The investigation of ovarian function by measurement of urinary oestrogen and pregnanediol excretion

Towards the Clinical Evaluation of the Luteal Phase in Fertile Women: A Preliminary Study of Normative Urinary Hormone Profiles

Objective: To describe and evaluate urinary hormone profiles in the luteal phase.

Setting and Patients: Twenty-five healthy fertile women, with regular ovulatory pattern cycles as assessed by temperature and cervical mucus, at a university based center.

Methods: Daily urinary hormonal assessment of luteinizing hormone, estrone glucuronide, and pregnanediol glucuronide. This was done during 3 or more cycles, with 78 completed cycles. Samples were analyzed by both crude levels and levels adjusted for the hormone excretion rate. Correlation between measured parameters (LH surge, vulvar mucus) was assessed with regard to their ability to detect presumed ovulation.

Results: An upper, middle, and lower tercile range for the main urinary reproductive hormones was determined and a classification system of zones proposed, considering profiles over or under the 10th percentile. Adjustment for the urine excretion rate proved useful for interpreting individual samples; this was less necessary with multiple samples over time where trends could be determined. This serial evaluation, in at least two cycles, lowered the possibility of finding an isolated luteal phase defect and helped identify the recurrence of such. Vulvar mucus findings performed well in determining the timing of ovulation. Despite the proven fertility of the study population, lower luteal phase hormones were detected in both an isolated and, in some situations, recurrent manner.

Conclusion: A feasible method is proposed to accurately, thoroughly and reproducibly study the luteal phase in order to evaluate and treat identified abnormalities in a properly timed, restorative manner. This preliminary study provides the basis for future research, correlating urinary hormones with clinical findings, particularly those of luteal phase defects.

The Use of Estrone-3-Glucuronide and Pregnanediol-3-Glucuronide Excretion Rates to Navigate the Continuum of Ovarian Activity

The patterns of a woman's normal ovarian activity can take many forms from childhood to menopause. These patterns lie on a continuum ranging from no ovarian activity to a fully fertile ovulatory cycle, but among the other defined patterns are cycles with anovulatory ovarian activity, including luteinized unruptured follicles (LUFs), and ovulatory cycles with deficient or short luteal phases. For any woman, these patterns can occur in any order, and one can merge into the next, without an intervening bleed, or be missed entirely. Consequently, it is not yet possible to predict the pattern of a future cycle, but it is possible to use our knowledge of the continuum to interpret the current cycle, which has clear implications for the management of personal fertility. An individual's position in the continuum can be monitored directly in real time by daily monitoring of ovarian hormone excretion rates, without either calendar-type calculations or reference to population means and standard deviations. The excretion of urinary estrone glucuronide (E1G) gives a direct measure of follicular growth, and the post-ovulatory rise in urinary pregnanediol glucuronide (PdG) following an E1G peak provides good evidence of ovulation. Specific values of the PdG excretion rate can be used to determine whether a cycle is anovulatory with or without a LUF, or is ovulatory and infertile or ovulatory and fertile. These specific values are important signposts for navigating the continuum. For a woman to take advantage of the knowledge of the continuum, the data must be reliable, and their interpretation has to be based on the underlying science and provided in an appropriate form. We discuss the various factors involved in acquiring and providing such information to enable each woman to navigate her own reproductive life.

Monitoring of ovarian activity by daily measurement of urinary excretion rates of oestrone glucuronide and pregnanediol glucuronide using the Ovarian Monitor, Part III: variability of normal menstrual cycle profiles

STUDY QUESTION

What are the characteristics of, and how variable are, individual normal menstrual cycle profiles of excretion rates for the urinary metabolites oestrone glucuronide (E1G) and pregnanediol glucuronide (PdG)?

SUMMARY ANSWER

There is a continuum of menstrual cycle profiles that differ from standard textbook profiles but which can be understood simply in terms of growth, atresia and ovulation of ovarian follicles.

WHAT IS KNOWN ALREADY

Point-of-care assays with the Ovarian Monitor pre-coated assay tubes, using urine samples diluted to a constant volume per unit time, give laboratory accurate clinical data for individual menstrual cycles. Lay operators can perform the point-of-care assay system at home to achieve reliable and reproducible results, which can be used for natural family planning.

