MEASURE(S)

Pregnancy rates in relation to leading follicle size.

RESULTS

Mono/bi-follicular response was observed in 418 cycles. Pregnancy rates were highest (13.6-18.6%) when hCG was administered in the presence of an 18-22 mm follicle, lowest with 17 mm, 23 mm and 24 mm (8.8%, 8.8% and 5.7%, respectively). No differences were observed in pregnancy rates between mono and bi-follicular cycles.

CONCLUSIONS

In CC treatment, hCG should be administered when follicular size is at the range of 18-22 mm.

Letrozole versus laparoscopic ovarian diathermy for ovulation induction in clomiphene-resistant women with polycystic ovary syndrome: a randomized controlled trial

PURPOSE

To compare the effect of letrozole with laparoscopic ovarian diathermy (LOD) for ovulation induction in clomiphene citrate (CC) resistant women with polycystic ovary syndrome (PCOS).

METHODS

Two hundred and sixty anovulatory women with CC-resistant PCOS were selected in this randomized controlled trial. Group A (n = 128) received 2.5 mg letrozole daily for 5 days for up to six cycles. Group B (n = 132) underwent LOD with 6 months follow-up. Outcome measures were ovulation rate, midcycle endometrial thickness, pregnancy, miscarriage and live birth rates.

RESULTS

Ovulation occurred in 335/512 cycles (65.4%) in letrozole group and 364/525 cycles (69.3%) in LOD group without significant difference between both groups. Resumption of regular menstruation was similar in both treatment groups. A significant increase in midcycle endometrial thickness was observed in letrozole group (8.8 ± 1.1 mm vs. 7.9 ± 1.2 mm) (P < 0.05). Pregnancy rate was similar in both groups (15.6 vs. 17.5%). There were no statistical significant differences as regards miscarriage and live birth rates between both groups. No multiple pregnancy or ovarian hyperstimulation occurred in either group.

CONCLUSION

Letrozole and LOD are equally effective for inducing ovulation and achieving pregnancy in CC-resistant PCOS patients.

Clomiphene citrate or anastrozole for ovulation induction in women with polycystic ovary syndrome? A prospective controlled trial

OBJECTIVE

To compare the effects of anastrozole (1 mg) and clomiphene citrate (CC; 100 mg) used for ovulation induction in women with polycystic ovary syndrome.

DESIGN

Prospective controlled trial.

SETTING

University teaching hospital and private-practice setting.

PATIENT(S)

The study comprised a total of 216 infertile women (469 cycles) with polycystic ovary syndrome.

INTERVENTION(S)

Patients received anastrozole (1 mg/d; 115 patients, 243 cycles) for 5 days, starting on day 3 of menses. A matched historical group of patients with polycystic ovary syndrome who were treated with CC (100 mg/d; 101 patients, 226 cycles) was used as a control group. Timed intercourse was advised 24-36 hours after hCG injection.

MAIN OUTCOME MEASURE(S)

Number of follicles, serum E(2), serum P, endometrial thickness, and pregnancy and miscarriage rates.

RESULT(S)

The mean age, parity, and duration of infertility in both groups were similar, but statistically significantly more polycystic ovaries were found in the anastrozole group (odds ratio = 2.44; 95% confidence interval = 1.19-5.02). The total numbers of follicles were significantly higher in the CC group (3.8 +/- 0.6 vs. 3.4 +/- 0.5). Endometrial thickness at the time of hCG administration was significantly greater in the anastrozole group (10.1 +/- 0.22 mm vs. 8.2 +/- 0.69 mm). The duration of stimulation was similar in the two groups. Ovulation occurred in 165 (67.9%) of 243 cycles in the anastrozole group and in 150 (68.6%) of 226 cycles in the CC group without significant difference. Serum P was significantly higher in the CC group (7.1 +/- 1.11 vs. 8.1 +/- 0.88 ng/mL). The pregnancy and miscarriage rates were similar in the two groups.

CONCLUSION(S)

Anastrozole was associated with significantly fewer mature and growing follicles, thicker endometrium, and slightly higher pregnancy rate. Anastrozole may be helpful in situations in which multiple pregnancy is not desirable or the risk of ovarian hyperstimulation syndrome is high.

RETRACTED: Clomiphene citrate or letrozole for ovulation induction in women with polycystic ovarian syndrome: a prospective randomized trial

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the ASRM Publications Committee Several reports of randomized clinical trials were recently the subject of an investigation conducted by the publications committee of the ASRM. The committee reviewed concerns related to the validity of data reported in those reports. The committee noted significant duplication of data reported in this manuscript with data reported in another journal (PMID 17364286; https://doi.org/10.1080/00016340601090337) and another publication in Fertility and Sterility (PMID: 18692823; https://doi.org/10.1016/j.fertnstert.2008.06.013) pertaining to different study groups that could not be explained. As we cannot vouch for the validity of the data, we have issued a retraction of this paper.

