Extended clomiphene citrate (CC) and prednisone for the treatment of chronic anovulation resistant to CC alone

Ovulation induction with letrozole and dexamethasone in infertile patients with letrozole-resistant polycystic ovary syndrome

PURPOSE

To assess efficacy of adjuvant dexamethasone during letrozole cycles for ovulation induction (OI) in women with letrozole-resistant polycystic ovary syndrome (PCOS).

METHODS

We retrospectively evaluated 42 cycles of OI from 28 infertile women with letrozole-resistant PCOS between September 2019 and November 2022. Letrozole was initiated on cycle day 3 for 5 days and increased via a stair-step approach to 7.5 mg as indicated. Patients were deemed letrozole-resistant if no dominant follicle was identified on transvaginal ultrasound following this dose. Resistant patients then received 5 additional days of letrozole 7.5 mg with low-dose dexamethasone 0.5 mg for 7 days and had a repeat ultrasound. The primary outcome was ovulation rate determined by the presence of a dominant follicle on ultrasound. Secondary outcomes included endometrial thickness, number of measurable follicles, and pregnancy outcomes among responders.

RESULTS

Twenty-two of 28 (79%) letrozole-resistant PCOS patients had evidence of ovulation after the addition of dexamethasone in 35 out of 42 (83%) cycles. Clinical pregnancy occurred in 20% of ovulatory cycles with a cumulative rate of 32%. All clinical pregnancies resulted in a live birth. Patients who responded to adjuvant dexamethasone were more likely to have a shorter duration of infertility; however, there were no differences in other demographics, serum androgens including DHEA-S, or pretreatment glycemic status.

CONCLUSION

Adding dexamethasone to letrozole increased ovulation rates in letrozole-resistant PCOS patients undergoing OI with similar pregnancy outcomes to prior studies. The addition of dexamethasone is an effective, inexpensive, and safe option for PCOS patients otherwise at risk for cycle cancelation.

Ovulation induction techniques in women with polycystic ovary syndrome

Anovulation is very common and has several different clinical manifestations, including amenorrhea, oligomenorrhea and abnormal uterine bleeding. Various mechanisms can cause anovulation. The clinical consequences and commonest chronic anovulatory disorder, polycystic ovary syndrome (PCOS), has a prevalence that ranges between 6 to 10% of the global population. While multiple causes can eventually result in PCOS, various methods have been described in the literature for its management, often without ascertaining the underlying cause. Ovulation Induction (OI) is a group of techniques that is used in women with PCOS who are looking to conceive and are unbale to do so with natural means. This narrative review presents a summary of the current evidence and available techniques for OI in women with PCOS, highlighting their performance and applicability.

Successful pregnancy with restorative reproductive medicine after 16 years of infertility, three recurrent miscarriages, and eight unsuccessful embryo transfers with in vitro fertilization/intracytoplasmic sperm injection: a case report

BACKGROUND

Restorative reproductive medicine represents a comprehensive approach to subfertility (infertility and miscarriage) with investigations, diagnoses, and treatments combined with fertility charting to restore optimal reproductive function. Restorative reproductive medicine assumes that multiple factors need to be identified and treated (cycle optimization) for up to 12 cycles to achieve a successful pregnancy. Conception can occur during normal intercourse without intrauterine insemination or in vitro fertilization.

CASE PRESENTATION

A 35-year-old Croatian female presented for fertility treatment in May 2019 with a previous diagnosis of polycystic ovaries, infertility of 16 years duration, and 8 unsuccessful embryo transfers with in vitro fertilization and intracytoplasmic sperm injection. She was gravida 3 para 0, with 2 miscarriages after spontaneous conception at 5-6 weeks gestation in 2002 and 2004, followed by a miscarriage after in vitro fertilization at 12 weeks gestation in 2011. We initially found poor follicle function and suboptimal progesterone levels. Restorative reproductive medicine treatment resulted in conception after two cycles of treatment. This pregnancy ended in miscarriage at 7 weeks 4 days. Additional investigations found a balanced Robertsonian translocation (13, 14) and a uterine septum. We achieved repeat fertilization with restorative reproductive medicine after three cycles of treatment following resection of the uterine septum and ovulation induction with letrozole and human chorionic gonadotrophin. She had a full-term healthy pregnancy and live birth in 2021.

CONCLUSION

We propose that a full evaluation of underlying factors, and up to 12 cycles of cycle optimization, should be offered to subfertile patients before considering in vitro fertilization treatment.

Long-term use of clomiphene citrate in induction of ovulation in PCO patients with clomiphene citrate resistance

OBJECTIVE

The aim of our study to evaluate the effect of extended clomiphene citrate treatment on the ovulation rate, pregnancy rate, and hormonal profile of clomiphene resistant PCOS.

