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Berdin A, Bellaïche K, El Hachem H, Vielle B, Legendre G, Descamps P, May-Panloup P, Prevost S, Bouet PE. Comparison of two cancellation strategies to lower the risk of multiple pregnancies in gonadotropin stimulated intrauterine insemination cycles. Int J Gynaecol Obstet 2024; 166:692-698. [PMID: 38425230 DOI: 10.1002/ijgo.15449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 01/09/2024] [Accepted: 02/12/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVE To compare two cancellation policies in controlled ovarian stimulation-intrauterine insemination (COS-IUI) cycles to lower the risk of multiple pregnancies (MP). DESIGN We performed a bicentric retrospective cohort study in two academic medical centers: Angers (group A) and Besançon (group B) University Hospitals. We included 7056 COS-IUI cycles between 2011 and 2019. In group A, cancellation strategy was based on an algorithm taking into account the woman's age, the serum estradiol level, and the number of follicles of 14 mm or greater on ovulation trigger day. In group B, cancellation strategy was case-by-case and physician-dependent, based on the woman's age, number of follicles of 15 mm or greater, and the previous number of failed COS-IUI cycles, without any predefined cut-off. Our main outcome measures were the MP rate (MPR) and the live-birth rate (LBR). RESULTS We included 884 clinical pregnancies (790 singletons, 86 twins, and 8 triplets) obtained from 6582 COS-IUI cycles. MPR was significantly lower in group A compared with group B (8.1% vs 13.3%, P = 0.01), but LBR were comparable (10.8% vs 11.8%, P = 0.19). Multivariate logistic regression found the following to be risk factors for MP: the "cancellation strategy" effect (adjusted odds ratio [aOR] 1.63, 95% confidence interval [CI] 1.02-2.60) and the number of follicles of 14 mm or greater (aOR 1.39, 95% CI 1.16-1.66). Cycle cancellation rate for excessive response was significantly lower in group A compared with group B (1.3% vs 2.4%, P < 0.001). CONCLUSIONS The use of an algorithm based on the woman's age, serum estradiol level and number of follicles of at least 14 mm on trigger day allows the MPR to be reduced without impacting the LBR.
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Affiliation(s)
- Aurélie Berdin
- Department of Reproductive Medicine, Besançon University Hospital, Besançon, France
| | - Kevin Bellaïche
- Department of Reproductive Medicine, Angers University Hospital, Angers, France
| | - Hady El Hachem
- Department of Obstetrics and Gynecology, Lebanese American University Medical Center, Beirut, Lebanon
| | - Bruno Vielle
- Clinical Research Center, Angers University Hospital, Angers, France
| | - Guillaume Legendre
- Department of Reproductive Medicine, Angers University Hospital, Angers, France
| | - Philippe Descamps
- Department of Reproductive Medicine, Angers University Hospital, Angers, France
| | - Pascale May-Panloup
- Department of Reproductive Medicine, Angers University Hospital, Angers, France
| | - Sarah Prevost
- Department of Reproductive Medicine, Besançon University Hospital, Besançon, France
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Raperport C, Desai J, Qureshi D, Rustin E, Balaji A, Chronopoulou E, Homburg R, Khan KS, Bhide P. The definition of unexplained infertility: A systematic review. BJOG 2023. [PMID: 37957032 DOI: 10.1111/1471-0528.17697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 09/21/2023] [Accepted: 10/15/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND There is no consensus on tests required to either diagnose unexplained infertility or use for research inclusion criteria. This leads to heterogeneity and bias affecting meta-analysis and best practice advice. OBJECTIVES This systematic review analyses the variability of inclusion criteria applied to couples with unexplained infertility. We propose standardised criteria for use both in future research studies and clinical diagnosis. SEARCH STRATEGY CINAHL and MEDLINE online databases were searched up to November 2022 for all published studies recruiting couples with unexplained infertility, available in full text in the English language. DATA COLLECTION AND ANALYSIS Data were collected in an Excel spreadsheet. Results were analysed per category and methodology or reference range. MAIN RESULTS Of 375 relevant studies, only 258 defined their inclusion criteria. The most commonly applied inclusion criteria were semen analysis, tubal patency and assessment of ovulation in 220 (85%), 232 (90%), 205 (79.5%) respectively. Only 87/220 (39.5%) studies reporting semen analysis used the World Health Organization (WHO) limits. Tubal patency was accepted if bilateral in 145/232 (62.5%) and if unilateral in 24/232 (10.3%). Ovulation was assessed using mid-luteal serum progesterone in 115/205 (56.1%) and by a history of regular cycles in 87/205 (42.4%). Other criteria, including uterine cavity assessment and hormone profile, were applied in less than 50% of included studies. CONCLUSIONS This review highlights the heterogeneity among studied populations with unexplained infertility. Development and application of internationally accepted criteria will improve the quality of research and future clinical care.
