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Abu-Zaid A, Gari A, Sabban H, Alshahrani MS, Khadawardi K, Badghish E, AlSghan R, Bukhari IA, Alyousef A, Abuzaid M, Alsharif SA, Alomar O, Alamery AH, Baradwan S. Comparison of Letrozole and Clomiphene Citrate in Pregnancy Outcomes in Patients with Polycystic Ovary Syndrome: A Systematic Review and Meta-analysis. Reprod Sci 2024; 31:883-905. [PMID: 38030814 DOI: 10.1007/s43032-023-01404-8] [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: 06/08/2023] [Accepted: 11/04/2023] [Indexed: 12/01/2023]
Abstract
Clomiphene citrate (CC) and letrozole are the predominant medical interventions for the management of infertility in patients with polycystic ovary syndrome (PCOS). To comprehensively summarize the evidence, a systematic review and meta-analysis of randomized clinical trials (RCTs) was carried out to assess the effect of letrozole and CC on pregnancy outcomes in PCOS patients. We searched PubMed/MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials from inception to January 2023. We included RCTs conducted on PCOS women comparing letrozole to CC and assessing endometrial thickness, the number and size of follicles, and ovulation and pregnancy rates. The endpoints were summarized as risk ratio (RR) or standardized mean difference (SMD) with 95% confidence interval (CI) using the random-effects model. Heterogeneity was examined using the I2 statistic. Fifty trials met our inclusion criteria. The mean endometrial thickness was significantly higher in the letrozole group compared to CC group (SMD: 0.89; 95% CI: 0.49, 1.28; I2=97.72%); however, the number of follicles was higher in the CC group (SMD: -0.56; 95% CI: -0.96, -0.17; I2=96.34%). Furthermore, letrozole intake induced higher ovulation rate (RR: 1.20; 95% CI: 1.13, 1.26; I2=54.49%) and pregnancy rate (RR: 1.44; 95% CI: 1.28, 1.62; I2=65.58%) compared to CC. Compared to CC, letrozole has a positive effect on endometrial thickness, monofollicular development, and ovulation and pregnancy rates suggesting that letrozole may be a strong alternative to CC as a first-line medical intervention for chronic anovulation in PCOS women. Larger studies are warranted to further clarify these findings.
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Affiliation(s)
- Ahmed Abu-Zaid
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
| | - Abdulrahim Gari
- Department of Obstetrics and Gynecology, College of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
- Department of Obstetrics and Gynecology, Almurjan Hospital, Jeddah, Saudi Arabia
| | - Hussein Sabban
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
- Department of Obstetrics and Gynecology, Faculty of Medicine at Rabigh, King Abdulaziz University, Rabigh, Saudi Arabia
| | - Majed Saeed Alshahrani
- Department of Obstetrics and Gynecology, Faculty of Medicine, Najran University, Najran, Saudi Arabia
| | - Khalid Khadawardi
- Department of Obstetrics and Gynecology, College of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Ehab Badghish
- Department of Obstetrics and Gynecology, Maternity and Children Hospital, Makkah, Saudi Arabia
| | - Rayan AlSghan
- Department of Obstetrics and Gynecology, Maternity and Children Hospital, AlKharj, Saudi Arabia
| | - Ibtihal Abdulaziz Bukhari
- Department of Obstetrics and Gynecology, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Abdullah Alyousef
- Department of Obstetrics and Gynecology, King Abdullah bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
| | - Mohammed Abuzaid
- Department of Obstetrics and Gynecology, Muhayil General Hospital, Muhayil, Saudi Arabia
| | - Saud Abdullah Alsharif
- Department of Obstetrics and Gynecology, College of Medicine, Prince Sattam bin Abdulaziz University, Alkharj, Saudi Arabia
| | - Osama Alomar
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Aliyah Hadi Alamery
- Department of Obstetrics and Gynecology, Specialized Medical Center, Riyadh, Saudi Arabia
| | - Saeed Baradwan
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
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Bahawi YO, Radwan EM, Khouj MA, Alotaibi RK, Bajuwaiber NA, Baghlaf LF, AlFaraj WF, Oraif AM. Pregnancy Rates in Women With Polycystic Ovary Syndrome (PCOS) Using Letrozole Versus Clomiphene Citrate: A Retrospective Record Review. Cureus 2023; 15:e42257. [PMID: 37605693 PMCID: PMC10440068 DOI: 10.7759/cureus.42257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2023] [Indexed: 08/23/2023] Open
Abstract
Background and objectives Polycystic ovary syndrome (PCOS) is a prominent cause of anovulation. Thus, this study aimed to compare the pregnancy rates of women with PCOS treated with letrozole (LE) or clomiphene citrate (CC) at King Abdulaziz University Hospital. Patients and methods A retrospective record review was conducted from April 2021 to August 2022 to review 1370 records of women with PCOS from January 2015 to December 2021. Sixty-one patients were included in this analysis. Chi-square tests and independent sample t-tests were used to analyze various associations. Statistical significance was set at P < 0.05. Results Letrozole was associated with a higher pregnancy rate (41.7%) than CC (32.0%). However, this relationship was not statistically significant (P = .619). Furthermore, patients treated with letrozole required fewer cycles to achieve pregnancy (two cycles compared to three cycles). The different age groups and body mass indexes did not affect the pregnancy rate in either group. Conclusion No significant difference was found between CC and LE in ovulation induction and outcome among PCOS patients. Studies with larger sample sizes and multiple centers should be conducted in Saudi Arabia to obtain more conclusive results, which will eventually lead to changes in guidelines for anovulation treatment in women with PCOS.
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Affiliation(s)
- Yara O Bahawi
- Department of Medicine, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
| | - Ebtesam M Radwan
- Department of Medicine, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
| | - Maryam A Khouj
- Department of Medicine, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
| | - Rahaf K Alotaibi
- Department of Medicine, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
| | - Nada A Bajuwaiber
- Department of Medicine, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
| | - Lama F Baghlaf
- Department of Medicine, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
| | - Wala F AlFaraj
- Department of Medicine, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
| | - Ayman M Oraif
- Department of Obstetrics and Gynecology, King Abdulaziz University, Jeddah, SAU
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Sharma P, Chandra R, Sarkar A, Jindal S, Sharma A, Sharma JC, Jaggarwal S. Assessment of Fertility Outcomes Following Combined Clomiphene and Letrozole Versus Letrozole Therapy for the Treatment of Polycystic Ovarian Syndrome Subfertility. Cureus 2023; 15:e38886. [PMID: 37303342 PMCID: PMC10257441 DOI: 10.7759/cureus.38886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2023] [Indexed: 06/13/2023] Open
Abstract
BACKGROUND Poly Cystic Ovarian Syndrome (PCOS) affects 8-13% of women in their reproductive age and is one of the foremost causes of female subfertility. Traditionally, clomiphene citrate has been the first-line treatment for ovulation induction in PCOS. However, the European Society of Human Reproduction and Embryology (ESHRE) international evidence-based guidelines in 2018 recommended the use of letrozole as first-line therapy for ovulation induction in anovulatory PCOS women, due to better pregnancy and live birth rates. Here we aimed to evaluate the effect of combined - clomiphene and letrozole versus letrozole for the treatment of PCOS subfertility. METHODS It was a retrospective cohort study conducted on reproductive-age women fulfilling Rotterdam Criteria for PCOS with a history of subfertility. All participants receiving at least one cycle of letrozole and clomiphene combination were recruited as cases. However, women receiving letrozole only for ovulation induction were taken as controls. Hospital records were abstracted for data on baseline characteristics such as age, duration of infertility, PCOS phenotype, body mass index (BMI), past medical and fertility history, treatment with ovulation induction agents, and metformin use. The mean size of the largest follicle, number of dominant follicles of size greater than 15 mm and endometrial thickness on Days 12-14 or on the day of the luteinizing hormone (LH) surge were recorded. A cycle was termed ovulatory if serum progesterone levels were > 5.0 ng/ml on the seventh day after the LH surge or day 22 in the absence of the LH surge. Data pertaining to therapy-associated side effects were also abstracted from the clinical records. RESULTS Amongst the ovulatory cycles in both groups, there was no significant difference in the day of the LH surge. Serum progesterone levels on the seventh day post-ovulation were higher with combination therapy (19.35 v/s 26.71, p=0.004). The number of ovulatory cycles was also greater with combination therapy, but the difference was just short of significant (25 vs 18, p=0.08). The mean diameter of the largest follicle, incidence of multi-follicular ovulation, and thin endometrium were similar in both groups. The adverse effect profile was similar in both groups. CONCLUSION Combination treatment of clomiphene citrate with letrozole may potentially improve fertility outcomes in PCOS subfertility in terms of the likelihood of ovulation and higher post-ovulatory progesterone levels, however, larger studies are required.
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Affiliation(s)
- Priyanka Sharma
- Obstetrics and Gynecology, Employee State Insurance Corporation (ESIC) Medical College and Hospital, Faridabad, Faridabad, IND
| | - Ramesh Chandra
- Obstetrics and Gynecology, Employee State Insurance Corporation (ESIC) Medical College and Hospital, Faridabad, IND
| | - Avir Sarkar
- Obstetrics and Gynecology, Employee State Insurance Corporation (ESIC) Medical College and Hospital, Faridabad, IND
| | - Sonam Jindal
- Obstetrics and Gynecology, Employee State Insurance Corporation (ESIC) Medical College and Hospital, Faridabad, IND
| | - Annu Sharma
- Obstetrics and Gynecology, Employee State Insurance Corporation (ESIC) Medical College and Hospital, Faridabad, IND
| | - Jagadish C Sharma
- Obstetrics and Gynecology, Employee State Insurance Corporation (ESIC) Medical College and Hospital, Faridabad, IND
| | - Saroj Jaggarwal
- Obstetrics and Gynecology, Employee State Insurance Corporation (ESIC) Medical College and Hospital, Faridabad, IND
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Letrozole Compared With Clomiphene Citrate for Polycystic Ovarian Syndrome: A Systematic Review and Meta-analysis. Obstet Gynecol 2023; 141:523-534. [PMID: 36735392 DOI: 10.1097/aog.0000000000005070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/17/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To estimate the effect of letrozole and clomiphene citrate in women with infertility and polycystic ovarian syndrome (PCOS). METHODS OF STUDY SELECTION MEDLINE through PubMed, Web of Science, EMBASE, Cochrane Library, and ClinicalTrials.gov were searched for relevant studies from inception to February 1, 2022. Two reviewers retrieved, filtered, and extracted data independently using the bibliographic software EndNote X9 and Excel workbook. We included randomized controlled trials (RCTs) reporting ovulation induction outcomes in women with infertility and PCOS treated with either letrozole or clomiphene citrate followed by timed intercourse or intrauterine insemination. The data were merged into a mean difference or risk ratio (RR) with 95% CI, depending on variable types. TABULATION, INTEGRATION, AND RESULTS Data collection and organization were conducted in accordance with the 2020 PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) statement. Twenty-nine RCTs were eligible, which included 3,952 women and 7,633 ovulation induction cycles. We acquired evidence from 22 RCTs for the ovulation rate, 28 RCTs for the clinical pregnancy rate, and eight RCTs for live-birth rate. Pooled analysis indicated that letrozole treatment prevailed against clomiphene citrate in ovulation rate (RR 1.14, 95% CI 1.06-1.21, P <.001), clinical pregnancy rate (RR 1.48, 95% CI 1.34-1.63, P <.001), and live-birth rate (RR 1.49, 95% CI 1.27-1.74, P <.001). CONCLUSIONS Letrozole was associated with improved ovulation, pregnancy, and live-birth rates compared with clomiphene citrate. We recommend letrozole over clomiphene citrate as an ovulation induction drug in women with infertility and PCOS, although the quality of the evidence is mixed. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42022308777.
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Franik S, Le QK, Kremer JA, Kiesel L, Farquhar C. Aromatase inhibitors (letrozole) for ovulation induction in infertile women with polycystic ovary syndrome. Cochrane Database Syst Rev 2022; 9:CD010287. [PMID: 36165742 PMCID: PMC9514207 DOI: 10.1002/14651858.cd010287.pub4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Polycystic ovary syndrome (PCOS) is the most common cause of infrequent periods (oligomenorrhoea) and absence of periods (amenorrhoea). It affects about 5% to 20% of women worldwide and often leads to anovulatory infertility. Aromatase inhibitors (AIs) are a class of drugs that were introduced for ovulation induction in 2001. Since about 2001 clinical trials have reached differing conclusions as to whether the AI, letrozole, is at least as effective as the first-line treatment clomiphene citrate (CC), a selective oestrogen receptor modulator (SERM). OBJECTIVES To evaluate the effectiveness and safety of AIs (letrozole) (with or without adjuncts) compared to SERMs (with or without adjuncts) for infertile women with anovulatory PCOS for ovulation induction followed by timed intercourse or intrauterine insemination. SEARCH METHODS We searched the following sources, from their inception to 4 November 2021, to identify relevant randomised controlled trials (RCTs): the Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase and PsycINFO. We also checked reference lists of relevant trials, searched the trial registers and contacted experts in the field for any additional trials. We did not restrict the searches by language or publication status. SELECTION CRITERIA We included all RCTs of AIs used alone or with other medical therapies for ovulation induction in women of reproductive age with anovulatory PCOS. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, extracted the data and assessed risks of bias using RoB 1. We pooled trials where appropriate using a fixed-effect model to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for most outcomes, and risk differences (RDs) for ovarian hyperstimulation syndrome (OHSS). The primary outcomes were live birth rate and OHSS rate. Secondary outcomes were clinical pregnancy, miscarriage and multiple pregnancy rates. We assessed the certainty of the evidence for each comparison using GRADE methods. MAIN RESULTS This is a substantive update of a previous review; of six previously included trials, we excluded four from this update and moved two to 'awaiting classification' due to concerns about validity of trial data. We included five additional trials for this update that now includes a total of 41 RCTs (6522 women). The AI, letrozole, was used in all trials. Letrozole compared to SERMs with or without adjuncts followed by timed intercourse Live birth rates were higher with letrozole (with or without adjuncts) compared to SERMs followed by timed intercourse (OR 1.72, 95% CI 1.40 to 2.11; I2 = 0%; number needed to treat for an additional beneficial outcome (NNTB) = 10; 11 trials, 2060 participants; high-certainty evidence). This suggests that in women with a 20% chance of live birth using SERMs, the live birth rate in women using letrozole with or without adjuncts would be 27% to 35%. There is high-certainty evidence that OHSS rates are similar with letrozole or SERMs (0.5% in both arms: risk difference (RD) -0.00, 95% CI -0.01 to 0.01; I2 = 0%; 10 trials, 1848 participants; high-certainty evidence). There is evidence for a higher pregnancy rate in favour of letrozole (OR 1.69, 95% CI 1.45 to 1.98; I2 = 0%; NNTB = 10; 23 trials, 3321 participants; high-certainty evidence). This suggests that in women with a 24% chance of clinical pregnancy using SERMs, the clinical pregnancy rate in women using letrozole with or without adjuncts would be 32% to 39%. There is little or no difference between treatment groups in the rate of miscarriage per pregnancy (25% with SERMs versus 24% with letrozole: OR 0.94, 95% CI 0.66 to 1.32; I2 = 0%; 15 trials, 736 participants; high-certainty evidence) and multiple pregnancy rate (2.2% with SERMs versus 1.6% with letrozole: OR 0.74, 95% CI 0.42 to 1.32; I2 = 0%; 14 trials, 2247 participants; high-certainty evidence). However, a funnel plot showed mild asymmetry, indicating that some trials in favour of SERMs might be missing. Letrozole compared to laparoscopic ovarian drilling (LOD) One trial reported very low-certainty evidence that live birth rates may be higher with letrozole compared to LOD (OR 2.07, 95% CI 0.99 to 4.32; 1 trial, 141 participants; very low-certainty evidence). This suggests that in women with a 22% chance of live birth using LOD with or without adjuncts, the live birth rate in women using letrozole with or without adjuncts would be 24% to 47%. No trial reported OHSS rates. Due to the low-certainty evidence we are uncertain if letrozole improves pregnancy rates compared to LOD (OR 1.47, 95% CI 0.95 to 2.28; I² = 0%; 3 trials, 367 participants; low-certainty evidence). This suggests that in women with a 29% chance of clinical pregnancy using LOD with or without adjuncts, the clinical pregnancy rate in women using letrozole with or without adjuncts would be 28% to 45%. There seems to be no evidence of a difference in miscarriage rates per pregnancy comparing letrozole to LOD (OR 0.65, 95% CI 0.22 to 1.92; I² = 0%; 3 trials, 122 participants; low-certainty evidence). This also applies to multiple pregnancies (OR 3.00, 95% CI 0.12 to 74.90; 1 trial, 141 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS Letrozole appears to improve live birth rates and pregnancy rates in infertile women with anovulatory PCOS, compared to SERMs, when used for ovulation induction, followed by intercourse. There is high-certainty evidence that OHSS rates are similar with letrozole or SERMs. There was high-certainty evidence of no difference in miscarriage rate and multiple pregnancy rate. We are uncertain if letrozole increases live birth rates compared to LOD. In this update, we added good quality trials and removed trials with concerns over data validity, thereby upgrading the certainty of the evidence base.
