Detrimental Effect of Induced or Spontaneous Menses Before Ovulation Induction on Pregnancy Outcome in Patients With Polycystic Ovary Syndrome:

Overview of infertility

Having a child is an innate trait in animals, including humans, and is required for the continued existence of all animal species. Therefore, for most women, the inability to conceive or to do so in a timely fashion - termed infertility - to enable the continuation of the family line can be emotionally distressing. The definition of infertility is controversial because of its separation into primary and secondary. This is further complicated by the loosely used term subfertility, which relates to couples who have reduced ability because they take longer than the natural time to conceive, as opposed to those who are infertile and are entirely unable to conceive after 6 to 12 months, depending on age. Infertility evaluation requires a thorough male and female history, physical examination of both partners, and targeted investigation to determine the cause of infertility in a particular couple. Various treatments apply to infertile couples depending on the age of the female partner, the results of investigations, the reason for infertility, the presence of inheritance of abnormal genes, the pregnancy rates the couple is happy with, the resources available, how desperate the couple is to achieve a live birth, and how much they want to commit to treatment. Infertility treatment could include counseling and expectant management only, intrauterine insemination in a natural or stimulated cycle, and IVF and or ICSI. Men with azoospermia will need surgical options to retrieve sperm for IVF/ ICSI, but rarely for IUI. This review overviews infertility's etiology, diagnosis, investigations, and treatment.

The stair-step approach in treatment of anovulatory PCOS patients

Clomiphene citrate (CC) is a widely accepted first-line treatment for anovulatory patients with polycystic ovarian syndrome (PCOS). The current practice is to prescribe CC with gradual dose increments until ovulation is achieved. Typically, progesterone withdrawal bleeding is induced between each dose increment and before the commencement of gonadotropin therapy in CC-resistant patients. It has been recently suggested that dose increments of CC can be administered once failure to induce ovulation at a certain dose has been documented, without induction of progesterone withdrawal bleeding, and this approach has been nicknamed the clomiphene-citrate stair-step (CC-SS) protocol. The same principle has been found feasible before introducing gonadotropin therapy in CC-resistant PCOS patients. Our objective was to review the world literature on the CC-SS protocol and to summarize our own experience with extending the CC-SS approach to initiation of gonadotropin therapy. Studies on CC-SS protocol (n = 4) have found that this approach leads to a significant reduction of the time to ovulation and to an increased ovulation rate. In our own retrospective case series, 18 CC-resistant PCOS patients initiated gonadotropin stimulation without induction of progesterone withdrawal bleeding, using the chronic low-dose regimen. The time to ovulation in the study group was 54.2 ± 6.2 days, while the estimated time to ovulation calculated according to the traditional approach was approximately 110 days. The clinical pregnancy rate was 44% (8/18), and all pregnancies were singletons. One patient miscarried; hence, the live birth rate was 38.9% (7/18). In summary, the CC-SS approach and its extension to the initiation of gonadotropin therapy results in considerable reduction of the time to ovulation, and favorable ovulation rates and reproductive outcome. Large-scale confirmation of these findings by properly designed randomized controlled trials may lead to a change of practice in the treatment of anovulatory infertility in PCOS patients, allowing simplification of treatment and a shorter time to ovulation and pregnancy.

Clomiphene Stair-Step Protocol for Women With Polycystic Ovary Syndrome

OBJECTIVE

To compare time to ovulation, ovulation rates, and side effect profile of traditional and the stair-step protocol for ovulation induction using clomiphene citrate in women with polycystic ovary syndrome (PCOS).

METHODS

We performed a retrospective study of women seeking care for infertility with a diagnosis of PCOS at a university-based infertility clinic from July 2012 to July 2014. We included patients who were resistant to the initial starting dose of 50 mg clomiphene. The primary outcome was time to ovulation. Secondary outcomes included ovulation rates, clinical pregnancy rates, and mild and moderate-to-severe side effects based on dose. For the traditional protocol, higher doses of clomiphene were used each subsequent month if no ovulation occurred. For the stair-step protocol, higher doses of clomiphene were given 7 days after the last dose if no dominant follicles were seen on ultrasonography. Our study had 80% power to detect a 20% difference in ovulation.