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Affiliation(s)
- Claudia Raperport
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Jessica Desai
- Queen Mary University of London Medical School, London, UK
| | | | | | - Aparna Balaji
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
- North West Anglia NHS Foundation Trust, Peterborough, UK
| | | | - Roy Homburg
- Hewitt Fertility Centre, Liverpool Women's Hospital, Liverpool, UK
| | - Khalid Saeed Khan
- Department of Preventative Medicine and Public Health, Faculty of Medicine, University of Granada, Granada, Spain
- CIBER Epidemiology and Public Health, Madrid, Spain
| | - Priya Bhide
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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Quaas P, Quaas AM, Fischer M, De Geyter C. Use of pulsatile gonadotropin-releasing hormone (GnRH) in patients with functional hypothalamic amenorrhea (FHA) results in monofollicular ovulation and high cumulative live birth rates: a 25-year cohort. J Assist Reprod Genet 2022; 39:2729-2736. [PMID: 36378460 PMCID: PMC9790838 DOI: 10.1007/s10815-022-02656-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 11/04/2022] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To analyze outcomes of pulsatile administration of gonadotropin-releasing hormone (GnRH) in infertile women diagnosed with functional hypothalamic amenorrhea (FHA). METHODS A single-center retrospective cohort study was conducted from 1996 to 2020. Sixty-six patients with the diagnosis FHA that underwent therapy using the pulsatile GnRH pump for conception were included and analyzed. The primary outcome was the live birth rate (LBR). Secondary outcomes were the number of dominant follicles, ovulation rate, biochemical pregnancy rate (BPR), clinical pregnancy rate (CPR), miscarriage rate, and multiple pregnancy rate. A matched control group was selected to compare the birth weight of newborn children. RESULTS During the study period, 66 patients with FHA underwent 82 treatments (14 of 66 patients had more than one treatment) and a total of 212 cycles (ovulation induction attempts) using pulsatile GnRH. The LBR per treatment was 65.9%. The ovulation rate per cycle was 96%, and monofollicular ovulation was observed in 75% of cycles. The BPR per treatment was 80.5%, and the cumulative CPR per treatment was 74.4%. The miscarriage rate was 11.5%. One dizygotic twin pregnancy was observed (1.6%). Average newborn birth weight (NBW) from patients with FHA was comparable to the control group. CONCLUSION(S) In patients with FHA, excellent pregnancy rates were achieved using the subcutaneous GnRH pump. The high cumulative LBR with normal NBW as well as low rates of multiple gestation indicate that the pulsatile GnRH pump represents a safer and more physiologic alternative to ovulation induction with injectable gonadotropins. TRIAL REGISTRATION Ethics Committee Northwest and Central Switzerland (Ethikkommission Nordwest- und Zentralschweiz - EKNZ) - Project-ID 2020-01612.
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Affiliation(s)
- Philipp Quaas
- Department of Obstetrics and Gynecology, University Hospital, University of Basel, Spitalstrasse 21, CH-4056 Basel, Switzerland
| | - Alexander M. Quaas
- Reproductive Medicine and Gynecological Endocrinology (RME), University Hospital, University of Basel, Vogesenstrasse 134, CH-4031 Basel, Switzerland
| | - Manuel Fischer
- Reproductive Medicine and Gynecological Endocrinology (RME), University Hospital, University of Basel, Vogesenstrasse 134, CH-4031 Basel, Switzerland
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Merviel P, Bouée S, Ménard M, Le Martelot MT, Roche S, Lelièvre C, Chabaud JJ, Jacq C, Drapier H, Beauvillard D. [Which ovarian stimulation to which women: The polycystic ovary syndrome (PCOS)]. ACTA ACUST UNITED AC 2018; 45:623-631. [PMID: 29100822 DOI: 10.1016/j.gofs.2017.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 10/01/2017] [Indexed: 10/18/2022]
Abstract
Polycystic ovarian syndrome (PCOS) is a frequent pathology in the young woman, linking infertility to a metabolic disease. Initial support will include a plan (in the case of overweight or obesity) to lose at least 5 to 10% of the weight. Subsequently, clomiphene citrate is the first treatment for ovulation induction with pregnancy rates of 40 to 80% after 6 cycles. If there is resistance to clomiphene citrate, the choice will be between the ovarian drilling (50-60% of pregnancy in the year following, including the half spontaneous) or ovarian stimulation with gonadotropins. The risk of ovarian stimulation in these women is hyperstimulation and multiple pregnancies. We also discuss the place of the GnRH pulsatile administration, insulin-sensitizers, in vitro fertilization and in vitro maturation in these women. Once infertility support, these women should be long-term followed because of the neoplasic and cardiovascular risks they present.
