Clomiphene citrate challenge test in the assessment of ovarian reserve before controlled ovarian hyperstimulation for intracytoplasmic sperm injection

Ovarian reserve tests

Ovarian reserve plays a crucial role in achieving pregnancy following any treatment in subfertile women. The estimation of ovarian reserve is routinely performed through various ovarian reserve tests (ORTs) in an effort to predict the response and outcome in couples prior to In Vitro Fertilization and counsel them. Most widely used tests are basal follicle stimulating hormone and anti-Mullerian hormone and antral follicle count. The role of ORTs in our routine practice is discussed in this article. A MEDLINE search was done to identify suitable articles for review.

The value of human chorionic gonadotropin stimulation test in predicting ovarian response during in-vitro fertilization

PURPOSE

To assess the predictive value of human Chorionic Gonadotropin (hCG) theca-stimulation test for ovarian reserve in women undergoing in-vitro fertilization (IVF) treatments.

METHODS

39 women were included in the study. All participants received a single hCG 10000 IU injection on cycle day 2-3. Serum levels of estradiol, testosterone, androstenedione and 17-OH progesterone were measured prior to the injection and on days 1, 3 and 7 following the injection. hCG-induced hormone levels were compared with ovarian response during the subsequent IVF cycle.

RESULTS

There were 11 good responders (>10 oocytes) and 22 low responders (<3 oocytes). Before hCG stimulation serum E2 levels were higher in low responders compared to good responders (370.3 ± 443 vs. 138.3 ± 54 pmol/ml). Following hCG stimulation, day 3 androstendione levels showed an increase in good responders compared to low responders. The ratio between day 3 androstendione and day 0 estradiol was significantly different between the two groups (p = 0.03). ROC analysis of this test revealed area = 0.837 (good prediction), which was much better than day 3 FSH (area = 0.635, poor prediction).

CONCLUSIONS

These preliminary results demonstrate the potential use of the hCG theca stimulation test in differentiating between good and poor responders. Larger series are needed for further verification of the test in routine clinical application.

Ovarian reserve tests and their utility in predicting response to controlled ovarian stimulation in rhesus monkeys

Controlled ovarian stimulation (COS) is an alternative to natural breeding in nonhuman primates; however, these protocols are costly with no guarantee of success. Toward the objective of predicting COS outcome in rhesus monkeys, this study evaluated three clinically used ovarian reserve tests (ORTs): day 3 (d3) follicle-stimulating hormone (FSH) with d3 inhibin B (INHB), the clomiphene citrate challenge test (CCCT), and the exogenous FSH Ovarian Reserve Test. A COS was also performed and response was classified as either successful (COS+) or unsuccessful (COS-) and retrospectively compared with ORT predictions. FSH and INHB were assessed for best hormonal index in conjunction with the aforementioned tests. INHB was consistently more accurate than FSH in all the ORTs used. Overall, a modified version of the CCCT using INHB values yielded the best percentage of correct predictions. This is the first report of ORT evaluation in rhesus monkeys and may provide a useful diagnostic test before costly follicle stimulations, as well as predicting the onset of menopause.

The clomiphene citrate challenge test for the prediction of poor ovarian response and nonpregnancy in patients undergoing in vitro fertilization: a systematic review

OBJECTIVE

To systematically review the value of the clomiphene citrate challenge test (CCCT) in the prediction of poor ovarian response and pregnancy in IVF.

DESIGN

Systematic review.

SETTING

All studies that evaluated the CCCT in the prediction of poor ovarian response or pregnancy after IVF.

PATIENT(S)

Infertility population undergoing an IVF treatment.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Poor ovarian response, nonpregnancy.

RESULT(S)

From the literature we identified and analyzed 12 studies on the CCCT according to preset criteria. In predicting poor response, the sensitivity and specificity of the CCCT varied from 35% to 93% and 47% to 98%, respectively. In predicting nonpregnancy, the sensitivity and specificity varied from 13% to 66% and 73% to 97%, respectively. Because of heterogeneity among studies, a summary receiver operating characteristics (ROC) curve could not be estimated. Back-to-back comparison of the CCCT with basal FSH was possible in six studies. In predicting poor response, the sensitivity of the CCCT increased to some extent, whereas specificity did not increase or even diminished. In predicting nonpregnancy, the CCCT also showed an increase in sensitivity, counteracted by a decrease in specificity.

CONCLUSION(S)

Summary estimates of test accuracy for the CCCT in IVF are not possible, because of heterogeneity among individual studies. A subanalysis of studies comparing basal FSH and the full CCCT showed that the CCCT has hardly any additional value.