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Affiliation(s)
- Sebastian Franik
- Department of Obstetrics and Gynaecology, University Hospital Münster, Münster, Germany
| | - Quang-Khoi Le
- Department of Obstetrics and Gynaecology, University Hospital Münster, Münster, Germany
| | - Jan Am Kremer
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands
| | - Ludwig Kiesel
- Department of Obstetrics and Gynaecology, University Hospital Münster, Münster, Germany
| | - Cindy Farquhar
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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Collée J, Mawet M, Tebache L, Nisolle M, Brichant G. Polycystic ovarian syndrome and infertility: overview and insights of the putative treatments. Gynecol Endocrinol 2021; 37:869-874. [PMID: 34338572 DOI: 10.1080/09513590.2021.1958310] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Infertility concerns 15% of the couples. Management of female infertility requires a complete history of the patient followed by a physical, gynecological and endocrine examination. Infertility etiology will be investigated thanks to different tests including ovarian function and reserve assessment, search for uterine abnormalities and evaluation of tubal permeability. Polycystic ovarian syndrome (PCOS) is a predominant cause of infertility and a common gyne-endocrine disorder affecting 7 to 15% of women in reproductive age. Behavioral, medical and surgical treatments have been evaluated in order to improve the fertility of women with PCOS. Lifestyle modifications (stop smoking, physical exercise and weight loss when necessary) are of the utmost importance. Clomiphene citrate remains the first line of medical treatment of infertility in women with PCOS in absence of other male or female causes of infertility. Use of metformin solely for infertility is not recommended in absence of metabolic anomaly and new treatment as myoinositol is emerging. Surgical techniques aiming to enhance ovulation and pregnancy rate are an option when medical treatment failed. Ovarian drilling by laparoscopy or by transvaginal hydrolaparoscopy is taking a larger place in the treatment of infertility. In vitro maturation and fertilization remain the third-line of treatment in PCOS.
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Affiliation(s)
- Julie Collée
- Department of Obstetrics and Gynecology, Hospital CHR Liège, University of Liège, Liège, Belgium
| | - Marie Mawet
- Department of Obstetrics and Gynecology, Hospital CHR Liège, University of Liège, Liège, Belgium
| | - Linda Tebache
- Department of Obstetrics and Gynecology, Hospital CHR Liège, University of Liège, Liège, Belgium
| | - Michelle Nisolle
- Department of Obstetrics and Gynecology, Hospital CHR Liège, University of Liège, Liège, Belgium
| | - Géraldine Brichant
- Department of Obstetrics and Gynecology, Hospital CHR Liège, University of Liège, Liège, Belgium
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Tsiami AP, Goulis DG, Sotiriadis AI, Kolibianakis EM. Higher ovulation rate with letrozole as compared with clomiphene citrate in infertile women with polycystic ovary syndrome: a systematic review and meta-analysis. Hormones (Athens) 2021; 20:449-461. [PMID: 34033068 DOI: 10.1007/s42000-021-00289-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Polycystic ovary syndrome (PCOS) is a common cause of anovulatory infertility. According to the latest guidelines, letrozole should be considered as the first-line pharmacological treatment for women with WHO Group II anovulation or PCOS. However, the use of letrozole as an ovulation induction agent is not FDA or EMA approved, and its use is "off-label." The main concern with respect to letrozole regards its potential teratogenic effect on the fetus. PURPOSE To determine whether the probability of ovulation is higher with letrozole as compared to clomiphene citrate (CC) in anovulatory women with PCOS. METHODS Randomized controlled trials (RCTs) comparing letrozole versus CC used for ovulation induction in infertile women with PCOS followed by timed intercourse (TI) or intrauterine insemination (IUI) were included in this meta-analysis. Primary outcome was ovulation. Secondary outcomes were live birth, clinical pregnancy, miscarriage, multiple pregnancy, and congenital anomalies. Subgroup analysis included patients who received letrozole or CC as first-line treatment, and patients with PCOS diagnosed according to the Rotterdam criteria. RESULTS Twenty-six RCTs published between 2006 and 2019, involving 4168 patients who underwent 8310 cycles of ovulation induction, were included. The probability of ovulation was significantly higher in letrozole as compared to CC cycles (RR: 1.148, 95% CI: 1.077 to 1.223, 3017 women, 19 trials, I2: 47.7%, low-quality evidence). CONCLUSION A higher probability of ovulation is expected in infertile patients with PCOS treated with letrozole as compared to CC. The higher ovulation rate might have contributed to the higher clinical pregnancy and live birth rate. This finding is also true for patients who were administered letrozole as first-line treatment. TRIAL REGISTRATION CRD42019125166.
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Affiliation(s)
- Alexandra P Tsiami
- National and Kapodistrian University of Athens, Irakleitou 1, 50132, Kozani, Greece.
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Papageorgiou General Hospital, Aristotle University of Thessaloniki, 54629, Thessaloniki, Greece
| | - Alexandros I Sotiriadis
- 2nd Department of Obstetrics and Gynecology, Faculty of Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, 54642, Thessaloniki, Greece
| | - Efstratios M Kolibianakis
- Unit of Human Reproduction, 1st Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki Papageorgiou General Hospital, 54629, Thessaloniki, Greece
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Shah N, Romanski PA, Bortoletto P, Rosenwaks Z, Kligman I. Determining the optimal follicle size at trigger in patients undergoing ovarian stimulation with a clomiphene citrate plus gonadotropin and GnRH antagonist protocol for in vitro fertilization. Minerva Obstet Gynecol 2021; 74:75-82. [PMID: 34180612 DOI: 10.23736/s2724-606x.21.04837-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Determine the optimal follicle size at trigger in clomiphene citrate-based IVF protocols. STUDY DESIGN This is a retrospective cohort study performed in at a single academic institution that included first IVF cycles with clomiphene citrate-based protocols at our center between 01/01/2013-03/31/2019. Patients were dichotomized by whether they had ≥2 follicles >20 mm on trigger day. Group A consisted of patients with <2 follicles >20 mm on trigger day and Group B consisted of patients with ≥2 follicles >20 mm on trigger day. The primary outcome was the number of mature oocytes retrieved. Secondary outcomes included pregnancy and live birth rates. RESULTS A total of 635 patients were included: (Group A = 399 patients and Group B = 236 patients). The median (IQR) diameter of the largest follicle was 20.0 mm (19.0-21.0) in Group A and 22.7 mm (21.8-24.0) in Group B (p < 0.001). Among the entire cohort, mean number of oocytes retrieved was significantly higher in Group B (9.9 ± 6.5; RR 1.08 (95% CI 1.03-1.14)) compared to Group A (9.2 ± 6.3). In a subgroup analysis of patients in the upper quartile for age (≥41.7 years), Group B had significantly more oocytes retrieved (8.1 ± 5.9 vs. 6.7 ± 4.5; RR 1.23 (95% CI 1.10-1.38)), more mature oocytes retrieved (6.0 ± 4.0 vs. 5.2 ± 3.4; RR 1.16 (95% CI 1.02-1.33)), and more zygotes (4.7 ± 3.5 vs. 3.6 ± 2.8; RR 1.32 (95% CI 1.13-1.55)). In the secondary analysis, pregnancy and live birth rates after fresh transfer were similar between groups. CONCLUSIONS In clomiphene citrate-based IVF protocols, administering the ovulatory trigger at larger follicle sizes yielded more total oocytes retrieved without a significant difference in mature oocyte number. In older patients, larger follicle sizes at trigger yielded more mature oocytes and zygotes per retrieval. Based on these results, in older patients it may be advantageous to administer the ovulatory trigger in clomiphene-based IVF cycles when two or more follicles measures >20 mm. However, this benefit was not observed when assessed among all ages combined.
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Affiliation(s)
- Nirali Shah
- Department of Obstetrics & Gynecology, Weill Cornell Medicine, New York, NY, USA
| | - Phillip A Romanski
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, NY, USA -
| | - Pietro Bortoletto
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, NY, USA
| | - Zev Rosenwaks
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, NY, USA
| | - Isaac Kligman
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical Center, New York, NY, USA
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Vagios S, Sacha CR, Hammer KC, Dimitriadis I, James KE, Bormann CL, Souter I. Response to ovulation induction treatments in women with polycystic ovary syndrome as a function of serum anti-Müllerian hormone levels. J Assist Reprod Genet 2021; 38:1827-1833. [PMID: 33934267 DOI: 10.1007/s10815-021-02217-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/28/2021] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To assess whether anti-Müllerian hormone (AMH) can predict response to ovulation induction (OI) with clomiphene citrate (CC), letrozole (LET), or follicle-stimulating hormone (FSH) in women with polycystic ovary syndrome (PCOS) undergoing OI/intrauterine inseminations (IUI). METHODS A total of 738 OI/IUI cycles from 242 patients at an academic center were stratified in three groups by medication: CC (n = 295), LET (n = 180), and FSH (n = 263), in a retrospective fashion. Ovarian response to treatment (RT, development of at least one dominant follicle) was assessed using mixed effects logistic regression models. RESULTS Overall, RT cycles had lower AMH levels compared to no-RT cycles (p < 0.001). This finding persisted when analysis was limited to oral agents but attenuated in FSH cycles. For CC and LET cycles, the predicted probability (PProb) for RT decreased as AMH levels increased (PProb (95%CI): 97% (93-100), 79% (70-88), and 75% (61-89); 85% (78-93), 75% (67-83), and 73% (63-86) for AMH pct.: ≤ 25th, ≥ 50th, and ≥ 75th, for CC and LET, respectively)). However, RT was noted in 98.5% of FSH/IUI cycles regardless of AMH. For CC cycles, those with AMH ≥ 75th pct. had lower odds for RT over cycles with AMH < 75th pct. (OR 0.2, 95%CI 0.04-0.8, p = 0.02). Similarly, lower odds for RT were observed in LET cycles with AMH ≥ 75th pct. (0.6, 0.3-1.4, p = 0.25). CONCLUSION In PCOS, increasing serum AMH levels are associated with lower probability of RT to oral agents. Our findings constitute a valuable tool for the clinician when counseling PCOS patients and designing a personalized ovulation induction treatment strategy.
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Affiliation(s)
- Stylianos Vagios
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Reproductive Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, Yawkey 10A, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Caitlin R Sacha
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Reproductive Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, Yawkey 10A, 55 Fruit Street, Boston, MA, 02114, USA
| | - Karissa C Hammer
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Reproductive Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, Yawkey 10A, 55 Fruit Street, Boston, MA, 02114, USA
| | - Irene Dimitriadis
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Reproductive Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, Yawkey 10A, 55 Fruit Street, Boston, MA, 02114, USA
| | - Kaitlyn E James
- Deborah Kelly Center for Outcomes Research, Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Charles L Bormann
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Reproductive Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, Yawkey 10A, 55 Fruit Street, Boston, MA, 02114, USA
| | - Irene Souter
- Massachusetts General Hospital Fertility Center, Department of Obstetrics, Gynecology, and Reproductive Biology, Division of Reproductive Endocrinology and Infertility, Massachusetts General Hospital and Harvard Medical School, Yawkey 10A, 55 Fruit Street, Boston, MA, 02114, USA
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10
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Nguyen TT, Doan HT, Quan LH, Lam NM. Effect of letrozole for ovulation induction combined with intrauterine insemination on women with polycystic ovary syndrome. Gynecol Endocrinol 2020; 36:860-863. [PMID: 32241195 DOI: 10.1080/09513590.2020.1744556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Objectives: To evaluate the efficacy and safety of letrozole on ovulation induction and pregnancy in infertility patients with polycystic ovary syndrome (PCOS). In addition, the insulin resistance was analyzed in these patients.Subjects and methods: Progressive description study with comparison. The study included 80 infertility women divided into two groups: 40 women with PCOS (the study group) and 40 women without PCOS (the control group). The both used letrozole for ovulation induction from cycle day 2.Results: No differences in the dominant follicle between the study group and the control group (1.16 ± 0.37 follicles and 1.30 ± 0.46 follicles, respectively). The clinical pregnancy rate was 22.5% of the both groups. The average insulin of the study group (10.85 ± 5.84 µUI/ml) and their average HOMA-IR (2.42 ± 1.34) were higher than the control group (7.44 ± 2.84 µUI/ml and 1.57 ± 0.68), p < .05. The QUICKI of the study group (0.35 ± 0.29) was lower than the control group (0.36 ± 0.25), p < .05.Conclusion: Letrozole is used to stimulate the ovaries of the infertile women with PCOS combined with intrauterine insemination is the effective treatment. These patients had the high risk of insulin resistance.