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Affiliation(s)
- P Merviel
- Fédération d'assistance médicale à la procréation, CHRU de Brest, hôpital Morvan, 2, avenue Foch, 29200 Brest, France.
| | - S Bouée
- Fédération d'assistance médicale à la procréation, CHRU de Brest, hôpital Morvan, 2, avenue Foch, 29200 Brest, France
| | - M Ménard
- Fédération d'assistance médicale à la procréation, CHRU de Brest, hôpital Morvan, 2, avenue Foch, 29200 Brest, France
| | - M-T Le Martelot
- Fédération d'assistance médicale à la procréation, CHRU de Brest, hôpital Morvan, 2, avenue Foch, 29200 Brest, France
| | - S Roche
- Fédération d'assistance médicale à la procréation, CHRU de Brest, hôpital Morvan, 2, avenue Foch, 29200 Brest, France
| | - C Lelièvre
- Fédération d'assistance médicale à la procréation, CHRU de Brest, hôpital Morvan, 2, avenue Foch, 29200 Brest, France
| | - J-J Chabaud
- Fédération d'assistance médicale à la procréation, CHRU de Brest, hôpital Morvan, 2, avenue Foch, 29200 Brest, France
| | - C Jacq
- Fédération d'assistance médicale à la procréation, CHRU de Brest, hôpital Morvan, 2, avenue Foch, 29200 Brest, France
| | - H Drapier
- Fédération d'assistance médicale à la procréation, CHRU de Brest, hôpital Morvan, 2, avenue Foch, 29200 Brest, France
| | - D Beauvillard
- Fédération d'assistance médicale à la procréation, CHRU de Brest, hôpital Morvan, 2, avenue Foch, 29200 Brest, France
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5
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White DM, Hardy K, Lovelock S, Franks S. Low-dose gonadotropin induction of ovulation in anovulatory women: still needed in the age of IVF. Reproduction 2018; 156:F1-F10. [PMID: 29459401 DOI: 10.1530/rep-17-0697] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 02/19/2018] [Indexed: 11/08/2022]
Abstract
Low-dose, step-up gonadotropin is the treatment of choice for women with polycystic ovary syndrome (PCOS) who have not conceived after anti-oestrogen treatment and as an effective alternative to pulsatile GnRH in women with hypogonadotropic hypogonadism (HH). There has been, however, no large-scale, comparative study between the two groups using low-dose gonadotropins. Here, we performed a retrospective, comparative analysis, in a single clinic database, of efficacy and safety of induction of ovulation using low-dose gonadotropins in 364 women with PCOS and 80 women with HH. The rate of ovulation was high in both PCOS (83%) and HH (84%) but mono-follicular, ovulatory cycles were more prevalent in PCOS than in HH (77% vs 53%, P < 0.0001) and the proportion of cycles that were abandoned was higher in HH than in PCOS (25% vs 15%, P < 0.0001). The median threshold dose of gonadotropin required to induce ovulation was 75 IU/day in PCOS and 113 IU/day in HH (P < 0.001) and the range of doses was greater in HH women. Forty-nine percent of women with PCOS and 65% of those with HH conceived (more than 90% within 6 cycles of treatment) and had at least one pregnancy. Multiple pregnancies (all twins) occurred in only 4% of women with PCOS and 5% of those with HH. These findings emphasise the efficacy and safety of low-dose gonadotropin treatment for both clomiphene-resistant women with PCOS and those with HH. These results highlight the importance of choosing the more physiological approach of gonadotropin induction of ovulation in both groups as the most appropriate treatment, in preference to IVF.
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Affiliation(s)
- Davinia M White
- Reproductive Medicine ClinicImperial College Healthcare NHS Trust, St Mary's Hospital, London, UK
| | - Kate Hardy
- Institute of Reproductive & Developmental BiologyImperial College London, Hammersmith Hospital, London, UK
| | - Suzannah Lovelock
- Institute of Reproductive & Developmental BiologyImperial College London, Hammersmith Hospital, London, UK
| | - Stephen Franks
- Institute of Reproductive & Developmental BiologyImperial College London, Hammersmith Hospital, London, UK
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6
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Yasmin E, Davies M, Conway G, Balen AH. British Fertility Society: ‘Ovulation induction in WHO Type 1 anovulation: Guidelines for practice’ Produced on behalf of the BFS Policy and Practice Committee. HUM FERTIL 2013; 16:228-34. [DOI: 10.3109/14647273.2013.829673] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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7
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Agrawal R, Burt E, Gallagher AM, Butler L, Venkatakrishnan R, Peitsidis P. Prospective randomized trial of multiple micronutrients in subfertile women undergoing ovulation induction: a pilot study. Reprod Biomed Online 2012; 24:54-60. [DOI: 10.1016/j.rbmo.2011.10.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2011] [Revised: 09/30/2011] [Accepted: 10/06/2011] [Indexed: 11/26/2022]
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8
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Diamond MP, Mitwally M, Casper R, Ager J, Legro RS, Brzyski R, Casson P, Eisenberg E, Zhang H. Estimating rates of multiple gestation pregnancies: sample size calculation from the assessment of multiple intrauterine gestations from ovarian stimulation (AMIGOS) trial. Contemp Clin Trials 2011; 32:902-8. [PMID: 21787883 PMCID: PMC3708642 DOI: 10.1016/j.cct.2011.07.009] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Revised: 06/03/2011] [Accepted: 07/04/2011] [Indexed: 11/18/2022]
Abstract
Infertility afflicts 15% of couples who wish to conceive. Despite intensive evaluation of both male and female partners, the etiology may remain unknown leading to a diagnosis of unexplained infertility. For such couples, treatment often entails ovulation induction (OI) with fertility medications coupled with intrauterine insemination. Complications of this therapy include ovarian hyperstimulation syndrome and creation of multiple gestation pregnancies, which can be complicated by preterm labor and delivery, and the associated neonatal morbidity and expense of care for preterm infants. The Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) study is designed to assess whether OI in couples with unexplained infertility with an aromatase inhibitor produces mono-follicular development in most cycles, thereby reducing multiple gestations while maintaining a comparable pregnancy success rate to that achieved by OI with either gonadotropins or clomiphene citrate. These results will provide future guidance of therapy for couples with unexplained infertility, and if comparable pregnancy rates are achieved with a substantial reduction in multiple gestations, the public health benefit will be considerable.