METHODOLOGY

This a prospective study conducted in Maternity Hospital Minia University, 200 patients with PCOS recruited in the study during the period from September 2015 till February 2016 (6 months was duration of the study), they were diagnosed as PCO with clomiphene resistance before being recruited in the study. They received 150mg clomiphene citrate for 10 days start in 2nd day of cycle for three consecutive cycles, and followed up for another three months without treatment, last follow-up cycle was on February. We studied the effect of extended treatment with CC in ovulation rate, pregnancy rate and hormonal profile in patients before and after treatment.

RESULTS

There was significant improvement in ovulation rate in the patients after extended CC treatment for 3 months and 3 months follow-up (as 12 cases in the first cycle and 32 cases in the second cycle and increased to 76 cases in the third cycle) while no ovulation documented before treatment pregnancy rate was 17% itis generally low but it highly significant when compared with was zero preceding treatment.

CONCLUSION

Extended CC treatment is good method to improve ovulation and pregnancy rate in CC resistant PCOS but further multi-center studies are needed to provide more powerful evidence.

Evaluation and treatment of anovulatory and unexplained infertility

Anovulatory disorders are a primary cause of female infertility. Polycystic ovarian syndrome is the major cause of anovulation and is generally associated with obesity. Lifestyle changes to encourage weight loss are the initial therapy for overweight and obese patients, followed by clomiphene citrate for ovulation induction. For those patients who fail to ovulate on clomiphene citrate, alternatives, such as letrozole; gonadotropins; and complimentary agents to enhance clomiphene citrate, such as metformin and glucocorticoids, are reviewed. Women with unexplained infertility (no identifiable cause of infertility on a routine evaluation) may benefit from ovulation induction with clomiphene citrate, letrozole, or gonadotropins.

Novel clomiphene "stair-step" protocol reduces time to ovulation in women with polycystic ovarian syndrome

OBJECTIVE

The objective of the study was to determine the efficacy of a novel "stair-step" clomiphene protocol in women with polycystic ovarian syndrome (PCOS) who do not respond to 50 mg clomiphene.

STUDY DESIGN

This was a retrospective analysis at an academic fertility center. The stair-step protocol is performed as follows: 50 mg clomiphene for 5 days, ultrasonography on days 11-14. If unresponsive, immediately begin 100 mg clomiphene for 5 days and repeat ultrasound in 1 week. If still unresponsive, begin 150 mg clomiphene for 5 days and repeat the ultrasound in 1 week. Stair-step cycles were compared with published historical clomiphene outcomes for women who were nonresponsive.

RESULTS

The time to ovulation was 32-53 days less with the stair-step protocol compared with a traditional regimen. The dose-dependent ovulation rate was 64% at 100 mg with the stair-step protocol compared with 22% with a traditional regimen.

CONCLUSION

It is not necessary to induce menses before increasing clomiphene doses in nonresponsive PCOS patients.

Clomiphene citrate and dexamethazone in treatment of clomiphene citrate-resistant polycystic ovary syndrome: a prospective placebo-controlled study

BACKGROUND

The aim of this work was to evaluate the efficacy of adding dexamethazone (DEX) (high dose, short course) to clomiphene citrate (CC) in CC-resistant polycystic ovary syndrome (PCOS) with normal dehydroepiandrosterone sulphate (DHEAS) in induction of ovulation.

METHODS

Eighty infertile women with CC-resistant PCOS were randomly assigned into two groups. Group I: Clomiphene citrate 100 mg/day was given from day 3 to day 7 of the cycle and DEX 2 mg/day from day 3 to day 12 of the cycle. Group II: Same protocol of CC combined with placebo (folic acid tablets) was given from day 3 to day 12 of the cycle. The main outcome was ovulation. Secondary measures included number of follicles >18 mm endometrial thickness and pregnancy rate. Ovarian follicular response was monitored by transvaginal ultrasound. HCG 10,000 U was given when at least one follicle measured 18 mm, and timed intercourse was advised.

RESULTS

There were no statistically significant differences between groups as regards age, duration of infertility, BMI, waist-hip ratio (WHR), menstrual pattern, hirsutism, serum DHEAS or day of HCG administration. The mean number of follicles>18 mm at the time of HCG administration and the mean endometrial thickness were significantly higher in the DEX group than in the placebo group (P<0.05). Similarly, there were significantly higher rates of ovulation (75 versus 15%) (P<0.001) and pregnancy (40 versus 5%) (P<0.05) in the DEX group. Dexamethazone was very well tolerated as no patients complained of any side effect. There was a significant difference between the responders and non-responders in the presence of oligomenorrhea, amenorrhea or hirsutism.

