Pregnancy after clomiphene citrate treatment

Old insights, same questions

The thing that hath been, it is that which shall be; and that which is done is that which shall be done: and there is no new thing under the sun. -Ecclesiastes 1:9, King James Bible.

Clomiphene citrate and pregnancy outcome

Data from Australia and elsewhere have shown consistently that adverse perinatal outcomes such as preterm birth and perinatal mortality are more common in pregnancies resulting from assisted conception with IVF and GIFT than normally conceived pregnancies. Factors that may contribute to the excess of poor outcomes include maternal factors, the assisted conception procedures themselves and possibly the influence of drugs used to induce superovulation. This review examines the medical literature describing pregnancies following ovulation induction with one of the drugs used to induce superovulation, clomiphene citrate, and compares their outcomes with Australian IVF and GIFT pregnancy outcomes. The review shows that whilst some studies have suggested higher rates of ectopic pregnancy, spontaneous abortion and congenital malformations in clomiphene citrate induced pregnancies, the findings are inconsistent and the data are flawed. There are only very poor data available on the incidence of preterm birth. Multiple pregnancy is a well-recognized adverse outcome of clomiphene citrate induced pregnancies. Attempts to improve perinatal outcomes of pregnancies following assisted conception will be helped by a better understanding of the relative contributions of maternal and treatment factors and further studies of pregnancy outcome after ovulation induction are needed.

Early miscarriage and fetal malformations after induction of ovulation (by clomiphene citrate and/or human menotropins), in vitro fertilization, and gamete intrafallopian transfer

From the reviewed data, it appears that CC, hMG-hCG, or the association of these drugs with IVF-ET and GIFT programs do not carry an increased risk for congenital malformations as a whole, nor is there any specific malformation that has an increased incidence or is related in any way with the use of these drugs. Table 7 represents the specific malformation rate per 1,000 births in the general population and in newborns delivered after treatment with CC, hMG-hCG, or IVF-ET and GIFT. The malformation rate in the treated groups does not differ from that of the general population. However, as shown by McIntosh et al., the incidence of congenital malformations often rises with a longer follow-up. Most of the reports about babies born after ovulation induction are based on the initial examination done shortly after birth. Thus, studies including examination of these infants up to at least 12 months of age will be undoubtedly of value. Also, data concerning the reproductive capability of women born after ovulation induction is lacking. With regard to the abortion rate in pregnancies achieved after such treatments and procedures, it can be concluded that it does not appear to be higher than that of the general population, particularly when early pregnancy loss, advanced maternal age, the infertility status, and the increased incidence of multiple pregnancies occurring in these patients are taken into consideration.

An association between clomiphene citrate and ectopic pregnancy: a preliminary report

Preliminary results of a case-control study suggest that CC or factors closely associated with CC therapy (or both) may increase the risk of ectopic pregnancy. It is hoped that these results will stimulate further research for more explicit evaluation of the role of CC and LPD in the etiology of ectopic pregnancy.

Effect of clomiphene on the functional morphology of oviductal and uterine mucosa

The effect of clomiphene on the functional morphology of the uterine and oviductal mucosa was studied in rabbits by means of light and electron microscopy (SEM and TEM). Tissues were obtained from mature nulliparous animals receiving subcutaneous doses ranging from 0.01-10 mg/kg per day. In all cases the effects were evaluated 2 days after termination of treatment. With 2 and 10 mg, effects were studied up to 12 and 7 days, respectively. Normally appearing oviductal and endometrial tissues, corresponding to various stages of the cycle, were observed with doses up to 5 mg. However, a burst of cellular secretory activity becomes evident with the administration of higher doses. Apical protrusions or cytoplasmic portions seem to be extruded, and draw attention. These cytologic events are concentrated near gland openings in the endometrium and can be seen abundantly among cilia of oviductal cells. Other ultrastructural changes are evident as well. These histologic changes may reflect nonsynchronous cellular activities which in turn interfere with oviductal and endometrial functions before implantation.