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.

A randomized comparison of ovulation induction and hormone profile between the aromatase inhibitor anastrozole and clomiphene citrate in women with infertility

BACKGROUND

IN the present study we evaluated and compared the effects of ovulation and hormonal dynamics induced by anastrozole and clomiphene citrate in women with infertility.

MATERIALS AND METHODS

Thirty-three infertile patients, aged 25-41 years, were enrolled. Patients received either anastrozole 1 mg daily (AI group) or clomiphene citrate 100 mg daily (CC group) from cycle day 3 to day 7. Number of mature follicles (> or =18 mm), endometrial thickness, pregnancy rate and serial hormone profiles (follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E(2)), testosterone and progesterone) were measured on cycle day 3, day 8, day 10, the day of intrauterine insemination (IUI), day 7 after IUI and day 14 after IUI.

RESULTS

Baseline parameters were similar in the two groups, including age, body mass index, infertility duration and day-3 serum hormones except FSH. The mean FSH value on day 3 was significantly different (4.3 mIU/ml in the AI group vs. 6.3 mIU/ml in the CC group; p < 0.05). The women receiving anastrozole had fewer ovulatory follicles (1.2 in the AI group vs. 1.8 in the CC group; p < 0.05) and a thicker endometrium (10.6 mm in the AI group vs. 7.8 mm in the CC group; p < 0.05). The levels of progesterone and testosterone were similar during ovulation stimulation cycles in both groups. On the other hand, the AI group had a significantly higher LH level but a significantly lower E(2) level in the stimulation cycle.

CONCLUSION

Anastrozole has a high pregnancy rate, although it induces fewer ovulatory follicles compared with clomiphene citrate. The two drugs gave different responses of FSH, LH and E2 during stimulation cycles.

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.

Effects of exercise and nutritional counseling in women with polycystic ovary syndrome

This pilot study assessed the effects of exercise and nutritional counseling on hormonal, menstrual, and reproductive function in women with polycystic ovary syndrome (PCOS). Twelve females with a clinical, biochemical, and ultrasonographic diagnosis of PCOS were randomly assigned to endurance and resistance exercise plus nutritional counseling (EN) or nutritional counseling only (N) for a period of 12 weeks. Anthropometry, resting metabolic rate (RMR), selected hormones, and ovarian follicle population were measured pre and post-intervention. Following the 12 week intervention, greater decreases in sum of 2 skinfolds (p = 0.002) and a greater increase in estimated VO2 max (p = 0.017) occurred in the exercise group. Significant decreases in waist girth (p = 0.001) and insulin levels (p = 0.03) occurred in both groups. Hormonal changes were not statistically significant; however, a trend towards an improved hormonal profile, specifically sex-hormone binding globulin (EN, 39% increase; N, 8% increase) and lutenizing hormone : follicle-stimulating hormone (LH:FSH) (EN, 9% decrease; N, 27% decrease) occurred in the absence of weight loss. These findings suggest exercise and nutritional counseling may benefit the metabolic and reproductive abnormalities associated with PCOS.

Basal ovarian cysts and clomiphene citrate ovulation induction cycles

OBJECTIVE

To evaluate the effect of simple basal ovarian cysts in patients undergoing infertility treatment with clomiphene citrate. To evaluate the effect of clomiphene citrate on pretreatment simple ovarian cysts.

METHODS

Prospective cohort trial of 84 infertility patients undergoing ovulation induction with clomiphene citrate. Patients with basal ovarian cysts of 10 mm or greater (n = 42) were compared with patients without ovarian cysts (n = 42). The main outcome measure was ovulation determined by menstrual cycle day 21 progesterone level. Each patients with an ovarian cyst was also evaluated for persistence or resolution of the cyst in association with ovulation and cyst size. Pretreatment and posttreatment transvaginal ultrasound examinations were performed on all patients.

RESULTS

Demographic data were similar among the groups. The mean ovarian cyst size was 17.4 +/- 5.8 mm. Patients in the ovarian cyst group were significantly less likely to ovulate (80.9% versus 97.6%, P < .05), but did not differ in pregnancy rate compared with patients without baseline ovarian cysts (4.8% versus 11.9%, P = .43). Persistent ovarian cysts occurred in 36.7% of the patients. The initial size of the cyst did not predict cyst persistence.

