Efficacy of human menopausal gonadotropins as therapy for abnormal cervical mucus

The role of superovulation with menotropins in ovulatory infertility: a review

The risks of menotropin therapy (ovarian hyperstimulation syndrome, multiple gestation, adnexal torsion) are well known and have been previously described. Superovulation should not be considered for the indications described herein until more traditional therapies for infertility have been tried and found unsuccessful and sufficient time has elapsed for conception to occur. The cost of superovulation is high: the medications are expensive, frequent E2 monitoring and US studies are costly, and pregnancy complications relating to the higher rate of pregnancy loss and multiple gestation may add substantially to the overall cost. Yet, compared with IVF and GIFT, superovulation cycles combined with IUI cost between one third to one sixth that of an IVF cycle. Protocols involving combined CC/hMG/hCG, which reduce the total number of ampules of Pergonal needed per cycle and still provide multiple follicular development, may further reduce costs. There is a growing consensus that superovulation-IUI protocols should be attempted before GIFT and IVF in couples with normal pelvic viscera. There is little doubt that IVF and GIFT cycles are more costly, stressful, and complex. No comparative data have clearly shown IVF and GIFT to be superior to superovulation protocols in ovulatory women with normal pelvic anatomy. In the only study examining this issue published to date, Kaplan et al. retrospectively analyzed all GIFT and superovulation/IUI cycles at a single university center and found GIFT to be three times more efficient. However, the inherent limitations of a nonrandomized, nonprospective study of this kind are obvious as these authors have suggested. Therefore, it may be wise to consider the use of superovulation before assisted reproductive technologies until this issue is settled. It would be interesting to determine if the high PRs reported for couples with unexplained infertility or mild endometriosis in IVF and GIFT cycles in some centers not incorporating superovulation/IUI protocols would hold up if such an approach was routinely followed. Despite the increasing acceptance of superovulation protocols, we must be aware that many of the studies suggesting a role of hMG in treating ovulatory infertile women with normal pelvic anatomy suffer from deficiencies in experimental design. In a payor-driven system, such as in the United States, the difficulties in designing and carrying out scientifically sound clinical studies examining infertility therapies are obvious. The lack of federal or outside funding for the study of infertility issues contributes to the problem. It is our hope that better designed studies examining the role of superovulation in the treatment of ovulatory infertile women with normal pelvic anatomy will be forthcoming.

Follicle size by ultrasound versus cervical mucus quality: normal and abnormal patterns in spontaneous cycles

Ultrasound (US) has been demonstrated to be the method of choice for diagnosing luteinized unruptured follicle syndrome and to be a valuable adjuvant in the assessment of luteal phase defect. In this prospective study, the use of US with postcoital testing (PCT) is evaluated. Fifty control infertility patients were examined with serial US for follicle dynamics in conjunction with PCT. Standard curves for follicle dynamics versus cervical mucus quality (Insler score) were calculated. Eighteen patients referred for abnormal mucus underwent similar evaluation. Their follicle dynamics versus mucus quality were compared with those of the controls. The findings were: (1) there is a predictable relationship between follicle size and mucus quality, (2) the majority of patients with abnormal mucus have normal follicular dynamics, and (3) a minority of patients with abnormal mucus have either a narrow mucus window or abnormal follicular dynamics. In addition, US was found to be cost-effective in the overall fertility evaluation.

Treatment validation of ultrasound-defined abnormal follicular dynamics as a cause of infertility

From March 1984 to February 1987, 109 patients with otherwise normal infertility evaluations (semen analysis, postcoital test, endometrial biopsy, hysterosalpingogram and/or hysteroscopy, and laparoscopy) underwent serial ultrasound (US) for follicular dynamics. Twenty-five patients were found to have repetitive abnormal follicular growth and/or rupture patterns. These patients were treated by ovulation induction protocols from clomiphene citrate (CC) to human menopausal gonadotropin (hMG). Of the 84 normal US patients, 47 elected no interventional therapy (control A). Twenty elected empiric treatment with hMG/hMG-intrauterine insemination (IUI) (control B). Seventeen were lost to follow-up or elected in vitro procedures within 1 year of diagnosis. Viable fecundibility (fv) was calculated for each group. Long-term viable conception was compared between groups by chi-square-Yates coefficient. Nineteen of 25 patients treated for abnormal US conceived on treatment (fv = 0.25) (chi-square to control A P less than 0.005, chi-square to control B P less than 0.05). Six of 20 control B patients conceived during treatment (fv = 0.11). Two control B patients conceived in nontreatment cycles (fv = 0.016). When nontreated and treated cycles are considered, the fv = 0.042, not significantly different from control A (fv = 0.035). There was no increase in control B pregnancies over the course of the study compared with control A (chi-square = 0). The authors concluded: (1) Abnormal follicular dynamics on US is a correctable cause of infertility. (2) Empiric treatment of unexplained infertility patients with hMG/hMG-IUI does not appear to improve long-term conception rates; rather, it tends to advance pregnancies into the treatment cycles.(ABSTRACT TRUNCATED AT 250 WORDS)