Monitoring techniques for improved pregnancy rates during clomiphene ovulation induction

Despite the introduction of new ovulation-inducing agents, CC remains the drug of choice for most anovulatory patients. Before initiating therapy, patients should be evaluated to determine the cause of anovulation. Patients with ovarian failure, hyperprolactinemia, hypothyroidism, or forms of CAH should be treated with the appropriate replacement therapy. Evaluation of male factor and tubal patency should be obtained. Once CC therapy is initiated, careful monitoring should be continued. Confirmation of ovulation by endometrial biopsy or serum P levels is essential. CC doses should be increased monthly until normal luteal function is demonstrated. If the patient does not conceive in three ovulatory cycles, her treatment should be further evaluated by postcoital testing, repeat serum P measurement, and review of her endocrine findings. Patients with poor cervical mucus may benefit from midcycle estrogen. Patients with elevated T may benefit from prednisone suppressive therapy. Patients with abnormal HSGs should have laparoscopy and surgical correction if feasible. After six ovulatory cycles without conception, all patients should undergo laparoscopy. If laparoscopy is normal, therapy can be continued for a total of 10 to 12 cycles. Patients with reduced fecundability (male factor, minimal endometriosis, or minimal tubal adhesions) may require a longer time to conceive.

Congenital malformations of newborn infants after clomiphene-induced ovulation

The effect of clomiphene citrate (CC) on the incidence of congenital malformations in newborn infants was assessed from the outcome of 1034 pregnancies after CC-induced ovulation recorded at nine university hospitals in a 5-year period. Of these pregnancies, 14.2% ended in abortion, 0.5% in ectopic pregnancy, 0.1% in molar pregnancy, and 1.6% in stillbirth. In all, 935 infants were born, and 21 (2.3%) showed visible malformations. This incidence of malformations was not significantly different from that in 30,033 infants (1.7%) after spontaneous ovulation (spontaneous ovulation group), and the types of malformations after CC treatment were similar to e those in the spontaneous ovulation group. These data indicate that CC has no teratogenic effect.

The rise in ectopic pregnancy--exploration of possible reasons

The rate of ectopic pregnancies has been rising in the past decade and it is responsible for an increasing proportion of maternal deaths. A history of pelvic inflammatory disease is strongly associated with ectopic pregnancy. There is a higher rate of ectopic pregnancy among intrauterine device users than non-users. A history of abdominal surgery has been associated with ectopic pregnancy and there is some evidence that women taking certain hormonal preparations experience excess ectopic pregnancies. Through a critical review of the literature, the author explores the evidence for these associations. The paper closes with recommendations for future research.

Gonadotrophin and the human secondary sex ratio

A review of published reports showed that the sex ratio (proportion of boys) was low among infants conceived after ovulation had been induced. The difference between the observed sex ratio and an expected one of 0 . 514 was highly significant. These findings suggest that maternal gonadotrophin concentrations at the time of conception directly affect the sex of the zygote.

Plasma oestradiol and progesterone estimation for the monitoring of induction of ovulation with clomiphene and chorionic gonadotrophin

Two hundred and thirty-five courses of treatment with clomiphene and human chorionic gonadotrophin (HCG) were administered for the induction of ovulation in 75 infertile women (three with primary amenorrhoea, 45 with secondary amenorrhoea and 27 with oligomenorrhoea) of whom 61 had previously been unsuccessfully treated with clomiphene alone. The treatment was monitored by plasma oestradiol estimations on day 15 and day 22 in 103 cycles and by plasma progesterone estimations on day 22 in all 235 cycles. Injections of HCG were given on day 15 and 22. Twenty patients failed to respond to treatment (43 courses). The remaining 55 patients showed no response in 32 courses, deficient responses in 55 cycles and adequate responses in 105 cycles (plasma progesterone level exceeding 10 ng per ml on day 22). The mean values (+/- SD) of plasma oestradiol on day 15, reflecting follicular development, were: 73 +/- 30 pg per ml for cycles with no response; 255 +/- 182 for deficient cycles and 366 +/- 226 pg per ml for adequate cycles. There was a positive correlation (r = 0-57) between day 15 plasma oestradiol and day 22 plasma progesterone values. Increased clomiphene dosage resulted in higher plasma oestradiol and progesterone levels. Thirty-nine pregnancies occurred in 34 out of 55 patients capable of response (62 per cent). The plasma progesterone levels during conception cycles were higher than those in non-conception cycles in the same patients. Monitoring of induction of ovulation by plasma hormone estimations allows detection and correction of inadequate response.