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Affiliation(s)
- Michael P. Diamond
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Wayne Sate University, 3800 Woodward Avenue, Suite 320, Detroit, Michigan, 48201,
| | - Mohamed Mitwally
- Canadian American Reproductive Medicine, 150 Bloor Street West, Suite 210, Toronto, Ontario, Canada, M5S 2X9,
| | - Robert Casper
- Samuel Lunenfeld Research Institute, Mount Sinai Hospital, 150 Bloor St W., Suite 210, Toronto, Ontario, Canada M5S 2X9,
| | - Joel Ager
- Department of Family Medicine and Public Health Sciences, Wayne State University, 540 E. Canfield, Detroit, MI 48201,
| | - Richard S. Legro
- Department of Obstetrics and Gynecology, H103, RM C3604 Pennsylvania State University College of Medicine 500 University Drive M.S. Hershey Medical Center Hershey, PA, 17033,
| | - Robert Brzyski
- UTHSCSA Department of Obstetrics and Gynecology 7703 Floyd Curl Drive MSC 7836, San Antonio, TX 78229-3900,
| | - Peter Casson
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Vermont, Fletcher Allen Health Care 111 Colchester Ave, Burlington, VT 05401,
| | - Esther Eisenberg
- Reproductive Medicine Network Reproductive Sciences Branch/CPR Eunice Kennedy Shriver National Institute of Child Health and Humand Development, NIH, 6100 Executive Boulevard, Room 8B-01, Bethesda, Maryland, 20892-7510, ;
| | - Heping Zhang
- Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT 06520-8031,
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9
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Agdi M, Zarei A, Al-Sannan B, Tulandi T, Tan SL. Effects of ovarian puncture for in vitro maturation on subsequent in vitro fertilization cycle in women with polycystic ovaries. Fertil Steril 2010; 94:381-3. [DOI: 10.1016/j.fertnstert.2009.09.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2009] [Revised: 09/12/2009] [Accepted: 09/16/2009] [Indexed: 10/20/2022]
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10
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Mukherjee S, Sharma S, Chakravarty BN. Comparative evaluation of pregnancy outcome in gonadotrophin-clomiphene combination vs clomiphene alone in polycystic ovarian syndrome and unexplained infertility-A prospective clinical trial. J Hum Reprod Sci 2010; 3:80-4. [PMID: 21209751 PMCID: PMC2970796 DOI: 10.4103/0974-1208.69341] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2009] [Revised: 02/02/2010] [Accepted: 07/17/2010] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES A large prospective clinical trial was conducted to compare the efficacy of single dose uFSH and clomiphene citrate combination with clomiphene citrate alone for ovulation induction to improve the pregnancy rate. MATERIALS AND METHODS The study was a randomized, prospective clinical trial. Totally, 1527 infertile women (4381 cycles) with polycystic ovarian syndrome (PCOS) (n=911/2573 cycles) and unexplained infertility (n=616/1808 cycles) were randomized into two groups. Group A received single dose of uFSH on D(3) of menstrual cycle along with clomiphene. Group B received clomiphene only for ovulation induction. We compared the pregnancy rate and miscarriage rate between two groups. RESULTS Group A had a pregnancy rate of 17% compared to 8.3% of Group B which was significantly higher (P=0.0001). The miscarriage rate was 11% in Group A and 10% in Group B which was not significant (P=0.99). Pregnancy rates in PCOS women were 22% in Group A and 9.3% in Group B which shows significantly higher pregnancy rate (P=0.0001) in anovulatory infertility. But in unexplained infertility, there was no significant difference in pregnancy rate between Group A (11%) and Group B(6.3%). Miscarriage rates were 8.8% and 9.5% in Group A and Group B, respectively, in PCOS women and 14% and 13% in women with unexplained infertility. CONCLUSION Addition of single dose of uFSH improves pregnancy outcome particularly in anovulatory infertility (WHO II). Correction of unexplained infertility may need more than simple correction of possible subtle ovulatory effect.
