Ovulation Induction Using Clomiphene Citrate Using Stair - Step Regimen versus Traditional Regimen in Polycystic Ovary Syndrome Women - A Randomized Control Trial

Endometrial and follicular development following stair-step and traditional protocols in women with polycystic ovary syndrome: An RCT

Background

Various strategies have been proposed for polycystic ovary syndrome (PCOS) treatment.

Objective

To investigate and compare the number and size of ovarian follicles, endometrial thickness, and ovulation rate by traditional protocol (TP) and stair-step protocol (SSP).

Materials and Methods

Sixty infertile PCOS women were allocated into two groups (SSP = 30 and control TP = 30) between May and October 2019 in the Besat Hospital, Sanandaj, Iran. In the SSP group, the infertile women were treated with 50 mg/daily clomiphene citrate (CC) for five days, while the nonresponsive women were prescribed 100 mg daily CC for five days in the same cycle. The maximum dose (150 mg) was administered until ovulation occurred. In the control group, in non-ovulatory cases, the dose was increased in the next cycle. Ultrasound was used to detect ovulation.

Results

Endometrial thickness changes with various doses of CC were significantly different in the TP. The comparison of both protocols showed a significant difference in endometrial thickness only at 50 mg CC. The number of follicles in the left ovary was significantly different in both protocols at 150-mg CC. The size of ovarian follicles in the left ovary was significantly different between the two protocols at 100-mg CC. The ovulation rate was significantly different in the SSP at 100- and 150-mg doses of CC. Moreover, 86% of ovulation occurred at 100-mg CC in the SSP, while this rate was 73% in the TP.

Conclusion

The most appropriate dose for ovulation in patients with PCOS is 100 mg CC.

The stair-step approach in treatment of anovulatory PCOS patients

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

Clomiphene citrate impairs the endometrial CD98 expression in ovariectomized and non-ovariectomized rats: Role of HCG

Background

Clomiphene citrate (CC) is one of the widely used drugs as an ovulation stimulant, but its adverse effects on the endometrium results in lowering down the pregnancy rate. Endometrium CD98 is also important in the process of implantation.

Objective

To evaluate the immunohistochemistry expression levels of endometrial CD98 following injection of CC with and without Human chorionic gonadotropin (HCG) in ovariectomized and non-ovariectomized rats.

Materials and Methods

Seventy two (12-14 wk old) female Wistar rats were randomly divided into two groups (n = 36): (a) ovariectomized and (b) non-ovariectomized. Each group was further divided into six subgroups (n = 6/each): (1) CC 10 mg/kg, (2) CC 20 mg/kg, (3) HCG, (4) CC 10 mg/kg with HCG, (5) CC 20 mg/kg with HCG, and (6) control. The experimental subgroups received a single dose of CC (daily, five days) and HCG (after the last injection of CC) alone or in combination. Immunohistochemistry staining was performed on paraffin-embedded endometrial tissues to evaluate the expression levels of CD98.

Results

Animals undergoing ovariectomy presented a significantly lower expression level of endometrial CD98 (p < 0.001) when compared with non-ovariectomized in the same condition that groups were subdivided. There was also a dose-dependent reduction (p < 0.001) in the expression of CD98 in non-ovariectomized subgroups when compared with control group. In addition, injection of HCG following treatment with CC improved its expression.

Conclusion

It was concluded that CC impairs CD98 expression in endometrium and this impairment is intensified with the removal of the ovary. Also, an injection of HCG following treatment with CC can slightly improve the expression of CD98.