CONCLUSION

According to these data, basal ovarian cysts significantly reduce ovulatory events in patients treated with clomiphene citrate.

LEVEL OF EVIDENCE

II-2.

Addition of human chorionic gonadotropin to clomiphene citrate ovulation induction therapy does not improve pregnancy outcomes and luteal function

In a randomized prospective study, 125 women with World Health Organization class II anovulation received 50 mg of clomiphene citrate alone (group A, n = 65) or 50 mg of clomiphene citrate plus hCG (group B, n = 60) in a total of 125 cycles during natural intercourse-advised cycles. There were no statistically significant differences between groups regarding pregnancy outcomes and midluteal P levels, but luteal phase length was longer in group A.

A randomized trial of letrozole versus clomiphene citrate in women undergoing superovulation

OBJECTIVE

To compare the effects of the aromatase inhibitor letrozole (7.5 mg) and clomiphene citrate (CC; 100 mg) in women undergoing superovulation and IUI.

DESIGN

Prospective randomized trial.

SETTING

University teaching hospital.

PATIENT(S)

We studied a total of 238 cycles of superovulation and IUI in women with idiopathic infertility.

INTERVENTIONS

Patients were randomized into treatment with 7.5 mg of letrozole daily (74 patients, 115 cycles) or 100 mg of CC daily (80 patients, 123 cycles).

MAIN OUTCOME MEASURE(S)

Number of follicles, endometrial thickness, pregnancy rate, and miscarriage rate.

RESULT(S)

The mean age, parity, and duration of infertility in both groups of patients were similar. There was no significant difference between the total number of developing follicles in the letrozole (5.7 +/- 3.7) and in the CC groups (4.8 +/- 2.5). The number of follicles of > or =14 mm and of >18 mm were 2.1 +/- 1.2 and 1.4 +/- 0.7 in the letrozole group, and 1.7 +/- 0.9 and 1.1 +/- 0.5 in the CC group, respectively. No difference was found in the endometrial thickness between the two groups (7.1 +/- 0.2 mm in the letrozole group, 8.2 +/- 5.9 mm in the CC group). The pregnancy rate per cycle was 11.5% in the letrozole group and 8.9% in the CC group. Four of the 11 pregnancies in the CC group resulted in a miscarriage (36.6%).

CONCLUSION(S)

Superovulation and IUI with letrozole and CC are associated with similar pregnancy rates, but the miscarriage rate is higher with CC. The ideal dose of letrozole remains unknown and further study is needed.

Characteristics of baseline ovarian cysts in clomiphene citrate ovulation cycles

To evaluate the incidence and factors associated with ovarian cysts in infertile patients receiving clomiphene citrate (CC), we performed a retrospective cohort study involving 466 CC treatment cycles. Ovarian cysts are a common finding in patients presenting for CC, with approximately one in five patients having a baseline ovarian cyst >10 mm.

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.

A nomogram to predict the probability of live birth after clomiphene citrate induction of ovulation in normogonadotropic oligoamenorrheic infertility

OBJECTIVE

To establish whether initial screening characteristics of normogonadotropic anovulatory infertile women can aid in predicting live birth after induction of ovulation with clomiphene citrate (CC).

DESIGN

Prospective longitudinal single-center study.

SETTING

Specialist academic fertility unit.

PATIENT(S)

Two hundred fifty-nine couples with a history of infertility, oligoamenorrhea, and normal follicle-stimulating hormone (FSH) concentrations who have not been previously treated with any ovulation-induction medication.

INTERVENTION(S)

50, 100, or 150 mg of oral CC per day, for 5 subsequent days per cycle.

MAIN OUTCOME MEASURE(S)

Conception leading to live birth after CC administration.

RESULT(S)

After receiving CC, 98 (38%) women conceived, leading to live birth. The cumulative live birth rate within 12 months was 42% for the total study population and 56% for the ovulatory women who had received CC. Factors predicting the chances for live birth included free androgen index (testosterone/sex hormone-binding globulin ratio), body mass index, cycle history (oligomenorrhea versus amenorrhea), and the woman's age.

CONCLUSION(S)

It is possible to predict the individual chances of live birth after CC administration using two distinct prediction models combined in a nomogram. Applying this nomogram in the clinic may be a step forward in optimizing the decision-making process in the treatment of normogonadotropic anovulatory infertility. Alternative first line of treatment options could be considered for some women who have limited chances for success.