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Affiliation(s)
- Shiuli Mukherjee
- Department of Reproductive Medicine, Institute of Reproductive Medicine, Salt Lake City, Kolkata - 700 106, India
| | - Sunita Sharma
- Department of Reproductive Medicine, Institute of Reproductive Medicine, Salt Lake City, Kolkata - 700 106, India
| | - B N Chakravarty
- Department of Reproductive Medicine, Institute of Reproductive Medicine, Salt Lake City, Kolkata - 700 106, India
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11
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Schieve LA, Devine O, Boyle CA, Petrini JR, Warner L. Estimation of the contribution of non-assisted reproductive technology ovulation stimulation fertility treatments to US singleton and multiple births. Am J Epidemiol 2009; 170:1396-407. [PMID: 19854803 DOI: 10.1093/aje/kwp281] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Infertility treatments that include ovulation stimulation, both assisted reproductive technologies (ARTs) and non-ART ovulation stimulation, are associated with increased risks of multiple birth and concomitant sequelae and adverse outcomes, even among singletons. While a US surveillance system for ART-induced births is ongoing, no population-based tracking system exists for births resulting from non-ART treatments. The authors developed a multistage model to estimate the uncertain proportion of US infants born in 2005 who were conceived by using non-ART ovulation treatments. Using published surveillance data, they estimated proportions of US multiple births conceived naturally and by ART and assumed that the remainder were conceived with non-ART treatments. They used Bayesian meta-analyses to summarize published clinical studies on the multiple-gestation risk associated with non-ART ovulation treatments, applied a fetal survival factor, and used this multiple-birth risk estimate and their own estimate of the proportion of US multiple births attributable to non-ART ovulation stimulation to estimate the total (and, through subtraction, singleton) proportion of infants conceived with such treatments. On the basis of the model, the authors estimate that 4.6% of US infants born in 2005 (95% uncertainty range: 2.8%-7.1%) resulted from non-ART ovulation treatments. Notably, this figure is 4 times greater than the ART contribution.
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Affiliation(s)
- Laura A Schieve
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, MS E-86, 1600 Clifton Road, Atlanta, GA 30333, USA.
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12
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Dickey RP. Strategies to reduce multiple pregnancies due to ovulation stimulation. Fertil Steril 2008; 91:1-17. [PMID: 18973894 DOI: 10.1016/j.fertnstert.2008.08.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2008] [Accepted: 08/05/2008] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To review factors associated with high-order multiple births (HOMB) due to ovulation induction (OI) and the efficacy of strategies to reduce their occurrence. DESIGN Retrospective analysis of published studies of OI with intrauterine insemination (IUI) where patient and cycle characteristics were fully documented. RESULT(S) High-order multiple pregnancies (HOMP) were positively related to use of high doses of gonadotropin, number of 7-10 mm preovulatory follicles, and E(2), and inversely related to age and number of treatment cycles. Strategies successful in reducing HOMP include: use of clomiphene (CC) before gonadotropins, minimal gonadotropin doses, cancellation for more than three follicles >10-15 mm, and aspiration of excess follicles. Depending on the strategy used, 5%-20% of cycles may be canceled but HOMP rates can be less than 2% and pregnancy rates can average 10%-20% per cycle. Pregnancy rates per patient need not be reduced if low doses are continued for 4-6 cycles. CONCLUSION(S) High-order multiple pregnancies due to OI can be reduced to 2% or less by less aggressive stimulation without reducing overall chances of pregnancy for most patients.
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Affiliation(s)
- Richard Palmer Dickey
- Department of Obstetrics and Gynecology, Louisiana State University School of Medicine, The Fertility Institute of New Orleans, New Orleans, Louisiana, USA.
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13
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Affiliation(s)
- P Merviel
- Service de gynécologie-obstétrique et médecine de la reproduction, centre de gynécologie-obstétrique (CGO), CHU d'Amiens, 124, rue Camille-Desmoulins, 80054 Amiens cedex 01, France.
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14
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Wang JX. Life table (survival) analysis to generate cumulative pregnancy rates in assisted reproduction: an alternative method of calculating the cumulative pregnancy rate in assisted reproduction technology. Hum Reprod 2005; 21:1-2. [PMID: 16155080 DOI: 10.1093/humrep/dei281] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The current method of calculating cumulative pregnancy rate can lead to an overestimation of treatment efficacy, especially over many cycles of assisted reproduction treatment. The choice of scale of passage of time should be dependent upon the types of treatment to be evaluated. The number of treatment cycles to which patients' effort and commitment is directly related may be appropriate where the chance of pregnancy is expected to be significantly higher than non-treatment for them. Limiting the calculation of cumulative pregnancy rate only to the second or third cycle within 1 or 2 years will ensure that most patients are included in the calculation. More research is needed to assess different methods and develop better variables for assessing the efficacy of infertility treatment that can be informative for patients over the course of their treatment.
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Affiliation(s)
- Jim X Wang
- Research Centre for Reproductive Health, Department of Obstetrics and Gynaecology, University of Adelaide, The Queen Elizabeth Hospital, Woodville, SA 5011, Australia.