A systematic review of tests predicting ovarian reserve and IVF outcome

The age-related decline of the success in IVF is largely attributable to a progressive decline of ovarian oocyte quality and quantity. Over the past two decades, a number of so-called ovarian reserve tests (ORTs) have been designed to determine oocyte reserve and quality and have been evaluated for their ability to predict the outcome of IVF in terms of oocyte yield and occurrence of pregnancy. Many of these tests have become part of the routine diagnostic procedure for infertility patients who undergo assisted reproductive techniques. The unifying goals are traditionally to find out how a patient will respond to stimulation and what are their chances of pregnancy. Evidence-based medicine has progressively developed as the standard approach for many diagnostic procedures and treatment options in the field of reproductive medicine. We here provide the first comprehensive systematic literature review, including an a priori protocolized information retrieval on all currently available and applied tests, namely early-follicular-phase blood values of FSH, estradiol, inhibin B and anti-Müllerian hormone (AMH), the antral follicle count (AFC), the ovarian volume (OVVOL) and the ovarian blood flow, and furthermore the Clomiphene Citrate Challenge Test (CCCT), the exogenous FSH ORT (EFORT) and the gonadotrophin agonist stimulation test (GAST), all as measures to predict ovarian response and chance of pregnancy. We provide, where possible, an integrated receiver operating characteristic (ROC) analysis and curve of all individual evaluated published papers of each test, as well as a formal judgement upon the clinical value. Our analysis shows that the ORTs known to date have only modest-to-poor predictive properties and are therefore far from suitable for relevant clinical use. Accuracy of testing for the occurrence of poor ovarian response to hyperstimulation appears to be modest. Whether the a priori identification of actual poor responders in the first IVF cycle has any prognostic value for their chances of conception in the course of a series of IVF cycles remains to be established. The accuracy of predicting the occurrence of pregnancy is very limited. If a high threshold is used, to prevent couples from wrongly being refused IVF, a very small minority of IVF-indicated cases (approximately 3%) are identified as having unfavourable prospects in an IVF treatment cycle. Although mostly inexpensive and not very demanding, the use of any ORT for outcome prediction cannot be supported. As poor ovarian response will provide some information on OR status, especially if the stimulation is maximal, entering the first cycle of IVF without any prior testing seems to be the preferable strategy.

Comparison of basal and clomiphene citrate induced FSH and inhibin B, ovarian volume and antral follicle counts as ovarian reserve tests and predictors of poor ovarian response in IVF

PURPOSE

To compare basal and clomiphene citrate (CC) induced follicle-stimulating hormone (FSH), estradiol (E2), and inhibin B levels with ultrasound indices of ovarian reserve in infertile women and to test the prognostic value of these tests on response to ovarian stimulation in in vitro fertilization (IVF).

METHODS

Fifty-six patients had basal and CC induced serum hormone levels and ultrasound measured mean ovarian volume (MOV) and mean antral follicle counts (MFC). Thirty-two patients were then appropriately selected to have a total of 41 cycles of IVF/ICSI treatment.

RESULTS

Women with diminished ovarian reserve had lower MOV, MFC, day 3 and day 10 inhibin B levels (p < 0.001). Only basal and CC induced FSH and inhibin B correlated with MOV and MFC. Poor responders in IVF/ICSI had higher basal FSH (p < 0.05), lower basal and induced inhibin B levels (p < 0.05), and lower MOV and MFC (p < 0.01) than normal responders. Ovarian volume alone was better than age and basal hormones in predicting poor ovarian response, while abnormal CC test was the only independent significant factor in predicting ovarian response. However, age was the only independent predictor of pregnancy in IVF as compared to hormonal and ultrasound indices of ovarian reserve.

CONCLUSION

CC test and ovarian volume are better than other hormonal and sonographic tests in predicting the response to ovarian stimulation in IVF cycles.