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Affiliation(s)
- Tung Thanh Nguyen
- IVF Department, Military Institute of Clinical Embryology and Histology, Military Medical University, Ha Noi, Vietnam
| | - Hang Thi Doan
- IVF Department, Military Institute of Clinical Embryology and Histology, Military Medical University, Ha Noi, Vietnam
| | - Lam Hoang Quan
- Military Institute of Clinical Embryology and Histology, Military Medical University, Ha Noi, Vietnam
| | - Ngoc Mai Lam
- Assisted Reproductive Technique Unit, Phu Tho Obstetrics and Pediatrics center, Viet Tri, Vietnam
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11
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Bordewijk EM, Wang R, van Wely M, Costello MF, Norman RJ, Teede H, Gurrin LC, Mol BW, Li W. To share or not to share data: how valid are trials evaluating first-line ovulation induction for polycystic ovary syndrome? Hum Reprod Update 2020; 26:929-941. [DOI: 10.1093/humupd/dmaa031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/25/2020] [Indexed: 12/19/2022] Open
Abstract
Abstract
BACKGROUND
In our recent individual participant data (IPD) meta-analysis evaluating the effectiveness of first-line ovulation induction for polycystic ovary syndrome (PCOS), IPD were only available from 20 studies of 53 randomized controlled trials (RCTs). We noticed that the summary effect sizes of meta-analyses of RCTs without IPD sharing were different from those of RCTs with IPD sharing. Granting access to IPD for secondary analysis has implications for promoting fair and transparent conduct of RCTs. It is, however, still common for authors to choose to withhold IPD, limiting the impact of and confidence in the results of RCTs and systematic reviews based on aggregate data.
OBJECTIVE AND RATIONALE
We performed a meta-epidemiologic study to elucidate if RCTs without IPD sharing have lower quality and more methodological issues than those with IPD sharing in an IPD meta-analysis evaluating first-line ovulation induction for PCOS.
SEARCH METHODS
We included RCTs identified for the IPD meta-analysis. We dichotomized RCTs according to whether they provided IPD (shared group) or not (non-shared group) in the IPD meta-analysis. We restricted RCTs to full-text published trials written in English.
We assessed and compared RCTs in the shared and non-shared groups on the following criteria: Risk of Bias (RoB 2.0), GRADE approach, adequacy of trial registration; description of statistical methods and reproducibility of univariable statistical analysis; excessive similarity or difference in baseline characteristics that is not compatible with chance; and other miscellaneous methodological issues.
OUTCOMES
In total, 45 trials (8697 women) were included in this study. IPD were available from 17 RCTs and 28 trials were categorized as the non-shared IPD group. Pooled risk rates obtained from the shared and non-shared groups were different. Overall low risk of bias was associated with 13/17 (76%) of shared RCTs versus 7/28 (25%) of non-shared RCTs. For RCTs that started recruitment after 1 July 2005, adequate trial registration was found in 3/9 (33%) of shared IPD RCTs versus 0/16 (0%) in non-shared RCTs. In total, 7/17 (41%) of shared RCTs and 19/28 (68%) of non-shared RCTs had issues with the statistical methods described. The median (range) of inconsistency rate per study, between reported and reproduced analyses for baseline variables, was 0% (0–92%) (6 RCTs applicable) in the shared group and 54% (0–100%) (13 RCTs applicable) in the non-shared group. The median (range) of inconsistency rate of univariable statistical results for the outcome(s) per study was 0% (0–63%) (14 RCTs applicable) in the shared group and 44% (0–100%) (24 RCTs applicable) in the non-shared group. The distributions of simulation-generated P-values from comparisons of baseline continuous variables between intervention and control arms suggested that RCTs in the shared group are likely to be consistent with properly conducted randomization (P = 0.163), whereas this was not the case for the RCTs in the non-shared group (P = 4.535 × 10−8).
WIDER IMPLICATIONS
IPD meta-analysis on evaluating first-line ovulation induction for PCOS preserves validity and generates more accurate estimates of risk than meta-analyses using aggregate data, which enables more transparent assessments of benefits and risks. The availability of IPD and the willingness to share these data may be a good indicator of quality, methodological soundness and integrity of RCTs when they are being considered for inclusion in systematic reviews and meta-analyses.
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Affiliation(s)
- Esmee M Bordewijk
- Department of Obstetrics and Gynecology, Monash University, Clayton, Australia
- Centre for Reproductive Medicine, Amsterdam UMC, Amsterdam, The Netherlands
| | - Rui Wang
- Department of Obstetrics and Gynecology, Monash University, Clayton, Australia
| | - Madelon van Wely
- Centre for Reproductive Medicine, Amsterdam UMC, Amsterdam, The Netherlands
| | - Michael F Costello
- School of Women's and Children's Health, The University of New South Wales, Sydney, Australia
| | - Robert J Norman
- Robinson Research Institute, The University of Adelaide, Adelaide, Australia
- Fertility SA, Adelaide, Australia
| | - Helena Teede
- Monash Centre for Health Research and Implementation, Monash University, Clayton, Australia
| | - Lyle C Gurrin
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Australia
| | - Ben W Mol
- Department of Obstetrics and Gynecology, Monash University, Clayton, Australia
| | - Wentao Li
- Department of Obstetrics and Gynecology, Monash University, Clayton, Australia
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12
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Qin F, Zhou Y, Huan L, Gui W. Comparison of clomiphene and letrozole for superovulation in patients with unexplained infertility undergoing intrauterine insemination: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e21006. [PMID: 32756085 PMCID: PMC7402796 DOI: 10.1097/md.0000000000021006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND With the medical advancement some studies put forward that letrozole (LE), a specific aromatase inhibitor with the function of reducing oestrogen synthesis, has recently been applied as a potentially better alternative compared with clomiphene citrate (CC), owing to that it has a superior efficacy as compared with CC in patients of unexplained infertility undergoing intrauterine insemination (IUI). However, there is no one study can clear and definite whether LE can replace the CC as first line drug. OBJECTIVE Our objective is to compare the LE with CC in the induction of ovulation in patients with unexplained infertility IUI. METHOD Searching databases consist of all kinds of searching tools, such as Medline, The Cochrane Library, Embase, PubMed, etc. All the include studies should meet our demand of this meta-analysis: RESULT:: Based on the current meta-analysis, we rigorously consider that LE has a likelihood to improve dominant follicles (MD= -0.56, I= 100%, P= .04; MD= -0.39, I= 73%, P = .0003, respectively) and reduces the miscarriage rate (RR= 0.61, I= 0%, P = .03). There is no significant differences between the 2 groups in The total rate of pregnancy, pregnancy rate per cycle, multiple pregnancy and endometrial thickness. (RR= 1.06, I= 11%, P = .38; RR= 1.09, I= 7%, P = .32; RR= 0.79, I= 0%, P = .46; respectively) CONCLUSION:: Combined with the results of current systematic review and meta-analysis through subgroup analysis and sensitivity analysis, we can be cautious: in general, compared with CC, LE is an effective treatment in the IUI cycle, has a likelihood to improve dominant follicles and reduces the miscarriage rate.
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Affiliation(s)
- Fei Qin
- Department of Assisted Reproduction, the First Affiliated Hospital of Chongqing Medical University
| | - Yanqiong Zhou
- Department of Assisted Reproduction, the First Affiliated Hospital of Chongqing Medical University
| | - Lu Huan
- Department of Hepatobiliary Surgery, the Chongqing Fifth People's Hospital, Chongqing, China
| | - Wenwu Gui
- Department of Assisted Reproduction, the First Affiliated Hospital of Chongqing Medical University
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13
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Wang R, Li W, Bordewijk EM, Legro RS, Zhang H, Wu X, Gao J, Morin-Papunen L, Homburg R, König TE, Moll E, Kar S, Huang W, Johnson NP, Amer SA, Vegetti W, Palomba S, Falbo A, Özmen Ü, Nazik H, Williams CD, Federica G, Lord J, Sahin Y, Bhattacharya S, Norman RJ, van Wely M, Mol BW. First-line ovulation induction for polycystic ovary syndrome: an individual participant data meta-analysis. Hum Reprod Update 2020; 25:717-732. [PMID: 31647106 DOI: 10.1093/humupd/dmz029] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 07/30/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Polycystic ovary syndrome (PCOS) is the most frequent cause of anovulatory infertility. In women with PCOS, effective ovulation induction serves as an important first-line treatment for anovulatory infertility. Individual participant data (IPD) meta-analysis is considered as the gold standard for evidence synthesis which provides accurate assessments of outcomes from primary randomised controlled trials (RCTs) and allows additional analyses for time-to-event outcomes. It also facilitates treatment-covariate interaction analyses and therefore offers an opportunity for personalised medicine. OBJECTIVE AND RATIONALE We aimed to evaluate the effectiveness of different ovulation induction agents, in particular letrozole alone and clomiphene citrate (CC) plus metformin, as compared to CC alone, as the first-line choice for ovulation induction in women with PCOS and infertility, and to explore interactions between treatment and participant-level baseline characteristics. SEARCH METHODS We searched electronic databases including MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials up to 20 December 2018. We included RCTs comparing the following interventions with each other or placebo/no treatment in women with PCOS and infertility: CC, metformin, CC plus metformin, letrozole, gonadotrophin and tamoxifen. We excluded studies on treatment-resistant women. The primary outcome was live birth. We contacted the investigators of eligible RCTs to share the IPD and performed IPD meta-analyses. We assessed the risk of bias by using the Cochrane risk of bias tool for RCTs. OUTCOMES IPD of 20 RCTs including 3962 women with PCOS were obtained. Six RCTs compared letrozole and CC in 1284 women. Compared with CC, letrozole improved live birth rates (3 RCTs, 1043 women, risk ratio [RR] 1.43, 95% confidence interval [CI] 1.17-1.75, moderate-certainty evidence) and clinical pregnancy rates (6 RCTs, 1284 women, RR 1.45, 95% CI 1.23-1.70, moderate-certainty evidence) and reduced time-to-pregnancy (6 RCTs, 1235 women, hazard ratio [HR] 1.72, 95% CI 1.38-2.15, moderate-certainty evidence). Meta-analyses of effect modifications showed a positive interaction between baseline serum total testosterone levels and treatment effects on live birth (interaction RR 1.29, 95% CI 1.01-1.65). Eight RCTs compared CC plus metformin to CC alone in 1039 women. Compared with CC alone, CC plus metformin might improve clinical pregnancy rates (8 RCTs, 1039 women, RR 1.18, 95% CI 1.00-1.39, low-certainty evidence) and might reduce time-to-pregnancy (7 RCTs, 898 women, HR 1.25, 95% CI 1.00-1.57, low-certainty evidence), but there was insufficient evidence of a difference on live birth rates (5 RCTs, 907 women, RR 1.08, 95% CI 0.87-1.35, low-certainty evidence). Meta-analyses of effect modifications showed a positive interaction between baseline insulin levels and treatment effects on live birth in the comparison between CC plus metformin and CC (interaction RR 1.03, 95% CI 1.01-1.06). WIDER IMPLICATIONS In women with PCOS, letrozole improves live birth and clinical pregnancy rates and reduces time-to-pregnancy compared to CC and therefore can be recommended as the preferred first-line treatment for women with PCOS and infertility. CC plus metformin may increase clinical pregnancy and may reduce time-to-pregnancy compared to CC alone, while there is insufficient evidence of a difference on live birth. Treatment effects of letrozole are influenced by baseline serum levels of total testosterone, while those of CC plus metformin are affected by baseline serum levels of insulin. These interactions between treatments and biomarkers on hyperandrogenaemia and insulin resistance provide further insights into a personalised approach for the management of anovulatory infertility related to PCOS.
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Affiliation(s)
- Rui Wang
- Robinson Research Institute and Adelaide Medical School, University of Adelaide, North Adelaide, SA, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia
| | - Wentao Li
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia
| | - Esmée M Bordewijk
- Centre for Reproductive Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Richard S Legro
- Department of Obstetrics and Gynecology, Pennsylvania State University, Hershey, PA, USA
| | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven, CO, USA
| | - Xiaoke Wu
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, China
| | - Jingshu Gao
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, China
| | - Laure Morin-Papunen
- Department of Obstetrics and Gynecology, Medical Research Center, PEDEGO Research Unit, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Roy Homburg
- Homerton Fertility Centre, Homerton University Hospital, London, UK
| | - Tamar E König
- Department of Obstetrics and Gynecology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Etelka Moll
- Department of Obstetrics and Gynaecology, Onze Lieve Vrouwe Gasthuis (OLVG) West, Amsterdam, the Netherlands
| | - Sujata Kar
- Department of Obstetrics and Gynaecology, Kar Clinic and Hospital, Bhubaneswar, India
| | - Wei Huang
- Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University, Chengdu, China
| | - Neil P Johnson
- Robinson Research Institute and Adelaide Medical School, University of Adelaide, North Adelaide, SA, Australia.,Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - Saad A Amer
- Department of Obstetrics and Gynaecology, University of Nottingham, Royal Derby Hospital, Derby, UK
| | - Walter Vegetti
- Infertility Unit, Fondazione I.R.C.C.S. Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Palomba
- Department of Obstetrics and Gynecology, Grande Ospedale Metropolitano of Reggio Calabria, Reggio Calabria, Italy
| | - Angela Falbo
- Department of Obstetrics and Gynecology, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Ülkü Özmen
- Department of Obstetrics and Gynecology, School of Medicine, Zonguldak Bulent Ecevit University, Kozlu, Zonguldak, Turkey
| | - Hakan Nazik
- Department of Obstetrics and Gynaecology, Adana City Training and Research Hospital, Adana, Turkey
| | | | - Grasso Federica
- Department of Surgery Obstetrics and Gynecology, University of Catania, Catania, Italy
| | - Jonathan Lord
- Department of Obstetrics and Gynaecology, Royal Cornwall Hospital, University of Exeter Medical School, Truro, UK
| | - Yilmaz Sahin
- Department of Obstetrics and Gynecology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | | | - Robert J Norman
- Robinson Research Institute and Adelaide Medical School, University of Adelaide, North Adelaide, SA, Australia.,Fertility SA, Adelaide, SA, Australia
| | - Madelon van Wely
- Centre for Reproductive Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Ben Willem Mol
- Robinson Research Institute and Adelaide Medical School, University of Adelaide, North Adelaide, SA, Australia.,Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia
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14
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Al-Obaidi MT, Ali ZH, Al-Saadi WI, Al-Wasiti EAR, Al-Aubaidy H. Impact of letrozole versus clomiphene citrate on endometrial receptivity in Iraqi women with polycystic ovarian syndrome. J Clin Pharm Ther 2019; 44:618-622. [PMID: 30868612 DOI: 10.1111/jcpt.12831] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 01/20/2019] [Accepted: 02/18/2019] [Indexed: 01/28/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVES Letrozole is widely known for its use as an ovulation inductor. This study aims to investigate the effects of letrozole and clomiphene citrate in females with polycystic ovarian syndrome. METHODS This is a randomized non-blinded controlled trial study that included 80 infertile females with polycystic ovarian syndrome receiving a standard dose of either clomiphene citrate or letrozole on day 2 of the cycle. An ultrasound was done to examine growth of the follicle, endometrial thickness on days 12-13, and a Doppler study to measure resistance index (RI), pulsatility index and ratio of systolic/diastolic velocity. RESULTS AND DISCUSSION The mean levels of dominant follicle and oestradiol were significantly higher in the clomiphene citrate group than in the letrozole group. The letrozole group had a significantly greater endometrial thickness than the clomiphene citrate group. The resistance index and pulsatility index were lower in the letrozole group and in pregnant women than in the clomiphene citrate group and the non-pregnant group. WHAT IS NEW AND CONCLUSION The use of letrozole for ovulation induction in polycystic ovarian syndrome patients has a better effect on endometrial receptivity markers when compared to clomiphene citrate.