RESULTS

One hundred nine patients were included in the analysis with 66 (60.6%) in the traditional and 43 (39.4%) in the stair-step protocol. Age and body mass index were similar between groups. The time to ovulation was decreased in the stair-step protocol group compared with the traditional protocol group (23.1±0.9 days vs 47.5±6.3 days). Ovulation rates were increased in the stair-step group compared with the traditional group at 150 mg (16 [37%] vs 8 [12%], P=.004) and at 200 mg (9 [21%] vs 3 [5%], P=.01). Pregnancy rates were similar between groups once ovulation was achieved (12 [18.1%] vs 7 [16.3%], P=.08). The stair-step protocol had an increased incidence of mild side effects (vasomotor flushes, headaches, gastrointestinal disturbance, mastalgia, changes in mood; 18 [41%] vs 8 [12%]), but there was no difference in the incidence of severe side effects (headaches, visual disturbances).

CONCLUSION

For women with PCOS, the stair-step clomiphene protocol is associated with decreased time to ovulation and increased ovulation rates at higher doses when compared with the traditional protocol.

Extension of the clomiphene citrate stair-step protocol to gonadotropin treatment in women with clomiphene resistant polycystic ovarian syndrome

Our objective was to evaluate the safety and efficacy of direct initiation of gonadotropin ovarian stimulation without prior withdrawal bleeding in anovulatory clomiphene citrate (CC) resistant polycystic ovarian syndrome (PCOS) patients. Eighteen PCOS patients underwent ovulation induction with CC using a stair-step regimen. Patients who failed to respond to the maximal dose of CC initiated gonadotropin stimulation without inducing withdrawal bleeding, using the chronic low dose regimen. The primary outcome measure was the time to ovulation from the beginning of CC treatment until the day of ovulatory trigger. This was compared with the time to ovulation calculated according to the traditional approach, which includes inducing progesterone withdrawal bleeding between each CC dose increment and before gonadotropin therapy. The time to ovulation in the study group was 67.0 ± 6.8 days. The estimated time to ovulation according to the traditional approach was approximately 110 days. The clinical pregnancy rate was 44% (8/18), and all pregnancies were singletons. One patient miscarried; hence the live birth rate was 38.9% (7/18). Direct initiation of gonadotropin therapy without prior induction of withdrawal bleeding in clomiphene resistant PCOS patients results in considerable reduction of the time to ovulation and is both safe and efficacious.

Randomized Trial Comparing the Effect of Endometrial Shedding With Medroxyprogesterone Acetate With Random Start of Clomiphene Citrate for Ovulation Induction in Oligo-ovulatory and Anovulatory Women

OBJECTIVE

A recent retrospective study demonstrated that anovulatory infertile women who did not have a progestogen-induced withdrawal bleed before treatment with clomiphene citrate (CC) had higher pregnancy rates than women who had a withdrawal bleed and those who had spontaneous menstrual bleeding. We sought to assess endometrial thickness at the time of ovulation in oligo-ovulatory and anovulatory women who took CC with or without a preceding progestogen-induced withdrawal bleed.

METHODS

We conducted a pilot randomized trial in which women with infertility and oligomenorrhea or amenorrhea were randomly assigned to take either CC after a withdrawal bleed induced by medroxyprogesterone acetate (MPA) 10 mg daily for 10 days or to take CC without such a bleed. Study participants underwent cycle monitoring with ultrasound assessment of endometrial thickness at the time of LH surge or a human chorionic gonadotropin trigger, followed by timed intercourse or intrauterine insemination. Women who had not ovulated by cycle day 21 took an increased dose of CC, with or without an MPA-induced withdrawal bleed, to a maximum of three cycles. Participants and nurses were asked to complete a questionnaire about the study.

RESULTS

There was no significant difference in endometrial thickness on the day of LH surge or human chorionic gonadotropin trigger between women who had a progestogen-induced withdrawal bleed and those who did not (P = 0.65). On average, the time to ovulation was 15 days longer in women who took MPA than in women who did not, but this difference was not statistically significant (P = 0.65). Satisfaction with the study was reported as high by both patients and nurses.

CONCLUSION

In anovulatory or oligo-ovulatory women treated with CC, we found no significant difference in endometrial thickness whether or not the use of CC was preceded by a withdrawal bleed induced by MPA.