Ovulation induction

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

Predictors of chances to conceive in ovulatory patients during clomiphene citrate induction of ovulation in normogonadotropic oligoamenorrheic infertility

The present prospective follow-up study was designed to identify whether clinical, endocrine, or ultrasound characteristics assessed by standardized initial screening of normogonadotropic oligo/amenorrheic infertile patients could predict conception in 160 women who reached ovulation after clomiphene citrate (CC) medication. Additional inclusion criteria were total motile sperm count of the partner above 1 million and a negative history for any tubal disease. Daily CC doses of 50 mg (increasing up to 150 mg in case of absent ovarian response) from cycle days 3-7 were used. First conception (defined as a positive urinary pregnancy test) was the end point for this study. A cumulative conception rate of 73% was reached within 9 CC-induced ovulatory cycles. Patients who did conceive presented more frequently with lower age (P < 0.0001) and amenorrhea (P < 0.05) upon initial screening. In a univariate analysis, patients with elevated initial serum LH concentrations (>7.0 IU/L) had a higher probability of conceiving (P < 0.01). In a multivariate analysis, age and cycle history (oligomenorrhea vs. amenorrhea) were identified as the only significant parameters for prediction of conception. These observations suggest that there is more to be gained from CC ovulation induction in younger women presenting with profound oligomenorrhea or amenorrhea. Screening characteristics involved in the prediction of ovulation after CC medication in normogonadotropic oligo/amenorrheic patients (body weight and hyperandrogenemia, as shown previously) are distinctly different from predictors of conception in ovulatory CC patients (age and the severity of cycle abnormality). This disparity suggests that the FSH threshold (magnitude of FSH required for stimulation of ongoing follicle growth and ovulation) and oocyte quality (chances for conception in ovulatory cycles) may be differentially regulated.

Serum concentrations of enclomiphene and zuclomiphene across consecutive cycles of clomiphene citrate therapy in anovulatory infertile women

OBJECTIVE

To determine the serum concentrations of enclomiphene and zuclomiphene across consecutive cycles of clomiphene citrate treatment in anovulatory infertile women.

DESIGN

Prospective cohort.

SETTING

Tertiary institutional infertility clinic.

PATIENT(S)

Fourteen consenting anovulatory infertile women receiving standardized, cyclic, incremental treatment with clomiphene citrate for ovulation induction.

INTERVENTION(S)

Clomiphene citrate treatment (50-150 mg/d, cycle days 5-9), titrated to the minimum effective ovulation-inducing dose, was administered for three to six total cycles. Blood samples were obtained on cycle days 3 and 10 in each treatment cycle.

MAIN OUTCOME MEASURE(S)

Serum concentrations of enclomiphene and zuclomiphene.

RESULT(S)

Cycle day 3 zuclomiphene levels were below assay limits in all initial cycles, increased progressively across three consecutive cycles, and thereafter plateaued. Cycle day 3 enclomiphene concentrations were uniformly undetectable. Cycle day 10 enclomiphene levels increased with dose administered, but these observations were not statistically significant.

CONCLUSION(S)

Clomiphene citrate induction of ovulation results in an isomer-specific systemic accumulation of zuclomiphene across consecutive cycles of treatment. The combined maximum concentration of enclomiphene and zuclomiphene attained in practice approximates 100 nmol/L and is generally well below levels previously demonstrated to have adverse effects in vitro.

Crossover or parallel design in infertility trials? The discussion continues

OBJECTIVE

To determine whether a crossover design results in a different estimate of treatment effect compared with a parallel design.

DESIGN

With the aid of a computer program, data sets of subfertile patients were simulated under different assumptions. These patients were subjected to 2 treatments that were compared in either a parallel-design or a crossover-design trial. Results were analyzed using logistic regression.

SETTING

University hospital.

PATIENT(S)

Simulated patients of a heterogeneous subfertile population.

INTERVENTION(S)

Two treatment modalities with a pregnancy rate of 10% and of 20% in the first cycle were offered for 6 cycles to simulated heterogeneous populations.

MAIN OUTCOME MEASURE(S)

After 1,000 simulations for each assumption, median pregnancy rates and odds ratios were compared between the crossover- and parallel-design trials.

RESULT(S)

No relevant difference in estimated treatment effect was found between the designs. The crossover design resulted in more pregnancies overall than the parallel design.

CONCLUSION(S)

In infertility research, parallel and crossover designs will lead to about the same results. Although the crossover design showed a slight tendency to overestimate the treatment effect of the most effective treatment, this overestimation is clinically not relevant and is small in relation to the random error. Because of its practical advantages and because more pregnancies are achieved, a crossover design should be the first choice in infertility research.