STUDY DESIGN, SIZE, DURATION

This prospective study involved 62 women, with normal menstrual cycles, recruited from three centres: Palmerston North, New Zealand, Sydney, Australia and Santiago, Chile. The study lasted 3 years.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women collected daily urine samples and determined their E1G and PdG rates with a pre-coated enzyme assay system known as the Ovarian Monitor. For two cycles, the assays were repeated in a study centre and the results were averaged to give 113 individual menstrual cycles for analysis. The cycles were displayed individually in a proprietary database program.

MAIN RESULTS AND THE ROLE OF CHANCE

The individual normal hormonal profiles were more complex than the classic composite curves for 40% of the cycles. Of 113 ostensibly normal cycles, only 91 were potentially fertile and 22 had some luteal phase defect. The oestrone glucuronide and PdG excretion rates were reliable and informative in the non-invasive elucidation of ovulation and ovarian function for both simple and complex profiles. Daily monitoring revealed the variability of normal menstrual cycle profiles. The LH peaks were variable and ambiguous markers for ovulation.

LIMITATIONS, REASONS FOR CAUTION

The study consisted of cycles only from women with regular cycles of 20-40 days duration. All the women were intending to avoid a pregnancy during the study thus the limits of the fertile window were not tested.

WIDER IMPLICATIONS OF THE FINDINGS

The principles established in this study should apply to cycles of any length. All peaks in oestrone glucuronide excretion should be tested by concurrent measurements of PdG, which gives a positive indication of the fate of the follicle it represents. The Ovarian Monitor provides a useful addition for practitioners of natural family planning.

STUDY FUNDING/COMPETING INTEREST(S)

Financial support for this study was obtained from the UNDP/UNFPA/World Bank/WHO Special Programme of Research, Development and Research Training in Human Reproduction (HRP). D.G.C. is currently employed by and holds stock in Manawatu Diagnostics Ltd, a company in the development phase of a potentially competing product. The remaining authors have nothing to declare.

Mean versus individual hormonal profiles in the menstrual cycle

OBJECTIVE

To evaluate hormonal profiles of normal menstrual cycles.

DESIGN

Prospective, descriptive study of a case series.

SETTING

University-based natural family planning center.

PATIENT(S)

Twenty-five natural family planning users for three or more cycles (n = 78). These women were healthy, contraception-free, parous, with regular ovulatory cycles.

INTERVENTION(S)

Immunoassays for estrone glucuronide, LH, and pregnanediol glucuronide were done in daily timed and measured samples of early morning urine.

MAIN OUTCOME MEASURE(S)

Estrone glucuronide, LH, and pregnanediol glucuronide levels were measured during the menstrual cycle.

RESULT(S)

All cycles showed an ovulatory pattern configuring classic hormonal mean curves. Most (77%) differed from the mean curve pattern. All had estrone glucuronide peaks, LH peaks, and pregnanediol glucuronide increases. Estrone glucuronide and LH peaks were not always clear; some lasted more than 1 day (long peak: estrone glucuronide 19%, LH 9%) or fluctuated (double peak: estrone glucuronide 4%, LH 6%; small LH peak: 19%). There were also prepeak estrone glucuronide surges, and pre- and postpeak LH surges. Pregnanediol glucuronide increased more clearly (6% fluctuated 1 day). Some women had repeated cycles with long estrone glucuronide peaks (16%) and fluctuations in LH surge (44%).

CONCLUSION(S)

Normal menstrual cycle hormonal profiles generally differ from mean curves, which are usually considered standard.