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15
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Abstract
Ovulation induction is the method for treating anovulatory infertility. For patients with hypogonadotrophic hypogonadism, the treatment involves administration of both FSH and LH, while HCG is injected for follicle rupture. Pulsatile GnRH has the same effectiveness as gonadotrophins and the advantage of the low multiple pregnancy rate. In polycystic ovary syndrome (PCOS), the first treatment choice is clomiphene citrate. With this drug, in properly selected patients, the cumulative pregnancy rate approaches that of normal women. Low-dose protocols of FSH are the second line of treatment, effective in inducing monofollicular development. Laparoscopic ovarian drilling can be an alternative but not as a first choice treatment in clomiphene-resistant patients. Other treatments, such as pulsatile GnRH and GnRH agonists, are hardly used today in PCOS. However, in obese women with PCOS, weight loss and exercise should be recommended as the first line of therapy. Newer agents including aromatase inhibitors and insulin sensitizers, although promising, need further evaluation.
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Affiliation(s)
- Ioannis E Messinis
- Department of Obstetrics and Gynaecology, University of Thessalia, Medical School, Larissa, Greece.
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16
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Abstract
The practice of ovulation induction and superovulation for IVF has progressed in many ways since the first reports of pregnancies after IVF over 25 years ago. The pharmacology of gonadotrophins has advanced alongside other developments, leading to safer, easier and more effective treatments for anovular infertility and IVF ovulation induction. This review uses current concepts of the basic physiology of gonadotrophin actions during the natural ovarian cycle as a starting point from which to assess their uses in anovulation and assisted reproduction. The relative merits of urinary and recombinant gonadotrophins are discussed, along with their uses in combination with gonadotrophin-releasing hormone agonists and antagonists.
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Affiliation(s)
- William Ledger
- University of Sheffield, Centre for Reproductive Medicine and Fertility, Jessop Wing, Royal Hallamshire Hospital, Sheffield S10 2SF, UK.
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Ulug U, Ben-Shlomo I, Tosun S, Erden HF, Akman MA, Bahceci M. The reproductive performance of women with hypogonadotropic hypogonadism in an in vitro fertilization and embryo transfer program. J Assist Reprod Genet 2005; 22:167-71. [PMID: 16021861 PMCID: PMC3455285 DOI: 10.1007/s10815-005-4914-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2004] [Accepted: 12/30/2004] [Indexed: 10/25/2022] Open
Abstract
PURPOSE To evaluate the outcome of women with hypogonadotropic hypogonadism undergoing in-vitro fertilization (IVF). METHODS We retrospectively assessed outcomes in 58 women with hypogonadotropic hypogonadism (HH) and, as matched controls, in 116 women with tubal factor (TF) infertility who underwent assisted reproduction treatment (ART). For ovulation induction, human menopausal gonadotropin (hMG) was used in HH patients and a combination of hMG and gonadotropin releasing hormone (GnRH) agonist was used in TF patients. Conception and implantation rates, as well as duration of stimulation and number of oocytes retrieved, were the main outcome measures. RESULTS Of the 58 HH patients, 53 (91.3%) responded adequately to ovulation induction and underwent ET. A larger amount of gonadotropins and a longer duration of ovarian stimulation were needed in HH patients than in TF patients. The mean number of retrieved oocytes and implantation rates did not differ between the groups. In addition, there were no differences between the HH and TF groups in pregnancy (53.8 vs. 48.6%) and multiple pregnancy (63.4 vs. 48.4%) rates. In the HH group, the miscarriage rate was 3.4%, and none of these patients developed severe OHSS. CONCLUSION IVF in HH patients, in which there was a background of previous failed ovulation induction, was as successful as in women with TF infertility.
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Affiliation(s)
- Ulun Ulug
- Bahceci Women Health Care Center and German Hospital at Istanbul, Istanbul, Turkey
| | - Izhar Ben-Shlomo
- Division for Reproductive Biology, Department of Obstetrics and Gynecology, Room S383 Stanford University Medical Center, Stanford, CA
| | - Süleyman Tosun
- Bahceci Women Health Care Center and German Hospital at Istanbul, Istanbul, Turkey
| | - Halit Firat Erden
- Bahceci Women Health Care Center and German Hospital at Istanbul, Istanbul, Turkey
| | - Mehmet Ali Akman
- Bahceci Women Health Care Center and German Hospital at Istanbul, Istanbul, Turkey
| | - Mustafa Bahceci
- Bahceci Women Health Care Center and German Hospital at Istanbul, Istanbul, Turkey
- Yeditepe University School of Medicine, Istanbul, Turkey
- Azer Is Merkezi 44/17 Kat 6, Abdi İpekci Cad. Nisantasi 80200, Istanbul, Turkey
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18
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Schüring AN, Kiesel L. Hormonelle Therapie des polyzystischen Ovarsyndroms (PLOS). GYNAKOLOGE 2005. [DOI: 10.1007/s00129-005-1673-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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19