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Affiliation(s)
- Manal T Al-Obaidi
- The High Institute of Infertility Diagnosis and Assisted Reproductive Technologies, Al-Nahrain University, Baghdad, Iraq
| | - Zainab H Ali
- The High Institute of Infertility Diagnosis and Assisted Reproductive Technologies, Al-Nahrain University, Baghdad, Iraq
| | | | - Estabraq A R Al-Wasiti
- The High Institute of Infertility Diagnosis and Assisted Reproductive Technologies, Al-Nahrain University, Baghdad, Iraq.,College of Medicine, Al-Nahrain University, Baghdad, Iraq
| | - Hayder Al-Aubaidy
- School of Life Sciences, La Trobe University, Bundoora, Victoria, Australia
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15
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Yu Q, Hu S, Wang Y, Cheng G, Xia W, Zhu C. Letrozole versus laparoscopic ovarian drilling in clomiphene citrate-resistant women with polycystic ovary syndrome: a systematic review and meta-analysis of randomized controlled trials. Reprod Biol Endocrinol 2019; 17:17. [PMID: 30728032 PMCID: PMC6366034 DOI: 10.1186/s12958-019-0461-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 01/28/2019] [Indexed: 11/10/2022] Open
Abstract
The objective of this systematic review was to examine the literature and to compare the effectiveness of letrozole (LE) versus laparoscopic ovarian drilling (LOD) for the induction of ovulation in women with clomiphene citrate (CC)-resistant polycystic ovary syndrome (PCOS). The PUBMED, Web of Science, and EMBASE databases were searched systematically for eligible randomized controlled trials (RCTs) from English language articles published from database inception to September 2018. Data were independently extracted and analyzed using the fixed-effects model or random-effects model according to the heterogeneity of the data. Four RCTs including 621 patients (309 in the LE group and 312 in the LOD group) met the inclusion criteria. There were no differences with regard to ovulation rate (relative risk [RR] 1.12; 95% confidence interval [CI] 0.93 to 1.34; P = 0.12, I2 = 90%, 541 patients, three studies), pregnancy rate (RR 1.21; 95% CI 0.95 to 1.53; P = 0.12, I2 = 0%, 621 patients, four studies), live birth rate (RR 1.27; 95% CI 0.96 to 1.68; P = 0.09, I2 = 19%, 541 patients, three studies), and abortion rate (RR 0.7; 95% CI 0.3 to 1.61; P = 0.40, I2 = 0%, 621 patients, four studies) between the two groups. These results indicated that LE and LOD appear to be equally effective in achieving live birth rate in patients with CC-resistant PCOS.
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Affiliation(s)
- Qiong Yu
- Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Shifu Hu
- Family Planning Research Institute, Tongji Medical College, Huazhong University of Science and Technology, Hangkong Road 13, Wuhan, 430030, Hubei, China
| | - Yingying Wang
- Family Planning Research Institute, Tongji Medical College, Huazhong University of Science and Technology, Hangkong Road 13, Wuhan, 430030, Hubei, China
| | - Guiping Cheng
- Family Planning Research Institute, Tongji Medical College, Huazhong University of Science and Technology, Hangkong Road 13, Wuhan, 430030, Hubei, China
| | - Wei Xia
- Family Planning Research Institute, Tongji Medical College, Huazhong University of Science and Technology, Hangkong Road 13, Wuhan, 430030, Hubei, China.
- Reproductive Medicine Center, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.
| | - Changhong Zhu
- Family Planning Research Institute, Tongji Medical College, Huazhong University of Science and Technology, Hangkong Road 13, Wuhan, 430030, Hubei, China.
- Reproductive Medicine Center, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.
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16
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Costello MF, Misso ML, Balen A, Boyle J, Devoto L, Garad RM, Hart R, Johnson L, Jordan C, Legro RS, Norman RJ, Mocanu E, Qiao J, Rodgers RJ, Rombauts L, Tassone EC, Thangaratinam S, Vanky E, Teede HJ. Evidence summaries and recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome: assessment and treatment of infertility. Hum Reprod Open 2019; 2019:hoy021. [PMID: 31486807 PMCID: PMC6396642 DOI: 10.1093/hropen/hoy021] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 12/13/2018] [Indexed: 12/12/2022] Open
Abstract
STUDY QUESTION What is the recommended assessment and management of infertile women with polycystic ovary syndrome (PCOS), based on the best available evidence, clinical expertize and consumer preference? SUMMARY ANSWER International evidence-based guidelines, including 44 recommendations and practice points, addressed prioritized questions to promote consistent, evidence-based care and improve the experience and health outcomes of infertile women with PCOS. WHAT IS KNOWN ALREADY Previous guidelines on PCOS lacked rigorous evidence-based processes, failed to engage consumer and multidisciplinary perspectives or were outdated. The assessment and management of infertile women with PCOS are inconsistent. The needs of women with PCOS are not being adequately met and evidence practice gaps persist. PARTICIPANTS/MATERIALS, SETTING, METHODS Governance included a six continent international advisory and a project board, a multidisciplinary international guideline development group (GDG), consumer and translation committees. Extensive health professional and consumer engagement informed the guideline scope and priorities. The engaged international society-nominated panel included endocrinology, gynaecology, reproductive endocrinology, obstetrics, public health and other experts, alongside consumers, project management, evidence synthesis and translation experts. Thirty-seven societies and organizations covering 71 countries engaged in the process. Extensive online communication and two face-to-face meetings over 15 months addressed 19 prioritized clinical questions involving nine evidence-based reviews and 10 narrative reviews. Evidence-based recommendations (EBRs) were formulated prior to consensus voting within the guideline panel. STUDY DESIGN, SIZE, DURATION International evidence-based guideline development engaged professional societies and consumer organizations with multidisciplinary experts and women with PCOS directly involved at all stages. A (AGREE) II-compliant processes were followed, with extensive evidence synthesis. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was applied across evidence quality, desirable and undesirable consequences, feasibility, acceptability, cost, implementation and ultimately recommendation strength. The guideline was peer-reviewed by special interest groups across our partner and collaborating societies and consumer organizations, was independently assessed against AGREE II criteria and underwent methodological review. This guideline was approved by all members of the GDG and has been approved by the NHMRC. MAIN RESULTS AND THE ROLE OF CHANCE The quality of evidence (QOE) for the EBRs in the assessment and management of infertility in PCOS included very low (n = 1), low (n = 9) and moderate (n = 4) quality with no EBRs based on high-quality evidence. The guideline provides 14 EBRs, 10 clinical consensus recommendations (CCRs) and 20 clinical practice points on the assessment and management of infertility in PCOS. Key changes in this guideline include emphasizing evidence-based fertility therapy, including cheaper and safer fertility management. LIMITATIONS, REASONS FOR CAUTION Overall evidence is generally of low to moderate quality, requiring significantly greater research in this neglected, yet common condition. Regional health systems vary and a process for adaptation of this guideline is provided. WIDER IMPLICATIONS OF THE FINDINGS The international guideline for the assessment and management of infertility in PCOS provides clinicians with clear advice on best practice based on the best available evidence, expert multidisciplinary input and consumer preferences. Research recommendations have been generated and a comprehensive multifaceted dissemination and translation program supports the guideline with an integrated evaluation program. STUDY FUNDING/COMPETING INTEREST(S) The guideline was primarily funded by the Australian National Health and Medical Research Council of Australia (NHMRC) supported by a partnership with ESHRE and the American Society for Reproductive Medicine (ASRM). GDG members did not receive payment. Travel expenses were covered by the sponsoring organizations. Disclosures of conflicts of interest were declared at the outset and updated throughout the guideline process, aligned with NHMRC guideline processes. Dr Costello has declared shares in Virtus Health and past sponsorship from Merck Serono for conference presentations. Prof. Norman has declared a minor shareholder interest in the IVF unit Fertility SA, travel support from Merck and grants from Ferring. Prof. Norman also has scientific advisory board duties for Ferring. The remaining authors have no conflicts of interest to declare. This article was not externally peer-reviewed by Human Reproduction Open.
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Affiliation(s)
- M F Costello
- School of Women's and Children's Health, University of New South Wales, High St, Kensington, Sydney, New South Wales, Australia
| | - M L Misso
- Monash Centre for Health Research and Implementation, Monash Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia.,Monash Health, Clayton, Melbourne, Australia
| | - A Balen
- Reproductive Medicine and Surgery, Leeds Centre for Reproductive Medicine, Leeds Teaching Hospitals, Leeds, UK
| | - J Boyle
- Monash Centre for Health Research and Implementation, Monash Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia.,Monash Health, Clayton, Melbourne, Australia
| | - L Devoto
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Chile, Santiago, Chile
| | - R M Garad
- Monash Health, Clayton, Melbourne, Australia.,National Health and Medical Research Council Centre for Research Excellence in PCOS, Monash Centre for Health Research and Implementation, Monash Public Health and Preventive Medicine, Monash University, Victoria, Australia
| | - R Hart
- Division of Obstetrics and Gynaecology, University of Western Australia, Crawley, WA, Australia
| | - L Johnson
- Victorian Assisted Reproductive Treatment Authority, Victoria, Australia
| | - C Jordan
- Victorian Assisted Reproductive Treatment Authority, Victoria, Australia.,Genea Hollywood Fertility, 190 Cambridge St, Wembley WA, Australia
| | - R S Legro
- Department of Obstetrics and Gynecology, Penn State University College of Medicine, USA
| | - R J Norman
- National Health and Medical Research Council Centre for Research Excellence in PCOS, Monash University, Melbourne, Victoria, Australia.,Adelaide University, Adelaide, South Australia, Australia
| | - E Mocanu
- Royal College of Surgeons, Rotunda Hospital, 123 St Stephen's Green, Dublin, Ireland
| | - J Qiao
- Peking University Third Hospital, Haidian Qu, Beijing Shi, China
| | - R J Rodgers
- Robinson Research Institute, University of Adelaide and Fertility SA, Adelaide, South Australia, Australia
| | - L Rombauts
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Melbourne, Victoria 3168, Australia
| | - E C Tassone
- Monash Centre for Health Research and Implementation, Monash Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia.,Monash Health, Clayton, Melbourne, Australia
| | - S Thangaratinam
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - E Vanky
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - H J Teede
- Monash Health, Clayton, Melbourne, Australia.,National Health and Medical Research Council Centre for Research Excellence in PCOS, Monash Centre for Health Research and Implementation, Monash Public Health and Preventive Medicine, Monash University, Victoria, Australia
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Use of Letrozole versus clomiphene-estradiol for treating infertile women with unexplained infertility not responding well to clomiphene alone, comparative study. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2018. [DOI: 10.1016/j.mefs.2018.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Akinoso-Imran AQ, Adetunji H. Systematic review and meta-analysis of letrozole and clomiphene citrate in polycystic ovary syndrome. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2018. [DOI: 10.1016/j.mefs.2018.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Alnemr AAA, Ammar IMM, Aboelfath AMK, Talaat B. Effect of estradiol valerate on the pregnancy rate in patients receiving letrozole for induction of ovulation. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2018. [DOI: 10.1016/j.mefs.2017.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Franik S, Eltrop SM, Kremer JAM, Kiesel L, Farquhar C. Aromatase inhibitors (letrozole) for subfertile women with polycystic ovary syndrome. Cochrane Database Syst Rev 2018; 5:CD010287. [PMID: 29797697 PMCID: PMC6494577 DOI: 10.1002/14651858.cd010287.pub3] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Polycystic ovary syndrome (PCOS) is the most common cause of infrequent periods (oligomenorrhoea) and absence of periods (amenorrhoea). It affects about 4% to 8% of women worldwide and often leads to anovulatory subfertility. Aromatase inhibitors (AIs) are a class of drugs that were introduced for ovulation induction in 2001. Since about 2001 clinical trials have reached differing conclusions as to whether the AI letrozole is at least as effective as the first-line treatment clomiphene citrate (CC). OBJECTIVES To evaluate the effectiveness and safety of aromatase inhibitors for subfertile women with anovulatory PCOS for ovulation induction followed by timed intercourse or intrauterine insemination (IUI). SEARCH METHODS We searched the following sources from inception to November 2017 to identify relevant randomised controlled trials (RCTs): the Cochrane Gynaecology and Fertility Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO, Pubmed, LILACS, Web of Knowledge, the World Health Organization (WHO) clinical trials register and Clinicaltrials.gov. We also searched the references of relevant articles. We did not restrict the searches by language or publication status. SELECTION CRITERIA We included all RCTs of AIs used alone or with other medical therapies for ovulation induction in women of reproductive age with anovulatory PCOS. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, extracted the data and assessed risks of bias. We pooled studies where appropriate using a fixed-effect model to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for most outcomes, and risk differences (RDs) for ovarian hyperstimulation syndrome (OHSS). The primary outcomes were live birth and OHSS. Secondary outcomes were clinical pregnancy, miscarriage and multiple pregnancy. We assessed the quality of the evidence for each comparison using GRADE methods. MAIN RESULTS This is a substantive update of a previous review. We identified 16 additional studies for the 2018 update. We include 42 RCTs (7935 women). The aromatase inhibitor letrozole was used in all studies.Letrozole compared to clomiphene citrate (CC) with or without adjuncts followed by timed intercourseLive birth rates were higher with letrozole (with or without adjuncts) compared to clomiphene citrate (with our without adjuncts) followed by timed intercourse (OR 1.68, 95% CI 1.42 to 1.99; 2954 participants; 13 studies; I2 = 0%; number needed to treat for an additional beneficial outcome (NNTB) = 10; moderate-quality evidence). There is high-quality evidence that OHSS rates are similar with letrozole or clomiphene citrate (0.5% in both arms: risk difference (RD) -0.00, 95% CI -0.01 to 0.00; 2536 participants; 12 studies; I2 = 0%; high-quality evidence). There is evidence for a higher pregnancy rate in favour of letrozole (OR 1.56, 95% CI 1.37 to 1.78; 4629 participants; 25 studies; I2 = 1%; NNTB = 10; moderate-quality evidence). There is little or no difference between treatment groups in the rate of miscarriage by pregnancy (20% with CC versus 19% with letrozole; OR 0.94, 95% CI 0.70 to 1.26; 1210 participants; 18 studies; I2 = 0%; high-quality evidence) and multiple pregnancy rate (1.7% with CC versus 1.3% with letrozole; OR 0.69, 95% CI 0.41 to 1.16; 3579 participants; 17 studies; I2 = 0%; high-quality evidence). However, a funnel plot showed mild asymmetry, indicating that some studies in favour of clomiphene might be missing.Letrozole compared to laparoscopic ovarian drillingThere is low-quality evidence that live birth rates are similar with letrozole or laparoscopic ovarian drilling (OR 1.38, 95% CI 0.95 to 2.02; 548 participants; 3 studies; I2 = 23%; low-quality evidence). There is insufficient evidence for a difference in OHSS rates (RD 0.00, 95% CI -0.01 to 0.01; 260 participants; 1 study; low-quality evidence). There is low-quality evidence that pregnancy rates are similar (OR 1.28, 95% CI 0.94 to 1.74; 774 participants; 5 studies; I2 = 0%; moderate-quality evidence). There is insufficient evidence for a difference in miscarriage rate by pregnancy (OR 0.66, 95% CI 0.30 to 1.43; 240 participants; 5 studies; I2 = 0%; moderate-quality evidence), or multiple pregnancies (OR 3.00, 95% CI 0.12 to 74.90; 548 participants; 3 studies; I2 = 0%; low-quality evidence).Additional comparisons were made for Letrozole versus placebo, Selective oestrogen receptor modulators (SERMS) followed by intrauterine insemination (IUI), follicle stimulating hormone (FSH), Anastrozole, as well as dosage and administration protocols. There is insufficient evidence for a difference in either group of treatment due to a limited number of studies. Hence more research is necessary. AUTHORS' CONCLUSIONS Letrozole appears to improve live birth and pregnancy rates in subfertile women with anovulatory polycystic ovary syndrome, compared to clomiphene citrate. There is high-quality evidence that OHSS rates are similar with letrozole or clomiphene citrate. There is high-quality evidence of no difference in miscarriage rates or multiple pregnancy rates. There is low-quality evidence of no difference in live birth and pregnancy rates between letrozole and laparoscopic ovarian drilling, although there were few relevant studies. For the 2018 update, we added good-quality trials, upgrading the quality of the evidence.