Definition of the potentially fertile period from urinary steroid excretion rates. Part II. A threshold value for pregnanediol glucuronide as a marker for the end of the potentially fertile period in the human menstrual cycle

Application of time series analysis to a database containing serial pregnanediol data from 113 complete ovulatory menstrual cycles contributed by 83 women of proven fertility and 68 cycles for which pregnanediol values were available over the ovulatory period, detected the first statistically significant risk in pregnanediol excretion for all cycles for which a baseline was available (n = 170). However, even at the 99% confidence level, for 22% of cycles a rise was observed before the presumed day of ovulation. Therefore, a threshold value for pregnanediol was sought from the database as a better marker for the end of fertility. A value of 1.4 mg per 24 h was not reached before day 2 after the pre-ovulatory estrogen peak day for 96% of the cycles. In the remaining 4% of cycles it was reached one day after the total estrogen peak day. The validity of this threshold was confirmed in extensive studies using the Ovarian Monitor where the equivalent is 6.3 mumol per 24 h of pregnanediol glucuronide and measurements are performed on timed urine specimens with a minimum collection time of three hours. These studies were as follows: 1) a World Health Organization study on the use of the Ovarian Monitor as a fertility self test in the home (108 cycles), 2) a multicenter study on returning fertility during breast feeding conducted by Family Health International (73 women), and 3) the general application of the Ovarian Monitor for pregnancy achievement and avoidance during the past ten years (over 250,000 PdG assays performed in ten countries). With rare exceptions, the use of these threshold values is applicable for all women provided correction is made for urine volume.

Clomiphene citrate and ovarian resistance

An uncommon association between clomiphene citrate and the development of ovarian resistance to gonadotrophins is described. We advise against the use of clomiphene in the rare patient with the resistant ovary syndrome, and advise caution in any patient who exhibits a decreasing oestrogen response to clomiphene ovulation induction.

Induction of ovulation with subcutaneous pulsatile gonadotropin-releasing hormone: correlation with body weight and other parameters

We treated 21 anovulatory infertile patients with subcutaneous pulsatile gonadotropin-releasing hormone (GnRH) administered via a syringe pump. Response to treatment was assessed by urinary estrogen excretion and ultrasound measurement of follicular growth. Ten patients ovulated and 8 subsequently conceived, for a total of 10 pregnancies. Human chorionic gonadotropin (hCG) was not administered routinely, but two patients required hCG to induce follicular rupture. The majority of the patients who conceived had a body mass index (BMI) of less than 21 and a luteinizing hormone (LH)/follicle-stimulating hormone ratio of less than 1. Conversely, those patients with either elevated BMI or LH or both generally failed to respond satisfactorily to this treatment. It is suggested that pulsatile GnRH is most likely to succeed in inducing ovulation if the BMI is less than 21 and the LH is normal, but is unlikely to be successful if there is both an elevated LH and a BMI of greater than 25. Between these two extremes, the response is variable and a therapeutic trial may be appropriate.

Post-tubal sterilization problems correlated with ovarian steroidogenesis

Mid-luteal phase total urinary oestrogen excretion was found to be significantly reduced in women who had previously undergone tubal sterilization at least two years before assay; pregnanediol levels at or below 2.0 mg/24 hrs were significantly more frequent for the study group. These findings indicate that reduced ovarian function is associated with that procedure. The major problems declared as having been experienced subsequent to tubal sterilization were classified into three categories; some women declared problems in more than one category: (1) Abnormal uterine bleeding and/or menorrhagia, (2) Physical problems, (3) Psychological and/or psychiatric problems. Category 1 was associated with a significant fall in total oestrogen excretion, and category 2 with a significant fall in both total oestrogen and pregnanediol excretion. Analysis of category 3 will be published elsewhere. A negative correlation between total oestrogens and cholesterol was observed.

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.

The prediction of ovulation and monitoring of the fertile period

Simple and reliable methods have been sought for both predicting and confirming ovulation. Application of these methods could include management of infertile couples to aid in conception and for increasing the reliability of natural family planning (NFP) as a method of birth control. With the advent of specific hormone assays, serial measurements of estrogens, progesterone (and metabolites), and luteinizing hormone have been the gold standard of monitoring ovarian function in women. However, newer and simpler methodologies have been described and are currently either in use or being tested. These include the measurement of basal body temperature (BBT), the evaluation of the volume, consistency and electro-conductivity of cervicovaginal fluid, salivary steroid content and cellular enzymatic activity, the use of enzyme-linked immunosorbent assays applied to solid-phase formats, and the investigation of new hormonal molecules as markers of reproductive state and function. These new technologies are described herein and their potential for monitoring ovarian function is discussed.