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Dickey RP, Taylor SN, Lu PY, Sartor BM, Rye PH, Pyrzak R. Risk factors for high-order multiple pregnancy and multiple birth after controlled ovarian hyperstimulation: Results of 4,062 intrauterine insemination cycles. Fertil Steril 2005; 83:671-83. [PMID: 15749497 DOI: 10.1016/j.fertnstert.2004.10.030] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2004] [Revised: 10/28/2004] [Accepted: 10/28/2004] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine factors responsible for high-order multiple pregnancy (HOMP) and high-order multiple births when multiple cycles of controlled ovarian hyperstimulation-IUI (COH-IUI) are performed. DESIGN Retrospective analysis. SETTING Private infertility clinic. PATIENT(S) Women (n = 2,272) who underwent 4,067 consecutive COH-IUI cycles. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) High-order multiple pregnancy rate, pregnancy rate (PR), and birth rate (PR) per cycle. RESULT(S) High-order multiple pregnancy was related to number of follicles of diameter > or = 10 mm, age, and treatment cycle. For age <32 years, HOMP was 6% for three to six follicles and 20% for seven or more follicles. For ages 32 to 37 years, HOMP was 5% for three to six follicles and 12% for seven or more follicles. In the first COH-IUI cycle, HOMP was 8% for three to six follicles and 15% for seven or more follicles. In the second cycle, HOMP did not occur unless there were more than six follicles. No HOMP occurred after the second cycle. Pregnancy rate did not increase significantly when there were more than four follicles. Continuing COH-IUI past the third cycle resulted in additional pregnancies in patients with one to eight follicles. CONCLUSION(S) High-order multiple pregnancy can be predicted by age and number of follicles of diameter > or = 10 mm. Controlled ovarian hyperstimulation is not necessary to achieve satisfactory overall pregnancy rates if ovulation induction is continued past the third cycle in low responders.
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Affiliation(s)
- Richard P Dickey
- The Fertility Institute of New Orleans, New Orleans, Louisiana 70128, USA.
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20
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Abstract
Despite improvements in both diagnostic assessment and treatment of infertile couples, many couples still have no explanation for their infertility. Unexplained infertility (the failure to conceive of a couple in whom no definitive cause for infertility can be found) has an incidence of 10-20% in all infertile couples. The incidence varies with the population studied and with the criteria used. Unexplained infertility is not an absolute condition but rather a relative inability to conceive, and many of these couples may conceive without treatment. The treatment options for unexplained infertility are several and the treatment results are promising. Expectant management can be recommended if the woman is under 28-30 years of age and the infertility duration is less than 2-3 years. In vitro fertilization (IVF) has revolutionized the treatment of infertile couples, as well as profoundly increasing the basic understanding of human reproduction. IVF can be used as both a diagnostic and a therapeutic tool in couples with unexplained infertility. The pregnancy rates with IVF are good, at 40% per treatment cycle. In addition, the outcome of pregnancies among women with unexplained infertility is generally comparable to that of spontaneous and other pregnancies using assisted reproductive technologies.
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Affiliation(s)
- R Isaksson
- Department of Obstetrics and Gynecology, Helsinki University Central Hospital, Helsinki, Finland
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21
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Randolph JF, Ginsburg KA, Leach RE, Blacker CM, Moghissi KS, Diamond MP, Reame NE. Elevated early follicular gonadotropin levels in women with unexplained infertility do not provide evidence for disordered gonadotropin-releasing hormone secretion as assessed by luteinizing hormone pulse characteristics. Fertil Steril 2003; 80:320-7. [PMID: 12909494 DOI: 10.1016/s0015-0282(03)00612-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To determine whether women with rigorously defined unexplained infertility demonstrated altered GnRH secretion, as reflected by serum LH secretion patterns. DESIGN Prospective observational study. SETTING National Center for Infertility Research at Michigan. PATIENT(S) Nine women with rigorously defined unexplained infertility and 11 healthy, parous age-matched control women.Gonadotropin-releasing hormone (25 ng/kg) as a bolus injection. MAIN OUTCOME MEASURE(S) Daytime pulse patterns of LH secretion measured every 10 minutes; mean serum concentrations of LH, FSH, E(2), P, PRL, and cortisol; and response to a physiologic dose of GnRH in the early follicular, late follicular, mid-luteal, and late luteal phases of the same menstrual cycle. RESULT(S) Serum LH pulse frequency and pulse amplitude and LH secretion in response to a physiologic bolus of GnRH were not significantly different in unexplained infertility patients at any phase of the cycle. Luteinizing hormone pulse frequency and amplitude, as well as response to GnRH, varied significantly across the cycle. Mean early follicular serum LH and FSH concentrations were significantly higher in unexplained infertility patients than in fertile control subjects (LH: 5.31 +/-.51 vs. 4.03 +/-.33 [mIU/mL +/- SEM]; FSH: 5.81 +/-.63 vs. 3.80 +/-.45) but were not different at any other phase of the cycle. CONCLUSION(S) These data do not support the hypothesis that unexplained infertility is caused by an abnormality in pulsatile GnRH secretion or abnormal pituitary sensitivity to GnRH. However, the results are consistent with a difference in negative feedback from the ovary to the pituitary in unexplained infertility patients that is suggestive of diminished ovarian reserve.
