Anastrozole single-dose protocol in women with oligo- or anovulatory infertility: results of a randomized phase II dose-response study

OBJECTIVE

To compare the effects of anastrozole and clomiphene citrate (CC) on follicular development and ovulation in infertile women with ovulatory dysfunction.

DESIGN

Phase II, prospective, randomized, assessor-blind, multicenter, dose-finding, noninferiority study.

SETTING

Outpatient.

PATIENT(S)

Infertile women with ovulatory dysfunction, aged 18-35 years, and body mass index <35 kg/m(2).

INTERVENTION(S)

Single-dose anastrozole at 5 mg (n = 39), 10 mg (n = 39), 20 mg (n = 39), or 30 mg (n = 38) or a 5-day course of CC at 50 mg/d (n = 39) as starting doses.

MAIN OUTCOME MEASURE(S)

The primary endpoint was the ovulation rate in the first treatment cycle (cycle 1). Ovulation was defined as a midluteal phase serum P level ≥ 10 ng/mL or clinical pregnancy.

RESULT(S)

In cycle 1 the ovulation rates for a single dose of anastrozole at 5, 10, 20, and 30 mg were 46.2%, 41.0%, 23.1%, and 28.9%, respectively, whereas that for CC at 50 mg/d was 61.5%. Among women with fewer than six menses per year, the cumulative ovulation rates over three cycles were comparable in the anastrozole 5 mg (52.4%) and CC 50 mg/d (42.3%) groups.

CONCLUSION(S)

In terms of ovulation rates in cycle 1, single-dose anastrozole at 5, 10, 20, and 30 mg was not as effective as CC at 50 mg/d for 5 days (noninferiority was not shown).

Midluteal serum progesterone levels and pregnancy following ovulation induction with human follicle-stimulating hormone: results of a combined-data analysis

OBJECTIVE

This retrospective analysis of combined data (one Phase II and three Phase III clinical trials) of patients with oligo- or anovulatory infertility aimed to evaluate the association between pregnancy and midluteal serum progesterone (P4) level following ovulation induction and hence the indicative value of P4 for ovulation and pregnancy achievement.

STUDY DESIGN

All patients (n = 913) were treated with human follicle-stimulating hormone. Cycles (n = 1,554) with one or two serum P4 levels in the luteal phase (days 5-12) following human chorionic gonadotropin administration and complete data on cycle outcome were included.

RESULTS

Clinical pregnancy was achieved in 295/1,554 (19.0%) cycles; 87.5% of these led to live births (16.6%/cycle). Including and excluding multiple pregnancy data, 88% and 86% of all live births had P4 values >10 ng/mL, respectively. Overall clinical pregnancy rate plateaued at midluteal P4 levels >25 ng/mL but, when multiple pregnancies were excluded, plateaued at 20-25 ng/mL and then decreased. Mean midluteal P4 levels were twice as high in multiple versus singleton pregnancies.

CONCLUSION

A midluteal P4 level >10 ng/mL may represent an appropriate threshold for indication of ovulation resulting in live birth. Multiple pregnancies were associated with higher mean midluteal P4 levels.

Biological versus chronological ovarian age: implications for assisted reproductive technology

BACKGROUND

Women have been able to delay childbearing since effective contraception became available in the 1960s. However, fertility decreases with increasing maternal age. A slow but steady decrease in fertility is observed in women aged between 30 and 35 years, which is followed by an accelerated decline among women aged over 35 years. A combination of delayed childbearing and reduced fecundity with increasing age has resulted in an increased number and proportion of women of greater than or equal to 35 years of age seeking assisted reproductive technology (ART) treatment.

METHODS

Literature searches supplemented with the authors' knowledge.