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Affiliation(s)
- Sebastian Franik
- University Hospital MünsterDepartment of Obstetrics and GynaecologyAlbert‐Schweitzer‐Campus 1MünsterGermany48149
| | - Stephanie M Eltrop
- University Hospital MünsterDepartment of Obstetrics and GynaecologyAlbert‐Schweitzer‐Campus 1MünsterGermany48149
| | - Jan AM Kremer
- Radboud University Nijmegen Medical CenterDepartment of Obstetrics and GynaecologyPO Box 9101NijmegenNetherlands6500 HB
| | - Ludwig Kiesel
- University Hospital MünsterDepartment of Obstetrics and GynaecologyAlbert‐Schweitzer‐Campus 1MünsterGermany48149
| | - Cindy Farquhar
- University of AucklandDepartment of Obstetrics and GynaecologyFMHS Park RoadGraftonAucklandNew Zealand1003
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Amer SA, Smith J, Mahran A, Fox P, Fakis A. Double-blind randomized controlled trial of letrozole versus clomiphene citrate in subfertile women with polycystic ovarian syndrome. Hum Reprod 2018; 32:1631-1638. [PMID: 28854590 PMCID: PMC5850470 DOI: 10.1093/humrep/dex227] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 06/01/2017] [Indexed: 11/23/2022] Open
Abstract
STUDY QUESTION Would letrozole as a primary ovulation induction agent generate better pregnancy rates than clomiphene citrate (CC) in subfertile women with anovulatory polycystic ovarian syndrome (PCOS)? SUMMARY ANSWER Participants receiving letrozole as a primary treatment achieved a significantly (P = 0.022) higher clinical pregnancy rate per patient (61.2%) compared to CC (43.0%). WHAT IS KNOWN ALREADY According to a recent Cochrane systematic review (2014), letrozole appears to improve live-birth (LB) and pregnancy rates in anovulatory women with PCOS, compared to CC. However, the review concluded that the quality of evidence was low due to poor reporting of study methods and possible publication bias. STUDY DESIGN, SIZE, DURATION This double-blind randomized controlled trial (RCT) included 159 participants between April 2007 and June 2014. Subjects were randomly allocated to either CC (n = 79) or letrozole (n = 80) in a 1:1 ratio. Both drugs were encapsulated to look identical. Randomization was performed in mixed blocks and stratified by patients’ BMI (<30 and 30–35 kg/m2). PARTICIPANTS/MATERIALS, SETTING, METHODS The trial included subfertile women diagnosed with PCOS. Treatment started with one tablet (CC 50 mg, letrozole 2.5 mg) increasing to two in non-responders and continuing until pregnancy or for up to six ovulatory cycles. Non-responders were crossed over to the other treatment after a 6-week break. Cycles were initially monitored with ultrasound follicle tracking then mid-luteal serum progesterone measurement in subsequent cycles. MAIN RESULTS AND THE ROLE OF CHANCE Amongst the 159 participants included in the intention-to-treat analysis, four women conceived before treatment and six were lost-to-follow-up. The remaining 149 participants (74 on CC and 75 on letrozole) completed at least the first treatment. Women receiving letrozole achieved a significantly (P = 0.022; absolute difference [95% confidence interval] 18% [3–33%]) higher pregnancy rate (61.%) than those on CC (43%). The median number of treatment cycles received until pregnancy was significantly (log rank P = 0.038) smaller with letrozole (4[3–5] cycles) compared to CC (6[4–7] cycles). LB rates were not statistically (P = 0.089) different between the two groups, although there was a trend towards higher rates on letrozole (48.8%) compared to CC (35.4%). After the crossover, pregnancy and LB rates on letrozole (n = 45; 28.9 and 24.4%, respectively) were not statistically (P = 0.539 and P = 0.601) different from CC (n = 31; 22.6 and 19.4%). LIMITATIONS, REASONS FOR CAUTION One possible limitation of this trial may be the exclusion of PCOS women with BMI > 35 kg/m2, which would limit the applicability of the results in this subgroup of PCOS. However, this group of women are generally excluded from treatment in the majority of fertility centres, especially in Europe, due to the associated challenges and risks. WIDER IMPLICATIONS OF THE FINDINGS The results of this trial are consistent with the recent Cochrane systematic review. However, with its robust design, the current RCT provides more valid and compelling evidence for the superiority of letrozole over CC as a primary ovulation induction agent in PCOS women with 40% increase in pregnancy rates and with a shorter time-to-pregnancy. Furthermore, the participants in this RCT are a good representation of subfertile PCOS population receiving fertility treatment in Europe and worldwide. The results are therefore globally generalizable for clinical practice. STUDY FUNDING/COMPETING INTEREST(S) This RCT was mainly funded by the R&D Funding Scheme of Derby Hospitals NHS Foundation Trust. The study also received funds from School of Medicine, University of Nottingham. The Trust R&D department was involved in the development of the protocol and the running of the trial. The trial was sponsored and monitored by the University of Nottingham. The authors have no conflicts of interest. TRIAL REGISTRATION NUMBER www.Clinicaltrials.gov: NCT00478504. TRIAL REGISTRATION DATE Registration was verified on 23/05/2007. DATE OF FIRST PATIENT'S ENROLMENT 25/04/2007.
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Affiliation(s)
- S A Amer
- Department of Obstetrics and Gynaecology, University of Nottingham, Royal Derby Hospital, Uttoxeter Road, Derby DE22 3DT, UK
| | - J Smith
- R&D Department, Derby Teaching Hospitals NHS Foundation Trust, Uttoxeter Road, Derby DE22 3NE, UK
| | - A Mahran
- Department of Obstetrics and Gynaecology, University of Nottingham, Royal Derby Hospital, Uttoxeter Road, Derby DE22 3DT, UK.,Department of Obstetrics and Gynaecology, Faculty of Medicine, Minia University, Minia, Egypt
| | - P Fox
- Pharmacy Department, Derby Teaching Hospitals NHS Foundation Trust, Uttoxeter Road, Derby DE22 3NE, UK
| | - A Fakis
- R&D Department, Derby Teaching Hospitals NHS Foundation Trust, Uttoxeter Road, Derby DE22 3NE, UK
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Letrozole versus clomiphene citrate in polycystic ovary syndrome: a meta-analysis of randomized controlled trials. Arch Gynecol Obstet 2018; 297:1081-1088. [PMID: 29392438 DOI: 10.1007/s00404-018-4688-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 01/24/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE Polycystic ovary syndrome (PCOS) is a common endocrine disturbance affecting women in the reproductive age group. The present study aimed to compare the effects of letrozole (LE) and clomiphene citrate (CC) for ovulation induction in women with PCOS. METHODS The PUBMED, Web of Science, and EMBASE databases were screened systematically for randomized controlled trials (RCTs) published from database inception to July 2017. RESULTS Eleven RCTs involving 2255 patients were included, and data were independently extracted and analyzed using 95% risk ratios (RRs) and confidence intervals (CIs) based on a random- or fixed-effect model (as appropriate). Meta-analyses of nine RCTs comparing LE and CC ovulation induction, followed by timed intercourse, indicated that the former significantly increased the ovulation rate (RR = 1.18; 95% CI 1.03-1.36, P = 0.01), pregnancy rate (RR = 1.34; 95% CI 1.09-1.64, P = 0.006), and live birth rate (RR = 1.55; 95% CI 1.28-1.88, P < 0.00001). However, LE and CC did not differ significantly in terms of the multiple pregnancy and abortion rates. Furthermore, LE for ovulation induction significantly improved the pregnancy rate after IUI. CONCLUSION LE is superior to CC for ovulation induction in patients with PCOS.
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Gadalla MA, Huang S, Wang R, Norman RJ, Abdullah SA, El Saman AM, Ismail AM, van Wely M, Mol BWJ. Effect of clomiphene citrate on endometrial thickness, ovulation, pregnancy and live birth in anovulatory women: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:64-76. [PMID: 29055102 DOI: 10.1002/uog.18933] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 10/08/2017] [Accepted: 10/11/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To compare the impact of clomiphene citrate (CC) vs other drug regimens on mid-cycle endometrial thickness (EMT), ovulation, pregnancy and live birth rates in women with World Health Organization (WHO) group II ovulatory disorders. METHODS We searched MEDLINE, EMBASE, Scopus, Web of Science, The Cochrane Central Register of Clinical Trials (CENTRAL) and the non-MEDLINE subset of PubMed from inception to December 2016 and cross-checked references of relevant articles. We included only randomized controlled trials (RCTs) comparing CC used alone vs other drug regimens for ovulation induction in women with WHO group II anovulation. Outcomes were mid-cycle EMT, ovulation, pregnancy and live birth rates. We pooled weighted mean differences (WMD) with 95% confidence intervals (CI) for continuous variables (EMT) and risk ratios (RR) with 95% CI for binary variables (ovulation, pregnancy and live birth rates). RESULTS We retrieved 1718 articles of which 33 RCTs (4349 women, 7210 ovulation induction cycles) were included. In 15 RCTs that compared CC with letrozole, EMT was lower in the CC group (1957 women, 3892 cycles; WMD, -1.39; 95% CI, -2.27 to -0.51; I2 = 100%), ovulation rates after CC and letrozole were comparable (1710 women, 3217 cycles; RR, 0.97; 95% CI, 0.90-1.04; I2 = 47%), while CC led to a lower pregnancy rate (1957 women, 3892 cycles; RR, 0.78; 95% CI, 0.63-0.95; I2 = 43%) and a lower live birth rate (RR, 0.70; 95% CI, 0.49-0.98; I2 = 35%). In two RCTs that compared CC with CC plus metformin, EMT, ovulation and pregnancy rates were comparable (101 women, 140 cycles; WMD, -0.23; 95% CI, -0.92 to 0.45; I2 = 78%; RR, 0.84; 95% CI, 0.67-1.06; I2 = 0%; and RR, 0.79; 95% CI, 0.33-1.87; I2 = 0%). In three studies that compared CC with CC plus N-acetyl cysteine (NAC), EMT was lower in the CC group (340 women, 300 cycles; WMD, -1.51; 95% CI, -1.98 to -1.04; I2 = 45%). In two studies that compared CC with CC + nitric oxide (NO) donor, EMT was lower in the CC group (120 women, 304 cycles; WMD, -1.75; 95% CI, -2.08 to -1.41; I2 = 0%). Compared with CC plus NO donor or NAC, CC showed statistically significant lower ovulation and pregnancy rates. Compared with tamoxifen in three studies, CC showed a tendency towards lower EMT (571 women, 844 cycles; WMD, -1.34; 95% CI, -2.70 to 0.01; I2 = 96%) with comparable ovulation and pregnancy rates. CONCLUSIONS In women with WHO group II ovulatory disorders, ovulation induction with CC might result in lower EMT than other ovulation induction regimens. Whether the lower EMT caused the lower pregnancy and live birth rates remains to be elucidated. Letrozole seems to be beneficial for these women. However, our findings should be interpreted with caution as the quality of evidence was very low. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M A Gadalla
- Women's Health Hospital, Department of Obstetrics and Gynecology, Assiut University, Assiut, Egypt
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - S Huang
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, Australia
- Reproductive Medicine Centre, Peking University Third Hospital, Beijing, China
| | - R Wang
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - R J Norman
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - S A Abdullah
- Women's Health Hospital, Department of Obstetrics and Gynecology, Assiut University, Assiut, Egypt
| | - A M El Saman
- Women's Health Hospital, Department of Obstetrics and Gynecology, Assiut University, Assiut, Egypt
| | - A M Ismail
- Women's Health Hospital, Department of Obstetrics and Gynecology, Assiut University, Assiut, Egypt
| | - M van Wely
- Center for Reproductive Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - B W J Mol
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, Australia
- South Australian Health and Medical Research Institute, Adelaide, Australia
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Liu C, Feng G, Huang W, Wang Q, Yang S, Tan J, Fu J, Liu D. Comparison of clomiphene citrate and letrozole for ovulation induction in women with polycystic ovary syndrome: a prospective randomized trial. Gynecol Endocrinol 2017; 33:872-876. [PMID: 28557652 DOI: 10.1080/09513590.2017.1332174] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
To compare the therapeutic efficacy of clomiphene citrate (CC) and letrozole (LE) on ovulation, pregnancy, and live birth in women with polycystic ovary syndrome (PCOS); and to ensure if LE can replace CC as the first-line therapy for ovulation induction in these women. This is a prospectively, randomized, controlled trial in the tertiary hospital. Two-hundred and sixty-eight anovulatory PCOS patients were treated by CC or CC plus metformin and LE or LE plus metformin for three continuous cycles or conception; their ovulation rates, pregnancy rates, and live birth rates were calculated and compared. No significant difference was noted among the four groups regarding to the baseline data of clinical manifestations, serum sex hormone levels, and serum insulin levels. A total of 240 patients completed the therapies. The ovulation rate was significantly higher in the group LE than the group CC; however, no significant difference was noted between the groups LE and CC, CC, and CC + MET, or LE and LE + MET in the pregnancy rate, abortion rate, and live birth rate. No birth defect was found in the total of 63 newborns. CC regimen was still recommended to be the first-line therapy of ovulation induction for PCOS.