Comparative study of total urinary oestrogen and first morning urinary oestrogen in monitoring gonadotrophin therapy

Total 24-hour urinary oestrogen has been used extensively and proven to be reliable in monitoring gonadotrophin therapy for induction of ovulation. However, the method is time consuming for the patient and incomplete collection, as expected, is not uncommon, hence interfering with the treatment result. Oestrone-3-glucuronide in first morning urine samples has been shown to correlate well with plasma oestradiol-17 beta levels during normal menstrual cycles. A comparative study was made to examine the correlation between the levels of 24-hour urinary oestrogen and first morning urinary oestrogen in patients on gonadotrophin therapy. Creatinine levels were also determined to exclude the factor of variable excretion of oestrogen. The correlation thus found is highly significant (p less than 0.001). Hence first morning urinary oestrogen to creatinine ratios may be used to replace 24-hour urinary oestrogen in biochemical monitoring of gonadotrophin therapy.

A rational approach to ovulation induction

Appropriate investigation has led to the recognition of five major endocrinologic categories of anovulatory patients. The clinician is able to follow a definitive therapeutic program for each of these; and except where the FSH levels are elevated, pregnancy rates should approach values observed for normally ovulating women. Although clomiphene citrate is likely to remain the most common drug prescribed to anovulatory women, treatment programs with clomiphene have recently been modified with much improved success rates resulting. Bromocriptine, the drug of choice for women with hyperprolactinemia, restores ovulatory cycles in most women treated. It not only restores fertility, however, but also reduces tumor growth in patients with pituitary adenomas, making surgical removal often unnecessary. Exogenous gonadotropin therapy should be reserved for patients who do not respond to treatment with clomiphene and/or bromocriptine. With adequate monitoring, the multiple pregnancy rate should be able to kept below 20% and high-multiple pregnancies avoided. Pulsatile GnRH therapy is likely to replace gonadotropin therapy for most patients, because this therapy has distinct advantages in terms of cost, patient convenience, and a lowering of multiple pregnancy rates.

Ultrasound control of clomiphene/human chorionic gonadotropin stimulated cycles for oocyte recovery and in vitro fertilization

Three pregnancies have been achieved through in vitro fertilization (IVF) following clomiphene/human chorionic gonadotropin (hCG) stimulation monitored only with ultrasound. When the results of 120 stimulated cycles were compared with those from 213 spontaneous cycles during a one-year period, the clomiphene-ultrasound-hCG method led to a significantly higher laparoscopy rate as well as significantly better yields of mature oocytes and embryos for intrauterine transfer. The luteal phase was normal in the stimulated group. This ultrasound-monitored technique was simpler to manage and less costly and appears to be the current method of choice for obtaining oocytes for IVF.

Ultrasonic observation of the mechanism of human ovulation

Nine subjects were studied by means of ultrasound to determine the precise time of ovulation and to document follicular changes immediately prior to, during, and after rupture. There were no demonstrable changes in the size of appearance of the follicle over a period of up to 7 hours prior to its rupture. In one of the four subjects in whom follicular collapse was witnessed, the follicle emptied completely within less than 1 minute. In two of the other three subjects, there was an initial rapid loss of fluid followed by a flower release of the remaining contents. This latter process took 7 minutes in the first patient and 35 minutes in the second patient. The slow phase of follicular collapse may well be an important aspect in the release of the ovum. The corpus hemorrhagicum was seen to develop within 1 hour of ovulation.

The significance of FSH elevation in young women with disorders of ovulation

High serum follicle stimulating hormone (FSH) values are consistent with ovarian failure. We studied the progress of 67 women aged under 35 years with oligomenorrhoea or secondary amenorrhoea in whom the serum FSH value was greater than 20 U/1. Twenty-four patients remained amenorrhoeic, but 17 ovulated and six conceived, two on two occasions. Coincident mean serum luteinising hormone (LH) concentrations were significantly lower and mean total urinary oestrogen concentrations were significantly higher in patients who subsequently ovulated, but the degree of increase in FSH did not correlate well with later ovarian function. Treatment with oestrogens, clomiphene citrate, human pituitary gonadotrophin, and bromocriptine was of no benefit in inducing an ovarian response while FSH concentrations remained raised. Our results suggest that a considerable proportion of younger women with ovulatory disorders associated with FSH values in the menopausal range will spontaneously resume ovulation and some will conceive.