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Affiliation(s)
- John F Randolph
- National Center for Infertility Research at Michigan and the University of Michigan, Ann Arbor, Michigan 48109-0276, USA.
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Affiliation(s)
- David L Healy
- Department of Obstetrics and Gynaecology, Monash University, Monash Medical Centre, Clayton, Victoria, Australia.
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23
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Dickey RP, Taylor SN, Lu PY, Sartor BM, Rye PH, Pyrzak R. Relationship of follicle numbers and estradiol levels to multiple implantation in 3,608 intrauterine insemination cycles. Fertil Steril 2001; 75:69-78. [PMID: 11163819 DOI: 10.1016/s0015-0282(00)01631-9] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the relationship of follicle numbers and estradiol (E(2)) levels to multiple implantations in human menopausal gonadotropin (hMG) and clomiphene citrate (CC) cycles. DESIGN Fifteen-year prospective study. SETTING Private infertility clinic. PATIENT(S) Women who underwent 3608 cycles of husband or donor intrauterine insemination (IUI). INTERVENTION(S) Ovulation induction (OI) with CC, hMG, or CC+hMG. MAIN OUTCOME MEASURE(S) Pregnancy and multiple implantations. RESULT(S) Triplet and higher-order implantations-but not twin implantations-were related to age, E(2) levels, and number of follicles > or = 12 mm and > or = 15 mm, but not number of follicles > or = 18 mm, in hMG and CC+hMG cycles. For patients less than 35 years old, three or more implantations tripled when six or more follicles were > or = 12 mm, in CC, hMG, and CC+hMG cycles, and when E(2) was > or = 1000 pg mL in hMG and CC+hMG cycles. For patients 35 or older, pregnancy rates in hMG and CC+hMG cycles doubled when six or more follicles were > or = 12 mm, or E(2) levels were >1000 pg mL, whereas 3 or more implantations were not significantly increased. CONCLUSIONS Withholding hCG or IUI in CC, hMG, and CC+hMG cycles when six or more follicles are > or = 12 mm may reduce triplet and higher-order implantations by 67% without significantly reducing pregnancy rates for patients under 35 years of age.
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Affiliation(s)
- R P Dickey
- The Fertility Institute of New Orleans, New Orleans, Louisiana 70128, USA
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Vollenhoven B, Clark S, Kovacs G, Burger H, Healy D. Prevalence of gestational diabetes mellitus in polycystic ovarian syndrome (PCOS) patients pregnant after ovulation induction with gonadotrophins. Aust N Z J Obstet Gynaecol 2000; 40:54-8. [PMID: 10870780 DOI: 10.1111/j.1479-828x.2000.tb03167.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Our aims were: 1. To investigate if women with PCOS who become pregnant using gonadotrophins have a higher incidence of gestational diabetes mellitus (GDM) compared to spontaneously pregnant matched control women, 2. To compare the prevalence of GDM in PCOS women with that in women with hypo/eugonadotrophic hypogonadism and in unexplained infertility and 3. To investigate differences in pregnancy outcomes between the groups. This was a retrospective case-control study. Women with PCOS were matched with a control by age, BMI, and ethnicity. There were 60 women with PCOS, 11 with hypogonadotrophic hypogonadism, 6 with eugonadotrophic hypogonadism, and 12 with unexplained infertility. Control women were those who attended a major public hospital for antenatal care and delivery We found no difference in the prevalence of GDM between the PCOS (22%) and the controls (17%) or between the PCOS and other groups. Women with GDM (diet or insulin controlled) had a significantly higher BMI than women without GDM (p = 0.019). There was no difference in pregnancy outcomes between the groups. There was a significant dependence of babies' birthweight on mother's BMI (p<0.001).
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Affiliation(s)
- B Vollenhoven
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
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25
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Abstract
Ovulation induction using clomiphene citrate, gonadotropins, and gonadotropin-releasing hormone is reviewed. The short- and long-term consequences of these therapies are discussed in detail.
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Affiliation(s)
- B J Vollenhoven
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
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Balen A. Endocrine methods of ovulation induction. BAILLIERE'S CLINICAL OBSTETRICS AND GYNAECOLOGY 1998; 12:521-39. [PMID: 10627765 DOI: 10.1016/s0950-3552(98)80049-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The rationale of ovulation induction is to achieve the development of a single follicle and ultimately a singleton healthy baby. Problems faced by women with anovulatory polycystic ovary syndrome are the sensitivity of the ovary to stimulation and health issues such as obesity. This chapter will discuss medical management including strategies to lose weight, address hyperinsulinaemia with insulin-sensitizing agents, such as metformin, and outline methods of ovulation induction from the usual first-line therapy of clomiphene citrate and the subsequent use of gonadotrophin therapy in clomiphene-resistant patients. Appropriately directed surgical ovulation induction with laparoscopic ovarian diathermy appears to be as efficacious as gonadotrophin therapy but will not be discussed in the context of this chapter.
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Affiliation(s)
- A Balen
- Department of Obstetrics and Gynaecology, General Infirmary, Leeds, UK
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