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Affiliation(s)
- Chang Liu
- a Department of Obstetrics and Gynecology , West China Second University Hospital of Sichuan University , Sichuan Sheng , PR China
| | - Guimei Feng
- a Department of Obstetrics and Gynecology , West China Second University Hospital of Sichuan University , Sichuan Sheng , PR China
- b Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital , PR China
| | - Wei Huang
- a Department of Obstetrics and Gynecology , West China Second University Hospital of Sichuan University , Sichuan Sheng , PR China
| | - Qiuyi Wang
- a Department of Obstetrics and Gynecology , West China Second University Hospital of Sichuan University , Sichuan Sheng , PR China
| | - Shiyuan Yang
- a Department of Obstetrics and Gynecology , West China Second University Hospital of Sichuan University , Sichuan Sheng , PR China
| | - Jing Tan
- a Department of Obstetrics and Gynecology , West China Second University Hospital of Sichuan University , Sichuan Sheng , PR China
| | - Jing Fu
- a Department of Obstetrics and Gynecology , West China Second University Hospital of Sichuan University , Sichuan Sheng , PR China
| | - Dong Liu
- a Department of Obstetrics and Gynecology , West China Second University Hospital of Sichuan University , Sichuan Sheng , PR China
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Use of clomiphene or letrozole for treating women with polycystic ovary syndrome related subfertility in Hilla city. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2017. [DOI: 10.1016/j.mefs.2016.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Wang R, Kim BV, van Wely M, Johnson NP, Costello MF, Zhang H, Ng EHY, Legro RS, Bhattacharya S, Norman RJ, Mol BWJ. Treatment strategies for women with WHO group II anovulation: systematic review and network meta-analysis. BMJ 2017; 356:j138. [PMID: 28143834 PMCID: PMC5421445 DOI: 10.1136/bmj.j138] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To compare the effectiveness of alternative first line treatment options for women with WHO group II anovulation wishing to conceive. DESIGN Systematic review and network meta-analysis. DATA SOURCES Cochrane Central Register of Controlled Trials, Medline, and Embase, up to 11 April 2016. STUDY SELECTION Randomised controlled trials comparing eight ovulation induction treatments in women with WHO group II anovulation: clomiphene, letrozole, metformin, clomiphene and metformin combined, tamoxifen, gonadotropins, laparoscopic ovarian drilling, and placebo or no treatment. Study quality was measured on the basis of the methodology and categories described in the Cochrane Collaboration Handbook. Pregnancy, defined preferably as clinical pregnancy, was the primary outcome; live birth, ovulation, miscarriage, and multiple pregnancy were secondary outcomes. RESULTS Of 2631 titles and abstracts initially identified, 54 trials reporting on 7173 women were included. All pharmacological treatments were superior to placebo or no intervention in terms of pregnancy and ovulation. Compared with clomiphene alone, both letrozole and the combination of clomiphene and metformin showed higher pregnancy rates (odds ratio 1.69, 95% confidence interval 1.33 to 2.14; 1.71, 1.28 to 2.27; respectively). Letrozole led to higher live birth rates when compared with clomiphene alone (1.67, 1.11 to 2.49). Metformin led to lower multiple pregnancy rates compared with clomiphene alone (0.22, 0.05 to 0.93). CONCLUSIONS In women with WHO group II anovulation, letrozole and the combination of clomiphene and metformin are superior to clomiphene alone in terms of pregnancy. Compared with clomiphene alone, letrozole is the only treatment showing a significantly higher rate of live birth. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015027579. READERS' NOTE This is the second version of this paper. The original version was corrected following the retraction of two studies and removal of another which were ineligible (references 40, 41, and 75 of the original paper). These studies are not shown in this version. A tracked changes version of the original version is attached as a supplementary file to the correction notice, which explains the issue further.
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Affiliation(s)
- Rui Wang
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology, School of Medicine, University of Adelaide, North Adelaide, Australia
- Reproductive Medicine Centre, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bobae V Kim
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology, School of Medicine, University of Adelaide, North Adelaide, Australia
| | - Madelon van Wely
- Centre for Reproductive Medicine, Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Neil P Johnson
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology, School of Medicine, University of Adelaide, North Adelaide, Australia
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - Michael F Costello
- School of Women's and Children's Health, University of New South Wales, Sydney, Australia
| | - Hanwang Zhang
- Reproductive Medicine Centre, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ernest Hung Yu Ng
- Department of Obstetrics and Gynaecology, University of Hong Kong, Hong Kong, China
| | - Richard S Legro
- Department of Obstetrics and Gynecology, Penn State College of Medicine, Hershey, USA
| | | | - Robert J Norman
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology, School of Medicine, University of Adelaide, North Adelaide, Australia
- FertilitySA, Adelaide, Australia
- NHMRC (National Health and Medical Research Council) Centre for Research Excellence in Polycystic Ovary Syndrome, Adelaide, Australia
| | - Ben Willem J Mol
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology, School of Medicine, University of Adelaide, North Adelaide, Australia
- South Australian Health and Medical Research Institute, Adelaide, Australia
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Brown J, Farquhar C. Clomiphene and other antioestrogens for ovulation induction in polycystic ovarian syndrome. Cochrane Database Syst Rev 2016; 12:CD002249. [PMID: 27976369 PMCID: PMC6464012 DOI: 10.1002/14651858.cd002249.pub5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Subfertility due to anovulation is a common problem in women. First-line oral treatment is with antioestrogens such as clomiphene citrate, but resistance may be apparent with clomiphene. Alternative and adjunctive treatments have been used including tamoxifen, dexamethasone, and bromocriptine. The effectiveness of these is to be determined. OBJECTIVES To determine the relative effectiveness of antioestrogen agents including clomiphene alone or in combination with other medical therapies in women with subfertility associated with anovulation, possibly caused by polycystic ovarian syndrome. SEARCH METHODS We conducted a search of the Cochrane Gynaecology and Fertility Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO, and CINAHL (all from inception to August 2016) to identify relevant randomised controlled trials (RCTs). We searched the United Kingdom National Institute for Clinical Excellence (NICE) guidelines and the references of relevant reviews and RCTs. We also searched the clinical trial registries for ongoing trials (inception until August 2016). SELECTION CRITERIA We considered RCTs comparing oral antioestrogen agents for ovulation induction (alone or in conjunction with medical therapies) in anovulatory subfertility. We excluded insulin-sensitising agents, aromatase inhibitors, and hyperprolactinaemic infertility. DATA COLLECTION AND ANALYSIS Two review authors independently performed data extraction and quality assessment. The primary outcome was live birth; secondary outcomes were pregnancy, ovulation, miscarriage, multiple pregnancy, ovarian hyperstimulation syndrome, and adverse effects. MAIN RESULTS This is a substantive update of a previous review. We identified an additional 13 studies in the 2016 update. The review now includes 28 RCTs (3377 women) and five RCTs awaiting classification. Five of the 28 included trials reported live birth/ongoing pregnancy. Secondary outcomes were poorly reported.The quality of the evidence ranged from low to very low. The primary reasons for downgrading the evidence were imprecision and risk of bias associated with poor reporting. Antioestrogen versus placebo Live birth rate, miscarriage rate, multiple pregnancy rate, and ovarian hyperstimulation syndrome (OHSS)No data were reported for these outcomes. Clinical pregnancy rateClomiphene citrate was associated with an increased chance of a clinical pregnancy compared with placebo, though the size of the benefit was very uncertain (odds ratio (OR) 5.91, 95% confidence interval (CI) 1.77 to 19.68; 3 studies; 133 women; low-quality evidence). If the chance of a clinical pregnancy was 5% in the placebo group, then between 8% and 50% of women would have a clinical pregnancy in the clomiphene group. Clomiphene citrate versus tamoxifen Live birth rateThere was no clear evidence of a difference in the chance of a live birth between the clomiphene citrate and tamoxifen groups (OR 1.24, 95% CI 0.59 to 2.62; 2 studies; 195 women; low-quality evidence). If 20% of women in the tamoxifen group had a live birth, then between 13% and 40% of women in the clomiphene citrate group would have a live birth. Miscarriage rateThere was no clear evidence of a difference in the chance of a miscarriage between the clomiphene citrate and tamoxifen groups (OR 1.81, 95% CI 0.80 to 4.12; 4 studies; 653 women; low-quality evidence). If 3% of women in the tamoxifen group had a miscarriage, then between 2% and 10% in the clomiphene citrate group would have a miscarriage. Clinical pregnancy rateThere was no clear evidence of a difference in the chance of a clinical pregnancy between the clomiphene citrate and tamoxifen groups (OR 1.30, 95% CI 0.92 to 1.85; 5 studies; 757 women; I2 = 69%; low-quality evidence). If 22% of women in the tamoxifen group had a clinical pregnancy, then between 21% and 35% in the clomiphene citrate group would have a clinical pregnancy. Multiple pregnancy rate There was insufficient evidence of a difference in the chance of a multiple pregnancy between the clomiphene citrate group (OR 2.34, 95% CI 0.34 to 16.04; 3 studies; 567 women; very low-quality evidence). If 0% of women in the tamoxifen group had a multiple pregnancy, then between 0% and 0.5% of women in the clomiphene group would have a multiple pregnancy. OHSSThere were no instances of OHSS in either the clomiphene citrate or the tamoxifen group reported from three studies. Clomiphene citrate with tamoxifen versus tamoxifen alone Clinical pregnancy rateThere was insufficient evidence to determine whether there was a difference between groups (OR 3.32, 95% CI 0.12 to 91.60; 1 study; 20 women; very low-quality evidence). No data were reported for the other outcomes. Other comparisons of interestLimited evidence suggested that compared with a gonadotropin, clomiphene citrate was associated with a reduced chance of a pregnancy, ongoing pregnancy, or live birth, with no clear evidence of a difference in multiple pregnancy rates.The comparison of clomiphene citrate plus medical adjunct versus clomiphene alone was limited by the number of trials reporting the comparison and poor reporting of clinical outcomes relevant to this systematic review and by the number of adjuncts reported (ketoconazole, bromocriptine, dexamethasone, combined oral contraceptive, human chorionic gonadotropin, hormone supplementation). The addition of dexamethasone or combined oral contraceptive suggested a possible benefit in pregnancy outcomes, but findings were very uncertain and further research is required to confirm this.There was limited evidence suggesting that a 10-day regimen of clomiphene citrate improves pregnancy outcomes compared with a 5-day regimen. Data for early versus late regimens of clomiphene citrate were insufficient to be able to make a judgement on differences for pregnancy outcomes. AUTHORS' CONCLUSIONS We found evidence suggesting that clomiphene citrate improves the chance of a clinical pregnancy compared with placebo, but may reduce the chance of live birth or ongoing pregnancy when compared with a gonadotropin. Due to low event rates, we advise caution interpreting these data.The comparison of clomiphene citrate plus medical adjunctive versus clomiphene alone was limited by the number of trials reporting the comparison. The evidence was very low quality and no firm conclusions could be drawn, but very limited evidence suggested a benefit from adjunctive dexamethasone or combined oral contraceptives. Low-quality evidence suggested that a 10-day regimen of clomiphene citrate improves pregnancy rates compared with a 5-day regimen, but further research is required.
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Affiliation(s)
- Julie Brown
- The University of AucklandLiggins InstitutePark RdGraftonAucklandNew Zealand1142
- University of AucklandDepartment of Obstetrics and GynaecologyPark RdGraftonAucklandNew Zealand1142
| | - Cindy Farquhar
- University of AucklandDepartment of Obstetrics and GynaecologyPark RdGraftonAucklandNew Zealand1142
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Seyedoshohadaei F, Tangestani L, Zandvakili F, Rashadmanesh N. Comparison of the Effect of Clomiphene- Estradiol Valerate vs Letrozole on Endometrial Thickness, Abortion and Pregnancy Rate in Infertile Women with Polycystic Ovarian Syndrome. J Clin Diagn Res 2016; 10:QC10-3. [PMID: 27656509 DOI: 10.7860/jcdr/2016/20954.8324] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 05/30/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Clomiphene citrate is the first-line therapy for ovulation induction in Polycystic Ovarian Syndrome (PCOS). This drug binds and blocks estrogen receptors and thought to have an anti estrogenic effect on endometrium volume, thus may have adverse effect on fertility. AIM This study aimed to compare the effect of Clomiphene citrate plus Estradiol Valerate with Letrozole on endometrial thickness, abortion and pregnancy rate in infertile women with PCOS undergoing ovulation induction. MATERIALS AND METHODS This was a randomized double blind clinical trial study on 100 women with PCOS, with an endometrial thickness less than 7mm in spite of follicles greater than 18mm after administration of Clomiphene citrate 100mg/d from 3(th) to 7(th) day of menstruation. They were randomly divided in two groups. Group A received 100mg Clomiphene citrate from day 3 to day 7 of menstruation and 4 mg Estradiol Valerate after the 8(th) day of menstruation until 14(th) day. Group B treated by 5mg Letrozole from day 3 to 7 of menstruation with placebo from 8(th) to 14(th) day of menstruation. In both groups endometrial thickness was measured by transvaginal sonography in the 14(th) day of menstruation. Data were analysed using SPSS Ver.18.0. RESULTS The mean age was 30.34 years in group A and 29.62 years in group B (p=0.381). The number of infertility years in group A was 3.73 years and in group B was 3.85 years. There was no significant relationship statistically between the two groups in terms of mean age and infertility years (p=0.99). Endometrial thickness in group A was 7.26mm and in group B was 8.17 mm. Pregnancy rates in group A and group B was 32% and 16% respectively. There was significant relationship statistically between the two groups in terms of endometrial thickness and pregnancy rates (p=0.021 and p=0.05). There was no abortion in group A and 5 cases had abortion in group B, there was a significant relationship between the two groups statistically (p=0.028). CONCLUSION Letrozole increased endometrial thickness and pregnancy rate in infertile women, therefore its administration is recommended.