Infertility: a review of 291 infertile couples over eight years

Two hundred and ninety-one infertile couples were studied over an 8-year period. Anovulation was the most common cause of infertility, being the causative factor in half of the patients. Ovulation induction with clomiphene or cyclic hormone therapy readily achieved pregnancy in the majority of these patients. The distribution of other etiologic factors was fairly uniform, but treatment was much less successful. Thorough evaluation of both partners is advised both for treatment purposes and as a more accurate guide to the prognosis for conception. Furthermore, even in the presence of oligospermia, ovulation induction may be successful in achieving a pregnancy.

Monitoring ovarian follicular development with real-time ultrasound

Ovarian follicular growth during the periovulatory period was measured using real-time ultrasound in 33 patients during 53 spontaneous ovulatory cycles. The mean follicular diameter increased from 14.1 mm four days before ovulation to a maximum of 20.1 mm on the day of presumptive ovulation. The results correspond with previous static ultrasound studies of follicular development and in nine cycles in which both methods were employed the correlation between measurements on the same day was highly significant (r = 0.944; p < 0.001). The day of ovulation could not be anticipated from a single measurement because of the relatively wide range of follicular size. Except in some obese subjects, real-time ultrasound examination of the developing follicle appears to be a useful technique for assessing the progress of the ovarian cycle.

Oestrogen and pregnanediol excretion through childhood, menarche and first ovulation

Urinary oestrogen and pregnanediol values were measured in 24 boys and 38 girls between the ages of 2 and 13 years. Longitudinal studies were conducted on eight girls, two of whom collected for periods of 4 and 5 years which included menarche and in one case establishment of ovulation. Highly sensitive assay methods were developed for measuring the very small amounts of oestrone, oestradiol and oestriol and pregnanediol present in the urine of young children. The total oestrogen values were within the submicrogram range of 0·1–0·5 μg/24 hr in the children aged 2–8 years, with no differences seen between the boys and girls. After the age of 8 years, oestrogen values above 1 μg/24 hr began to be encountered and by age 11½ years the majority of subjects were recording oestrogen values above this figure. The rise in the oestrogen values was more rapid in the girls than in the boys. Evidence was presented that a value of approximately 1 μg/24 hr represents the minimum oestrogen production for the initiation of breast development. The oestrogen values were fluctuating with irregular periodicities at all ages and the gradual general rises seen after the age of 8 years could be arrested at any stage for a year or more. Menarche was preceded by marked periodic fluctuations in oestrogen output which peaked above 15 μg/24 hr. In all subjects studied, the initial bleeding cycles were anovulatory as judged by the low pregnanediol values, the usual pattern being one of fluctuating oestrogen production. One subject was studied fully through to the establishment of ovulation, which first occurred 12 months after menarche. The approach of ovulation was indicated by pre-menstrual rises in pregnanediol which increased in amplitude from 0·4 mg/24 hr until finally 2 mg/24 hr was exceeded (the value accepted for ovulation). Evidence was presented that the interval from menarche to ovulation in different individuals was very variable, extending from ovulation at menarche itself to periods of more than a year. Recording of self-observed symptoms of production of cervical mucus could be of considerable value in documenting these events in larger populations.

Fertility and the physician

Gonadal function in both sexes is under the synergistic control of the pituitary gonadotrophins, follicle stimulating hormone (FSH) and luteinising hormone (LH) which are in turn influenced both by the hypothalamus (via the gonadotrophin releasing hormone) and by feedback signals from the gonads. There is good evidence that such feedback is mediated by steroid hormones and by a product of the germinal epithelium, termed inhibin. A logical approach to reproductive disorders involves the localization of the primary disturbance either to the hypothalamo-pituitary unit or to the gonad, on the basis of history, physical findings and the results of hormone assays. In men, the majority of disorders leading to infertility are of unknown aetiology and cannot, therefore, be treated specifically. In women, anovulation is usually readily treatable and recent studies have emphasised the usefulness of prolactin assays and of specific treatment for hyperprolactinaemia in restoring ferility. Increased understanding of the mechanisms leading to infertility may provide valuable new approaches to fertility control.