CONCLUSION

Induction of ovulation by adding DEX (high dose, short course) to CC in CC-resistant PCOS with normal DHEAS is associated with no adverse anti-estrogenic effect on the endometrium and higher ovulation and pregnancy rates in a significant number of patients. Induction with DEX appears to be independent on age, period of infertility, BMI or WHR.

Clomiphene citrate in the twenty-first century

Clomiphene citrate is the drug most commonly prescribed for ovulation induction. It is the first choice medication in normogonadotrophic oligo/amenorrhoeic infertility (WHO group 2), essentially associated with polycystic ovaries. Anovulatory women who are responsive to clomiphene citrate should be treated for at least six cycles and the treatment should probably be limited to a maximum of 12 cycles. It is necessary to monitor at least the first cycle with ultrasonography because of the risk of multiple pregnancy and the variable response of patients to different doses of clomiphene. In addition, the risk of ovarian hyperstimulation syndrome should not be underestimated. More triplets and higher order pregnancies result from ovulation induction than from in vitro fertilization, and multiple pregnancy has many risks for both mother and babies. The role of empirical clomiphene in the treatment of unexplained infertility is debatable and the present data are inconclusive. Obesity, hyperandrogenaemia and insulin resistance are important factors in clomiphene-resistant patients. Failure to ovulate in response to clomiphene has been approached by either medical or surgical treatment. An effective alternative medical treatment is gonadotrophin injections. Treatment with metformin and the new generation of insulin-sensitizing drugs is under evaluation. The most widely used surgical treatment today is laparoscopic ovarian drilling, which appears to be as effective as gonadotrophin therapy.

Polycystic ovary syndrome and ovulation induction

Before initiating treatment to induce ovulation in cases of PCOS, an appropriate evaluation of the patient and her partner, based on individual considerations, is important to optimize outcome. For obese patients with PCOS, weight-loss measures should be pursued before pharmacologic treatment is initiated. For most patients, the pharmacologic agent of choice to induce ovulation is clomiphene citrate, alone or in combination with a glucocorticoid. Treatment with metformin, alone or in combination with clomiphene citrate, may also be beneficial. For patients not responsive to clomiphene citrate, injectable gonadotropin treatment is usually warranted, although, depending on individual circumstances, laparoscopic ovarian drilling may be appropriate.

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.

Effect of prednisolone on serum and follicular fluid androgen concentrations in women with polycystic ovary syndrome undergoing in-vitro fertilization

Increased androgen concentrations are thought to be detrimental to oocyte quality and reproductive potential. Adjuvant treatment with glucocorticoids has been tried to suppress androgens in women undergoing infertility treatment. In the present study 20 infertile women with polycystic ovary syndrome were prospectively randomized in a placebo-controlled study to receive either placebo or prednisolone 10 mg at night, during standard in-vitro fertilization (IVF) treatment. Serum samples for assays of gonadotrophins, steroids and sex hormone-binding globulin (SHBG) were collected before treatment, at down-regulation, and at oocyte retrieval. Up to five follicles in each ovary were analysed separately regarding follicular fluid and oocytes, the rest according to the clinic's routines. In the placebo group, serum dehydroepiandrosterone (DHEA) and dehydroepiandrosterone-sulphate (DHEA-S) did not change between down-regulation and oocyte retrieval, whereas adjuvant prednisolone resulted in a significant decrease. In follicular fluid, adjuvant prednisolone resulted in significantly lower concentrations of DHEA-S as compared to placebo, no other significant differences were found. No significant differences were found in embryo characteristics or pregnancy rates between the groups.

Infertility in women: an update

OBJECTIVE

To review pharmacologic therapy of infertility disorders in women.

DATA SOURCES

Current clinical literature.

STUDY SELECTION

Not applicable.

DATA EXTRACTION

Not applicable.

DATA SYNTHESIS

The complex interplay of hormones and cells is the focus of most pharmacotherapeutic interventions in women with infertility problems. Treatment remains more of an art than a science at this time. Since the cause of infertility cannot be identified in many cases, practitioners use medications to overcome potential problems with anovulation, secondary ovarian failures, hypothalamic-pituitary dysfunction, and hyperprolactinemia. This article reviews the use of clomiphene, human chorionic gonadotropin, menotropins such as human menopausal gonadotropin and urofollitropin, gonadotropin-releasing hormone, and dopamine agonists.

CONCLUSION

Although few pharmacists are closely involved in the treatment of women with infertility, they can be sources of information, monitor families for signs and symptoms of psychologic stress associated with treatments, and help patients with practical instructions.