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Affiliation(s)
- Fariba Seyedoshohadaei
- Associate Professor, Department of Obstetrics and Gynecology, Faculty of Medicine, Kurdistan University of Medical Sciences , Sanandaj, Iran
| | - Laleh Tangestani
- Resident, Department of Obstetrics and Gynecology, Faculty of Medicine, Kurdistan University of Medical Sciences , Sanandaj, Iran
| | - Farnaz Zandvakili
- Assistant Professor, Department of Obstetrics and Gynecology, Faculty of Medicine, Kurdistan University of Medical Sciences , Sanandaj, Iran
| | - Naser Rashadmanesh
- Lecturer, Research Center for Gastroenterology and Hepatology, Faculty of Medicine, Kurdistan University of Medical Sciences , Sanandaj, Iran
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Morad AWA, Elhadi Farag MA. Impact of letrozole on ultrasonographic markers of endometrial receptivity in polycystic ovary syndrome women with poor endometrial response to clomiphene citrate despite adequate ovulation. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2015. [DOI: 10.1016/j.mefs.2014.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Huang H, Clancy KBH, Burhance C, Zhu Y, Madrigal L. Women who deliver twins are more likely to smoke and have high frequencies of specific SNPs: Results from a sample of African-American women who delivered preterm, low birth weight babies. Am J Hum Biol 2015; 27:605-12. [PMID: 25882505 DOI: 10.1002/ajhb.22723] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 01/16/2015] [Accepted: 03/03/2015] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES We examine if there are genetic and environmental differences between mothers of singleton and multiple pregnancies in a sample of African-American mothers. METHODS We focus on genomic areas suggested to increase or decrease the odds of multiple pregnancies. We computed the odds ratio (OR) and the 95% confidence interval (CI) for each SNP unadjusted or adjusted with smoking. SNPs' allelic differences between mothers of multiple pregnancies and singletons were also tested using Fisher's exact test. We considered additive terms for the SNPs' genotypes, smoking, and a multiplicative interaction term of two selected SNPs' genotypes. RESULTS We found significant interactions between smoking and SNPs of the CYP19A, MDM4, MTHFR and TP53 genes which correlated with higher odds of twinning. We also found a significant interaction between SNPs at the TP53 (rs8079544) and MTHFR gene (rs4846049), where the interaction between the homozygotes (TT for rs8079544, GG for rs4846049) correlated with lowered odds of multiple pregnancy. CONCLUSIONS We provide a mechanistic explanation and preliminary evidence for previous reports that mothers of twins are more likely to have smoked, despite seemingly conflicting evidence for the fertility-reducing effects of nicotine. Nicotine, as an aromatase inhibitor, inhibits estrogen synthesis and may allow for greater production of gonadotropins. While smoking may have deleterious effects on fertility across many genotypes, in women of specific genotypes it may raise their odds of producing twins. TP53 involvement suggests the necessity of future work examining relationships between women who bear multiples and cancer risk.
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Affiliation(s)
- Hong Huang
- School of Information, University of South Florida, 4202 E. Fowler Av, Tampa, Florida, 33620
| | - Kathryn B H Clancy
- Department of Anthropology, University of Illinois at Urbana-Champaign, 109 Davenport Hall, 607 S. Mathews Ave., Urbana, Illinois, 61801
| | - Crystal Burhance
- Department of Anthropology, University of South Florida, 4202 E. Fowler Av, Tampa, Florida, 33620
| | - Yilliang Zhu
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida
| | - Lorena Madrigal
- Department of Anthropology, University of South Florida, 4202 E. Fowler Av, Tampa, Florida, 33620
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Clinical use of fertility agents and risk of breast cancer: a recent update for an old problem. Curr Opin Obstet Gynecol 2015; 26:130-7. [PMID: 24751999 DOI: 10.1097/gco.0000000000000067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Female infertility is today a very common, expanding problem and therefore restoring fertility strategies are increasing in the last few years. An association between ovarian stimulation and breast cancer risk has been hypothesized, but the question has not yet been clarified. RECENT FINDINGS In the last 2 years, many important studies have been published on this topic. A lot of new combinations of drugs are in experimentation and other recent drugs are already in current use, such as aromatase inhibitors. Furthermore, the data from older studies were investigated by two recent meta-analyses. SUMMARY Infertility affects many couples in western countries and the use of fertility stimulation techniques is widespread in the last few years, determining personal anxiety, social costs, and organizing difficulties. It is well known that one of the most important causative agents for the development of breast cancer is the proliferative activity of endogenous and exogenous female hormones. Therefore, it seems appropriate to investigate the risk of breast cancer derived from the use of hormonal therapies in infertile women. The final clarification of this question is very important so that all women can realize their dream of having children, with the certainty of not being exposed to an increased risk of breast cancer.
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Roque M, Tostes ACI, Valle M, Sampaio M, Geber S. Letrozole versus clomiphene citrate in polycystic ovary syndrome: systematic review and meta-analysis. Gynecol Endocrinol 2015; 31:917-21. [PMID: 26479460 DOI: 10.3109/09513590.2015.1096337] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The objective of the present systematic review and meta-analysis was to examine the literature and to identify the results of randomized controlled trials (RCTs) comparing the use of letrozole to clomiphene citrate (CC) for ovulation induction in patients with polycystic ovary syndrome (PCOS). An exhaustive electronic literature search was performed using the MEDLINE and EMBASE databases until October 2014. Seven prospective RCTs comparing the use of letrozole to CC in PCOS patients met the inclusion criteria. Overall, the seven included studies accounted for 1833 patients (906 in the letrozole group and 927 in the CC group) and for 4999 ovulation induction cycles (2455 in the letrozole group and 2544 in the CC group). Five of the included studies reported data on live birth rates. There was a statistically significant increase in the live birth and pregnancy rates in the letrozole group when compared to the CC group, with a relative risk (RR) = 1.55 (95% confidence interval (CI): 1.26-1.90; I(2) = 0%) and RR = 1.38 (95% CI: 1.05-1.83; I(2) = 61%), respectively. There were no differences in the multiple pregnancy, miscarriage and ovulation rates between the two groups. Our study found that letrozole is superior to CC when considering the live birth and pregnancy rates in patients with PCOS.
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Affiliation(s)
- Matheus Roque
- a Origen-Center for Reproductive Medicine, Av Rodolfo de Amoedo , 140, Barra da Tijuca , Rio de Janeiro , Brazil
| | - Ana C I Tostes
- a Origen-Center for Reproductive Medicine, Av Rodolfo de Amoedo , 140, Barra da Tijuca , Rio de Janeiro , Brazil
| | - Marcello Valle
- a Origen-Center for Reproductive Medicine, Av Rodolfo de Amoedo , 140, Barra da Tijuca , Rio de Janeiro , Brazil
| | - Marcos Sampaio
- b Origen-Center for Reproductive Medicine, Av do Contorno , 7747, Lourdes , Belo Horizonte , Brazil , and
| | - Selmo Geber
- b Origen-Center for Reproductive Medicine, Av do Contorno , 7747, Lourdes , Belo Horizonte , Brazil , and
- c Universidade Federal de Minas Gerais, Avenida Alfredo Balena , 190, Belo Horizonte , Brazil
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Fattah GA, Al Mohammady M, Hamed DA. Combined pioglitazone–metformin and clomiphene citrate versus metformin and clomiphene citrate in induction of ovulation in women with clomiphene citrate-resistant polycystic ovary syndrome. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2014. [DOI: 10.1016/j.mefs.2013.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Franik S, Kremer JAM, Nelen WLDM, Farquhar C. Aromatase inhibitors for subfertile women with polycystic ovary syndrome. Cochrane Database Syst Rev 2014:CD010287. [PMID: 24563180 DOI: 10.1002/14651858.cd010287.pub2] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Polycystic ovary syndrome (PCOS) is the most common cause of infrequent periods (oligomenorrhoea) and absence of periods (amenorrhoea). It affects about 4% to 8% of women worldwide and often leads to anovulatory subfertility. Aromatase inhibitors (AIs) are a novel class of drugs that were introduced for ovulation induction in 2001. Over the last ten years clinical trials have reached differing conclusions as to whether the AI letrozole is at least as effective as the first-line treatment clomiphene citrate (CC). OBJECTIVES To evaluate the effectiveness and safety of aromatase inhibitors for subfertile women with anovulatory PCOS. SEARCH METHODS We searched the following sources from inception to 24/10/2013 to identify relevant randomised controlled trials (RCTs): the Menstrual Disorders and Subfertility Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PsycINFO, Pubmed, LILACS, Web of Knowledge, the World Health Organisation (WHO) clinical trials register and Clinicaltrials.gov. Furthermore, we manually searched the references of relevant articles.The search was not restricted by language or publication status. SELECTION CRITERIA We included all RCTs of aromatase inhibitors used alone or with other medical therapies for ovulation induction in women of reproductive age with anovulatory PCOS. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, extracted the data and assessed trial quality. Studies were pooled where appropriate using a fixed effect model to calculate pooled odds ratios (ORs) and 95% confidence intervals (CIs) for most outcomes and risk differences (RDs) for ovarian hyperstimulation syndrome (OHSS). The primary outcomes were live birth and OHSS. Secondary outcomes were pregnancy, miscarriage and multiple pregnancy. The quality of the evidence for each comparison was assessed using GRADE methods. MAIN RESULTS We included 26 RCTs (5560 women). In all studies the aromatase inhibitor was letrozole. Live birth (12 RCTs) One RCT compared letrozole with placebo in women who were clomiphene resistant and the results were inconclusive (OR 3.17, 95% CI 0.12 to 83.17, n=36)Nine RCTs compared letrozole with clomiphene citrate (with or without adjuncts) followed by timed intercourse. The birth rate was higher in the letrozole group (OR 1.63, 95% CI 1.31 to 2.03, n=1783, I²=3%)Two RCTs compared letrozole with laparoscopic ovarian drilling. There was no evidence of a difference between the groups in live birth rate (OR 1.19, 95% CI 0.76 to 1.86, n=407, I²=0%) OHSS (16 RCTs) There was no evidence of a difference in OHSS rates when letrozole was compared with placebo (one RCT, n=36), clomiphene citrate (with or without adjuncts) followed by timed intercourse (nine RCTs, n=2179), clomiphene citrate (with or without adjuncts) followed by intrauterine insemination (IUI) (two RCTs, n=1494), laparoscopic ovarian drilling (one RCT, n=260) or anastrozole (one RCT, n=220). Events were absent or very rare, and no study had more than 2 cases of OHSS. Clinical pregnancy (25 RCTs) One RCT compared letrozole versus placebo in women who were clomiphene resistant and the results were inconclusive (OR 3.17, 95% CI 0.12 to 83.17, n=36)Fourteen RCTs compared letrozole versus clomiphene citrate (with or without adjuncts) followed by timed intercourse. The pregnancy rate was higher in the letrozole group (OR 1.32, 95% CI 1.09 to 1.60, n=2066, I²=25%)Three RCTs compared letrozole versus clomiphene citrate (with or without adjuncts) followed by IUI. The pregnancy rate was higher in the letrozole group (OR 1.71, 95% CI 1.30 to 2.25, n=1597)Three RCTs compared letrozole versus laparoscopic ovarian drilling. There was no evidence of a difference in the clinical pregnancy rate (OR 1.14, 95% CI 0.80 to 1.65, n=553, I²=0%)Two RCTs compared letrozole versus anastrozole, one RCT compared a five day versus a 10 day administration protocol for letrozole and another RCT compared 5 mg of letrozole versus 7.5 mg of letrozole. There was no evidence of a difference in the clinical pregnancy rate in these comparisons.The quality of the evidence was rated as low for live birth and pregnancy outcomes. The reasons for downgrading the evidence were poor reporting of study methods, possible publication bias and the tendency for studies that reported live birth to report higher clinical pregnancy rates in the letrozole group than studies that failed to report live birth (suggesting that results might be somewhat less favourable to letrozole if all studies reported live birth). AUTHORS' CONCLUSIONS Letrozole appears to improve live birth and pregnancy rates in subfertile women with anovulatory PCOS, compared to clomiphene citrate. The quality of this evidence is low and findings should be regarded with some caution. There appears to be no difference in effectiveness between letrozole and laparoscopic ovarian drilling, though there were few relevant studies. OHSS was a very rare event, with no occurrences in most studies.
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Affiliation(s)
- Sebastian Franik
- Faculty of Medical School, Radboud University Nijmegen, Geert Grooteplein 9, PO Box 9101, Nijmegen, Netherlands, 6500HB
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Hajishafiha M, Dehghan M, Kiarang N, Sadegh-Asadi N, Shayegh SN, Ghasemi-Rad M. Combined letrozole and clomiphene versus letrozole and clomiphene alone in infertile patients with polycystic ovary syndrome. DRUG DESIGN DEVELOPMENT AND THERAPY 2013; 7:1427-31. [PMID: 24348019 PMCID: PMC3857067 DOI: 10.2147/dddt.s50972] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of childbearing age (6.8%–18%), is among the most common causes of infertility due to ovulation factors, and accounts for 55%–70% of infertility cases caused by chronic anovulation. In this study, we used a combination of letrozole and clomiphene in patients resistant to both drugs individually, and studied the effects of this combination in ovulation and pregnancy in resistant PCOS patients. Methods The study population included infertile couples diagnosed as PCOS in the wife. The women used clomiphene for at least six cycles in order to ovulate after failure to form the dominant follicle, and were then put on letrozole for four cycles. Patients who were unable to form the dominant follicle were enrolled on letrozole and clomiphene combination therapy. Results One hundred enrolled patients underwent 257 cycles of a combination of letrozole and clomiphene, in which 213 were able to form the dominant follicle (82.9%) and 44 were unable to do so (17.1%). The number of mature follicles was 2.3±1.1. The mean endometrial thickness in patients on the day of human chorionic gonadotropin administration was 8.17±1.3 mm. The pregnancy rate was 42%. Conclusion According to the results of this study, it can be proposed that in PCOS patients resistant to clomiphene and letrozole used as single agents, a combination of the two drugs can be administered before using more aggressive treatment that may have severe complications or surgery. This combination may also be used as a first-line therapy to induce ovulation in severe cases of PCOS in order to save time and expense.