Obesity and Clomiphene Challenge Test as Predictors of Outcome of in vitro Fertilization and Intracytoplasmic Sperm Injection

One hundred and sixty-two consecutive patients undergoing in vitro fertilization (IVF) or IVF/intracytoplasmic sperm injection (ICSI) were studied to determine the effect of obesity on the outcome of this treatment and to evaluate the prognostic value of the Clomiphene Challenge Test (CCT) in controlled ovarian hyperstimulation. In this prospective clinical study, we assessed the mean number of stimulation days, the mean gonadotropin level/day, cancellation rate, the mean thickness of the endometrium, the mean number of oocytes retrieved, the fertilization rate, the clinical pregnancy rate/embryo transfer and the abortion rate. Obese women had a doubled risk of cancellation due to poor response, although this was not statistically significant. Furthermore, they showed up to 45% lower fertilization rates compared to women of normal weight. The CCT was a good predictor of IVF and IVF/ICSI outcome. Women with an abnormal CCT needed more days of stimulation and higher doses of gonadotropins to reach an adequate stimulation, but still overall results were less than in women with a normal CCT. We conclude that obesity negatively affects IVF and IVF/ICSI outcome, and that CCT is a useful prognosticator of response to ovarian stimulation. Obese patients show a tendency to experience more cancellation due to poor response and lower fertilization rates. Obese women should be counseled on their possible poor performance in IVF and IVF/ICSI programs.

Antral follicle count and FSH concentration after clomiphene citrate challenge test in the prediction of ovarian response during IVF treatment

BACKGROUND

We compared: (i) antral follicle count (AFC) in the early follicular phase, after the clomiphene citrate challenge test (CCCT) and before ovarian stimulation following pituitary down-regulation; and (ii) age of women, body mass index, basal and stimulated serum FSH concentrations and AFC in predicting the ovarian response of infertile women aged <40 years with basal FSH <10 IU/l on recruitment in their first IVF cycle.

METHODS

Two months prior to the treatment cycle, AFC and basal FSH concentration were determined on day 2-3 of a spontaneous period and on day 10 after CCCT. All women received a standard stimulation regimen. Ovarian response was represented by the number of oocytes, serum estradiol, the duration and dosage of gonadotrophins.

RESULTS

There was no significant difference between basal, stimulated and down-regulated AFC. AFC achieved the best predictive value in relation to the number of oocytes, followed by combined FSH concentration (sum of the two FSH concentrations) and age of women. Both basal AFC and combined FSH concentration were predictive factors of serum estradiol concentration, whereas stimulated FSH concentration was predictive of the total dosage of gonadotrophins.

CONCLUSION

Combined FSH concentration after CCCT provides additional information in predicting ovarian response.

The interobserver reliability of ovarian volume measurement is improved with three-dimensional ultrasound, but dependent upon technique

The effect of measurement technique on the interobserver reliability of ovarian volume calculation from three-dimensional (3-D) ultrasound (US) data was investigated. Ovarian volume was calculated in 20 patients by two observers using both the "prolate ellipsoid formula" and a new 3-D rotational technique (VOCAL). There was a significant difference between observers in mean ovarian volume calculated by the prolate ellipsoid formula (31.54 mL vs. 26.54 mL: p < 0.05), which proved to be a significantly less reliable technique than 3-D rotational volume calculation with VOCAL. Image quality was significantly better (p < 0.001) and measurements were significantly more reliable (p < 0.05) in the B-plane than in the C- plane of the multiplanar display. Rotational measurement of ovarian volume from 3-D US data is significantly more reliable between observers than volume estimation from 2-D parameters using the prolate ellipsoid formula, but is dependent upon image quality, which is significantly better in the B-plane than in the C-plane.

Optimal treatment for poor responders to ovarian stimulation: does in vitro insemination offer any advantages to intrauterine insemination?

A retrospective study was performed of 1832 consecutive in vitro insemination (IVF)/intracytoplasmic sperm injection (ICSI) cycles over 18 months, to analyse the benefits or otherwise to the patient of continuing with in vitro treatment or converting the assisted conception cycle to intrauterine insemination (IUI). Two hundred and seventy cycles were identified in which three follicles or fewer were obtained after controlled ovarian hyperstimulation; in 143 of these cycles, the clinicians or patients elected to abandon all treatment, whereas treatment was continued in 127 patients. In 79 cycles, the patients proceeded with IVF/ICSI and in 48 patients, the cycles were converted to IUI. Data were analysed with regard to the clinical pregnancy rate. In addition, the data for IUI were compared with eight cycles of supraovulation IUI (S/IUI) performed over the same period. There were no significant differences in clinical pregnancy rates among any treatment modality 6/48 (12.5%), 6/79 (7.7%) and 1/8 (12.5%) for IUI, IVF and S/IUI, respectively (P = 0.64). The lowest total number of motile spermatozoa required to achieve pregnancy using IUI was 2.0 x 10(6). In conclusion, it appears that, if the treatment is suitable, patients who respond poorly to controlled hyperstimulation for IVF would not be disadvantaged in achieving a pregnancy by offering them conversion to the medically and financially less interventional IUI.