Serum prolactin levels in normal women and in women with disorders of menstruation

The mean (+/-SD) serum prolactin (PRL) level of 78 normal premenopausal women was 10-6+/-3-0 ng/ml, and this was significantly different from that of post-menopausal women (8-2+/-4-0 ng/ml) and women taking combined oral contraceptive preparations (12-2+/-4-0 ng/ml). No significant differences were found between follicular and luteal phase PRL levels. Serum PRL levels higher than the ranges given above were found in 31 of 87 patients with secondary amenorrhoea and two of 41 patients with oligomenorrhoea. Nine of the 33 patients with hyperprolactinaemia did not have galactorrhoea. Only two of the patients with hyperprolactinaemia had pituitary tumours evident on skull X-ray films. Serum PRL levels were of value in predicting the likely success in achieving ovulation with clomiphene citrate or CB-154; clomiphene citrate was less likely to be successful in the presence of hyperprolactinaemia, whereas the reverse applied for treatment with CB-154.

Serum prolactin levels and the value of bromocriptine in the treatment of anovulatory infertility

Basal serum levels of prolactin were measured in 37 infertile anovulatory patients who had failed to conceive on therapy with clomiphene citrate. Twenty of these patients, 16 of whom had galactorrhoea, had elevated basal serum prolactin values which were suppressed to normal or subnormal values during therapy with bromocriptine, the most commonly effective dose being 2.5 mg twice daily. Ovulation, as assessed by urinary oestrogen and pregnanediol measurements, was induced in 17 of these patients with pregnancy in 14. Ovarian responses short of defined criteria for ovulation were induced initially in eight patients, but these progressed to full ovulatory responses in five patients, either on the same or increased doses of bromocriptine. In all the patients who ovaulated, the prolactin levels had been reduced below the mean value for normal women (10.6 ng-ml). The three patients who failed to ovulate all had values higher than this at a dose of bromocriptine reaching 5.0 mg thrice daily. There seemed to be no value in increasing the dose of bromocriptine once ovulation had been achieved. Of the 17 patients with normal basal prolactin values, only one had an unequivocal response to bromocriptine with ovulation and conception, even though the prolactin values in the majority were suppressed to below normal.

Plasma gonadotrophin levels in ovulatory and anovulatory patients

Although episodes of FSH values were similar in subjects with secondary amenorrhoea and oligomenorrhoea, but patients with oligomenorrhoea had significantly higher plasma LH secretion in four normal, fourteen anovulatory and one postmenopausal woman were confirmed by samples taken every 15 minutes for three hours, single plasma samples invariably provided a valid estimate of the current mean plasma FSH level, and of the current mean plasma LH level during the follicular phase of the ovulatory menstrual cycle and in anovulatory women with a mean plasma LH value of less than 0-8 mIU/ml. If the mean plasma LH value in anovulatory women exceeded 0-8 mIU/ml, the maximum difference between single and mean values was 28-3+/-4-7 per cent for four patients with oligomenorrhoea and 43-4+/-5-2 per cent for five patients with secondary amenorrhoea. Single plasma samples were collected from 26 patients with primary amenorrhoea, 95 patients with secondary amenorrhoea, 51 patients with oligomenorrhoea and 33 postmenopausal patients not on replacement therapy. In each group there were subjects with plasma FSH values in the postmenopausal range and they were unlikely to respond to ovulation induction. Those patients aside, plasma FSH values were similar in subjects with secondary amenorrhoea and oligomenorrhoea, but patients with oligomenorrhoea had significantly higher plasma LH values (p less than 0-001); mean levels of neither FSH nor LH showed a significant correlation with response to treatment with clomiphene but in patients with secondary amenorrhoea an ovulatory response to clomiphene did not occur unless the individual's plasma FSH value was in excess of 1-4 mIU/ml. In patients with oligomenorrhoea, plasma LH levels below 0-8 mIU/ml precluded successful treatment with clomiphene.