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Affiliation(s)
- Masomeh Hajishafiha
- Department of Gynecology, Reproductive Health Research Center, Urmia University of Medical Sciences, Ajman, United Arab Emirates
| | - Meisam Dehghan
- Urmia University of Medical Sciences, Ajman, United Arab Emirates
| | - Nazila Kiarang
- Department of Gynecology, Reproductive Health Research Center, Urmia University of Medical Sciences, Ajman, United Arab Emirates
| | - Nahideh Sadegh-Asadi
- Department of Gynecology, Reproductive Health Research Center, Urmia University of Medical Sciences, Ajman, United Arab Emirates
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Luciano AA, Lanzone A, Goverde AJ. Management of female infertility from hormonal causes. Int J Gynaecol Obstet 2013; 123 Suppl 2:S9-17. [DOI: 10.1016/j.ijgo.2013.09.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Fatum M, McVeigh E, Child T. The case for aromatase inhibitors use in Oncofertility patients. Should aromatase inhibitors be combined with gonadotropin treatment in Breast Cancer patients undergoing ovarian stimulation for fertility preservation prior to chemotherapy? A debate. HUM FERTIL 2013; 16:235-40. [DOI: 10.3109/14647273.2013.800650] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Pavone ME, Bulun SE. Clinical review: The use of aromatase inhibitors for ovulation induction and superovulation. J Clin Endocrinol Metab 2013; 98:1838-44. [PMID: 23585659 PMCID: PMC3644592 DOI: 10.1210/jc.2013-1328] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Anovulation is likely responsible for 20% of female infertility. Although clomiphene citrate remains the first-line therapy for ovulation induction in anovulatory patients who are not estrogen-deficient and to treat unexplained infertility, there remains a discrepancy between ovulation and conception rates with its use, attributed to its antiestrogenic effects on cervical mucus and the endometrium. Alternative agents, including aromatase inhibitors, have been used that have not been associated with these side effects. EVIDENCE ACQUISITION A literature search was conducted to specifically explore the use of aromatase inhibitors for ovulation induction and superovulation. EVIDENCE SYNTHESIS Recent studies have found that aromatase inhibitors may be safe and useful agents for ovulation induction in patients with polycystic ovarian syndrome as well a treatment option for superovulation in patients with either unexplained infertility or endometriosis. CONCLUSIONS Aromatase inhibitors may be an effective alternative treatment to clomiphene citrate for both ovulation induction and superovulation.
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Affiliation(s)
- Mary Ellen Pavone
- Department of Obstetrics and Gynecology, Feinberg School of Medicine at Northwestern University, 250 East Superior Street, Chicago, Illinois 60611, USA
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Khanna SC, Kumar A, Joy SG, Tanwar R, Sharma S, Prasad S. Is letrozole superior to clomiphene for ovarian stimulation prior to intrauterine insemination? Arch Gynecol Obstet 2013; 287:571-5. [PMID: 23053313 DOI: 10.1007/s00404-012-2579-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2012] [Accepted: 09/20/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To compare the efficacy of letrozole with clomiphene citrate for ovarian stimulation prior to intrauterine insemination. METHODS A total of 272 patients underwent 362 cycles of stimulation prior to IUI from January 2009 to May 2011. One hundred and twenty-six patients (170 cycles) received letrozole 5 mg and 146 patients (192 cycles) received clomiphene citrate 100 mg for 5 days starting on day 3 of the cycle. Intrauterine insemination was done 36 ± 4 h after hCG injection in 99 patients (131 cycles) in the letrozole group and 115 patients (136 cycles) in the clomiphene group. The number of mature follicles and serum E2 levels was monitored on the day of hCG. Endometrial thickness was noted on the day of hCG and IUI as well. The pregnancy rate, the miscarriage rate, and other parameters were evaluated only for patients who underwent IUI. RESULTS The mean number of mature follicles was significantly more in the clomiphene group (1.66 ± 1.69 vs. 1.41 ± 1.53) than in the letrozole group. No significant difference in endometrial thickness on the day of hCG administration was found; however, endometrial thickness was statistically significantly higher in the clomiphene group on the day of IUI (9.28 ± 1.43 vs. 8.77 ± 1.34). Serum E(2) levels on the day of hCG were statistically significantly higher in the clomiphene group (501.09 ± 2.45 vs. 214.79 ± 2.43 pg/ml). Pregnancy rate was 9.2 %/cycle and 12.12 %/patient in the letrozole group, and 8.1 %/cycle and 9.5 %/cycle in the clomiphene group; these differences were not statistically significant. CONCLUSION This study found no superiority of letrozole over clomiphene when used for ovarian stimulation and IUI.
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Affiliation(s)
- Shalini C Khanna
- Department of Obstetrics and Gynaecology, IVF and Reproductive Biology Centre, Maulana Azad Medical College, New Delhi 110002, India.
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40
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Hussain NHN, Ismail M, Zain MM, Yeu PC, Ramli R, Mohammad WMZW. Randomized controlled trial of Letrozole versus Clomiphene citrate for induction of ovulation in polycystic ovarian syndrome (PCOS): A Malaysian experience. ACTA ACUST UNITED AC 2013. [DOI: 10.4236/ojog.2013.35a2003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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41
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Selim MF, Borg TF. Letrozole and Clomiphene Citrate Effect on Endometrial and Subendometrial Vascularity in Treating Infertility in Women with Polycystic Ovary Syndrome. J Gynecol Surg 2012. [DOI: 10.1089/gyn.2012.0033] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Tamer Farouk Borg
- Department of Obstetrics and Gynecology, Ain Shams University, Cairo, Egypt
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Roy KK, Baruah J, Singla S, Sharma JB, Singh N, Jain SK, Goyal M. A prospective randomized trial comparing the efficacy of Letrozole and Clomiphene citrate in induction of ovulation in polycystic ovarian syndrome. J Hum Reprod Sci 2012; 5:20-5. [PMID: 22870010 PMCID: PMC3409915 DOI: 10.4103/0974-1208.97789] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2011] [Revised: 09/05/2011] [Accepted: 02/20/2012] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVES: To compare the efficacy of letrozole and clomiphene citrate (CC) in patients of anovulatory polycystic ovarian syndrome (PCOS) with infertility. MATERIALS AND METHODS: This prospective randomized clinical trial included 204 patients of PCOS. 98 patients (294 cycles) received 2.5–5 mg of letrozole; 106 patients (318 cycles) received 50–100 mg of CC (both orally from Days 3–7 of menstrual cycle). The treatment continued for three cycles in both the groups. Main outcome measures: ovulation rate, endometrial thickness, and pregnancy rate. Statistical analysis was done using SPSS 13 software. P value less than 0.05 was considered significant. RESULTS: The mean number of dominant follicles in letrozole groups and CC groups was 1.86±0.26 and 1.92±0.17, respectively (P=0.126). Number of ovulatory cycle in letrozole group was 196 (66.6%) versus 216 (67.9%) in CC group (P=0.712). The mean mid-cycle endometrial thickness was 9.1±0.3 mm in letrozole group and 6.3±1.1 in CC group, which was statistically significant (P=0.014). The mean Estradiol [E2] level in clomiphene citrate group was significantly higher in CC group (364.2±71.4 pg/mL) than letrozole group (248.2± 42.2 pg/mL). 43 patients from the letrozole group (43.8%) and 28 patients from the CC group (26.4%) became pregnant. CONCLUSION: Letrozole and CC have comparable ovulation rate. The effect of letrozole showed a better endometrial response and pregnancy rate compared with CC.
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Affiliation(s)
- Kallol Kumar Roy
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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43
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Costello MF, Ledger WL. Evidence-Based Lifestyle and Pharmacological Management of Infertility in Women with Polycystic Ovary Syndrome. WOMENS HEALTH 2012; 8:277-90. [DOI: 10.2217/whe.12.14] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Polycystic ovary syndrome (PCOS) is the most prevalent endocrine disorder in women of reproductive age and by far the most common cause of anovulatory infertility. Lifestyle change alone, and not in combination with pharmacological ovulation induction such as clomifene citrate or metformin, is generally considered the first-line treatment for the management of infertile anovulatory women with PCOS who are overweight or obese. Clomifene citrate should be considered as a first-line pharmacological therapy to improve fertility outcomes. Second-line medical treatments may include ovulation induction with gonadotropins (in clomifene citrate-resistant or clomifene citrate failure women) or laparoscopic ovarian drilling (in clomifene citrate-resistant women) or possibly with metformin combined with clomifene citrate (in clomifene citrate-resistant women). There is currently insufficient evidence to recommend aromatase inhibitors over that of clomifene citrate in infertile anovulatory women with PCOS in general or specifically in therapy-naive or clomifene citrate-resistant women with PCOS.
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Affiliation(s)
- Michael F Costello
- School of Women's & Children's Health, Division of Obstetrics & Gynaecology, University of New South Wales, Level 1 Women's Health Institute, Royal Hospital for Women, Locked Bag 2000, Randwick, Sydney, NSW 2031, Australia
- Department of Reproductive Medicine & IVF Australia, Royal Hospital for Women, Sydney, NSW, Australia
| | - William L Ledger
- School of Women's & Children's Health, Division of Obstetrics & Gynaecology, University of New South Wales, Level 1 Women's Health Institute, Royal Hospital for Women, Locked Bag 2000, Randwick, Sydney, NSW 2031, Australia
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Legro RS, Kunselman AR, Brzyski RG, Casson PR, Diamond MP, Schlaff WD, Christman GM, Coutifaris C, Taylor HS, Eisenberg E, Santoro N, Zhang H. The Pregnancy in Polycystic Ovary Syndrome II (PPCOS II) trial: rationale and design of a double-blind randomized trial of clomiphene citrate and letrozole for the treatment of infertility in women with polycystic ovary syndrome. Contemp Clin Trials 2012; 33:470-81. [PMID: 22265923 DOI: 10.1016/j.cct.2011.12.005] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Revised: 12/01/2011] [Accepted: 12/21/2011] [Indexed: 12/26/2022]
Abstract
Polycystic Ovary Syndrome (PCOS) is a common cause of female infertility and first line treatment is currently oral clomiphene citrate, a selective estrogen receptor modulator, which results in both a high nonresponse rate and multiple pregnancy rate. Aromatase inhibitors such as letrozole may have more favorable ovarian and endometrial effects. The goal of the Pregnancy in Polycystic Ovary Syndrome II (PPCOSII) study is to determine the safety and efficacy of clomiphene citrate (CC) compared to letrozole, in achieving live birth in infertile women with PCOS. The population will consist of 750 infertile women with PCOS. Additionally, the couple will have no other major infertility factor. This will be a multi-center, prospective, double-blind clinical trial of CC vs. letrozole for 5 treatment cycles (or approximately up to 25 weeks). The randomization scheme will be coordinated through the central data coordinating center (DCC) and the randomization is stratified by each participating site. After progestin withdrawal as needed, 750 women will be equally randomized to two different treatment arms: A) CC 50mg every day for 5 days (days 3-7 of cycle), or B) letrozole 2.5mg every day for 5 days (days 3-7 of cycle), for a total of 5 cycles or 25 weeks. The dose will be increased in subsequent cycles in both treatment groups for non-response or poor ovulatory response up to a maximum of 150 mg of CC a day (×5 days) or 7.5mg of letrozole a day (×5 days). The primary analysis will use an intent-to-treat approach to examine differences in the live birth rate in the two treatment arms.
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Affiliation(s)
- Richard S Legro
- Department of Obstetrics and Gynecology, Pennsylvania State University, Hershey, PA, United States.
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Teede HJ, Misso ML, Deeks AA, Moran LJ, Stuckey BGA, Wong JLA, Norman RJ, Costello MF. Assessment and management of polycystic ovary syndrome: summary of an evidence-based guideline. Med J Aust 2011; 195:S65-112. [PMID: 21929505 DOI: 10.5694/mja11.10915] [Citation(s) in RCA: 198] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Accepted: 08/26/2011] [Indexed: 12/19/2022]
Affiliation(s)
- Helena J Teede
- Research Unit, Jean Hailes Foundation for Women's Health, Melbourne, VIC, Australia.
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46
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A randomized trial of ovulation induction with two different doses of Letrozole in women with PCOS. Arch Gynecol Obstet 2011; 284:1029-34. [DOI: 10.1007/s00404-011-1951-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Accepted: 06/09/2011] [Indexed: 12/26/2022]
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47
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He D, Jiang F. Meta-analysis of letrozole versus clomiphene citrate in polycystic ovary syndrome. Reprod Biomed Online 2011; 23:91-6. [DOI: 10.1016/j.rbmo.2011.03.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Revised: 03/22/2011] [Accepted: 03/24/2011] [Indexed: 10/18/2022]
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48
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Bedaiwy MA, Abdelaleem MA, Hussein M, Mousa N, Brunengraber LN, Casper RF. Hormonal, follicular and endometrial dynamics in letrozole-treated versus natural cycles in patients undergoing controlled ovarian stimulation. Reprod Biol Endocrinol 2011; 9:83. [PMID: 21693028 PMCID: PMC3131247 DOI: 10.1186/1477-7827-9-83] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Accepted: 06/21/2011] [Indexed: 11/10/2022] Open
Abstract
The objective of this study was to compare letrozole-stimulated cycles to natural cycles in 208 patients undergoing intrauterine insemination (IUI) between July of 2004 and January of 2007. Group I (n = 47) received cycle monitoring only (natural group), Group II (n = 125) received letrozole 2.5 mg/day on cycle days three to seven, and Group III (n = 36) received letrozole 5 mg/day on cycle days three to seven. There were no differences between the groups in endometrial thickness or P₄ on the day of hCG. Estradiol levels had higher variation in the second half of the follicular phase in both letrozole-treated groups compared to the control group. Estradiol per preovulatory follicle was similar in both letrozole cycles to that observed in the natural cycles. LH was lower on the day of hCG administration in the letrozole 2.5 mg/day group vs. the natural group. In summary, letrozole results in some minor changes in follicular, hormonal and endometrial dynamics compared to natural cycles. Increased folliculogenesis and pregnancy rates were observed in the letrozole-treated groups compared to the natural group. These findings need to be confirmed in larger, prospective studies.
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Affiliation(s)
- Mohamed A Bedaiwy
- Department of Obstetrics and Gynecology, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Assiut University, Assiut, Egypt
| | | | | | - Noha Mousa
- Reproductive Sciences Division, Department of Obstetrics and Gynecology, University of Toronto, Toronto, Canada
| | - Lisa N Brunengraber
- Department of Obstetrics and Gynecology, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Robert F Casper
- Reproductive Sciences Division, Department of Obstetrics and Gynecology, University of Toronto, Toronto, Canada
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49
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Kamath MS, George K. Letrozole or clomiphene citrate as first line for anovulatory infertility: a debate. Reprod Biol Endocrinol 2011; 9:86. [PMID: 21693034 PMCID: PMC3148573 DOI: 10.1186/1477-7827-9-86] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Accepted: 06/21/2011] [Indexed: 11/24/2022] Open
Abstract
Clomiphene citrate has been traditionally used as the drug of choice in treating women with anovulatory infertility. In the last decade letrozole, an aromatase inhibitor has emerged as alternative ovulation induction agent. Literature confirms that letrozole has a definitive role in anovulatory women who have not responded to the clomiphene therapy. However its role as an alternative to clomiphene as first line therapy continues to be debated. Although it is probable that the overall benefits of letrozole surpass clomiphene citrate, currently available data does not confirm this view. There is need for large well-designed trials.
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Affiliation(s)
- Mohan S Kamath
- Reproductive Medicine Unit, Christian Medical College Hospital, Vellore 632004, Tamil Nadu, India
| | - Korula George
- Reproductive Medicine Unit, Christian Medical College Hospital, Vellore 632004, Tamil Nadu, India
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50
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Predictors and characteristics of letrozole induced ovulation in comparison with clomiphene induced ovulation in anovulatory PCOS women. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2011. [DOI: 10.1016/j.mefs.2010.11.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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