RESULTS

Despite major advances in medical technology, there is currently no ART treatment strategy that can fully compensate for the natural decline in fertility with increasing female age. Although chronological age is the most important predictor of ovarian response to follicle-stimulating hormone, the rate of reproductive ageing and ovarian sensitivity to gonadotrophins varies considerably among individuals. Both environmental and genetic factors contribute to depletion of the ovarian oocyte pool and reduction in oocyte quality. Thus, biological and chronological ovarian age are not always equivalent. Furthermore, biological age is more important than chronological age in predicting the outcome of ART. As older patients present increasingly for ART treatment, it will become more important to critically assess prognosis, counsel appropriately and optimize treatment strategies. Several genetic markers and biomarkers (such as anti-Müllerian hormone and the antral follicle count) are emerging that can identify women with accelerated biological ovarian ageing. Potential strategies for improving ovarian response include the use of luteinizing hormone (LH) and growth hormone (GH). When endogenous LH levels are heavily suppressed by gonadotrophin-releasing hormone analogues, LH supplementation may help to optimize treatment outcomes for women with biologically older ovaries. Exogenous GH may improve oocyte development and counteract the age-related decline of oocyte quality. The effects of GH may be mediated by insulin-like growth factor-I, which works synergistically with follicle-stimulating hormone on granulosa and theca cells.

CONCLUSION

Patients with biologically older ovaries may benefit from a tailored approach based on individual patient characteristics. Among the most promising adjuvant therapies for improving ART outcomes in women of advanced reproductive age are the administration of exogenous LH or GH.

Nonpenetrating, arcuate-legged clip reconstruction of the rat uterine horn

A new method for reconstructing rat uterine horn was developed in which nonpenetrating, arcuate-legged clips are applied in interrupted fashion to everted seromuscular edges, forming an elastomeric flanged joint. This anastomosis has unusual physical and morphologic properties, with improved tissue healing and luminal restitution. Clipping is easier than suturing, and resulted in equivalent fertility rate (50-60%) and litter size. It also is associated with less granuloma formation and hystiocytic infiltration than suture. The new technique has the potential of endoscopic translation for human tubal reconstruction.

Hirsutism: implications, etiology, and management

Hirsutism usually results from a subtle excess of androgens. As such, it is a clue to possible endocrine disturbance in addition to presenting cosmetic problems. We use the term hirsutism to mean male-pattern hirsutism--excessive growth of hair in areas where female subjects normally have considerably less than male subjects. An elevation of the plasma free (unbound) testosterone level is the single most consistent endocrinologic finding in hirsutism. The plasma free testosterone level is sometimes elevated when the total level of plasma testosterone is normal because testosterone-estradiol--binding globulin (TEBG) levels are often depressed in hirsute women. Frequent blood sampling is sometimes necessary to demonstrate subtle hyperandrogenic states since androgen levels in the blood are pulsatile and seemingly reflect episodic ovarian and adrenal secretion. The source of hyperandrogenemia can usually be determined from dexamethasone suppression testing. Those patients whose plasma free androgen levels do not suppress normally usually have functional ovarian hyperandrogenism (polycystic ovary syndrome variants). Very high plasma androgen levels or evidence of hypercortisolism, which is not normally suppressible by dexamethasone, should lead to the search for a tumor or Cushing's syndrome. Those patients in whom hyperandrogenemia is suppressed normally by dexamethasone have a form of the adrenogenital syndrome, a prolactinoma, obesity, or idiopathic hyperandrogenemia. In such patients, glucocorticoid therapy may reduce hirsutism and acne and normalize menses. The treatment of hirsutism resulting from functional ovarian hyperandrogenism is not as satisfactory; estrogen-progestin treatment is the most useful adjunct to cosmetic approaches to hirsutism in this country. However, other manifestations of polycystic ovary syndrome, such as infertility, may take precedence over hirsutism when an optimal therapeutic program is designed for many patients.

Unexplained infertility. A reappraisal

During a 30-month period 229 couples were evaluated for infertility at the Naval Regional Medical Center, Oakland. Laparoscopy was used in all cases of otherwise unexplained infertility. The resulting laparoscopic examination of the female partner of 24 such couples demonstrated abnormal findings in 18 (75%). Of these 18 subjects, unsuspected endometriosis was found in 11 (46%) and peritubal adhesions in 7 (29%). Of the 229 couples evaluated, only 8 (3.5%) failed to show some etiologic factor associated with infertility. Thus, the previously reported 10 to 20% incidence of unexplained infertility is too high an estimate in view of the additional information made available through pelvic endoscopy.