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PubMed1993

A comparative study of three ovulation induction protocols in polycystic ovarian disease patients in an in vitro fertilization/embryo transfer program.

PURPOSE: This study compares the results of three ovulation induction protocols in polycystic ovarian disease (PCOD) patients undergoing an in vitro fertilization-embryo transfer (IVF-ET) program. A total of 85 cycles was studied. The patients were treated with clomiphene citrate (CC) plus human menopausal gonadotropin (hMG) (CC/hMG group), with purified menofollitropin (pFSH) plus hMG (pFSH/hMG group), and with pFSH/hMG plus gonadotropin releasing hormone analogue (GnRH-a) (analogue group). In the analogue group the suppression of luteinizing hormone (LH) with GnRH-a decreased the number of follicles < 12 mm on the day of human chorionic gonadotropin (hCG) administration and the number and percentage of immature oocytes retrieved and increased the percentage of mature oocytes retrieved. RESULTS: However, fertilization rates of oocytes, cleaved embryo rates, pregnancy rates following replacement, and pregnancy outcomes were not different. CONCLUSION: Although the suppression of the hypothalamic-pituitary-ovarian axis with GnRH-a in PCOD patients improved follicular synchrony and oocyte maturity, none of the ovulation induction protocols was superior to the others with respect to pregnancy rates and pregnancy outcomes.

Adult↗
PubMed2002

Intrauterine pregnancy following low-dose gonadotropin ovulation induction and direct intraperitoneal insemination for severe cervical stenosis.

BACKGROUND: We present a case of primary infertility related to extreme cervical stenosis, a subset of cervical factor infertility which accounts for approximately 5% of all clinical infertility referrals. CASE PRESENTATION: A 37 year-old nulligravida was successfully treated with ovulation induction via recombinant follicle stimulating hormone (FSH) and direct intraperitoneal insemination (IPI). Anticipating controlled ovarian hyperstimulation with in vitro fertilization/embryo transfer (IVF), the patient underwent hysteroscopy and cervical recanalization, but safe intrauterine access was not possible due to severe proximal cervical stricture. Hysterosalpingogram established bilateral tubal patency and confirmed an irregular cervical contour. Since the cervical canal could not be traversed, neither standard intrauterine insemination nor transcervical embryo transfer could be offered. Prepared spermatozoa were therefore placed intraperitoneally at both tubal fimbria under real-time transvaginal sonographic guidance using a 17 gage single-lumen IVF needle. Supplementary progesterone was administered as 200 mg/d lozenge (troche) plus 200 mg/d rectal suppository, maintained from the day following IPI to the 8th gestational week. A singleton intrauterine pregnancy was achieved after the second ovulation induction attempt. CONCLUSIONS: In this report, we outline the relevance of cervical factor infertility to reproductive medicine practice. Additionally, our andrology evaluation, ovulation induction approach, spermatozoa preparation, and insemination technique in such cases are described.

Journal Article↗
PubMed1991

Selective follicular reduction following ovulation induction by exogenous gonadotrophins in polycystic ovarian disease. A new approach to treatment.

Seven patients with polycystic ovarian disease (PCO) and having polyfollicular development following ovulation induction by human menopausal gonadotrophin underwent selective follicular reduction by transvaginal ultrasound-guided aspiration of all follicles greater than or equal to 10 mm in diameter leaving two or three preovulatory mature follicles. Twenty-four and 48 h after injection of human chorionic gonadotrophin, the couples had intercourse. Five patients achieved pregnancy in 15 treatment cycles, four in their first cycle after 14 previous unsuccessful stimulation cycles. Four have delivered healthy children: three singletons and one set of twins. One patient spontaneously aborted twins in week 22 of pregnancy. No major complications were encountered. Selective follicular reduction seems to be a possible approach to the treatment of PCO patients having polyfollicular development following ovulation induction.

Adult↗
PubMed1996

Dexamethasone during ovulation induction for in-vitro fertilization: a pilot study.

The purpose of the present study was to determine whether adrenal androgen suppression with dexamethasone (DEX) during ovulation induction improves the outcome of in-vitro fertilization (IVF) cycles. A total of 25 patients with serum dehydroepiandrosterone sulphate (DHEAS) concentrations > 2.5 micrograms/ml were randomized to receive either 0.5 mg DEX daily or placebo during ovulation induction with leuprolide acetate down-regulation plus human menopausal gonadotrophins (HMG). Nine patients undergoing a subsequent IVF cycle were crossed over to the other treatment group. Ovarian responsiveness and IVF outcome variables analysed included number of follicles > 12 mm in diameter, serum oestradiol concentrations on the day of human chorionic gonadotrophin (HCG) administration, number of ampoules of HMG administered, number of oocytes retrieved, percentage of oocytes fertilized, number of embryos transferred, implantation rate and numbers of clinical pregnancies and live birth pregnancies. The 31 randomized IVF cycles revealed a trend towards a higher implantation rate for the placebo-treated group compared to the DEX-treated group (24 versus 10%; P = 0.07). The remainder of the IVF cycle variables revealed no statistically significant differences. In conclusion, the suppression of adrenal androgens with DEX in women with DHEAS concentrations > 2.5 micrograms/ml appears to have no beneficial effects on ovarian responsiveness or clinical or live birth pregnancy rates.

Adult↗
PubMed1996

[Ovulation induction with adjuvant antiandrogen treatment in Stein-Leventhal syndrome].

Ovulation induction with adjuvant antiandrogen treatment was carried out in 50 cycles of 24 hyperandrogenic anovulatory patients. Besides the clomiphene and gonadotrophin (pure FSH) administration on the bases of antiandrogenic effects of the drugs three treatment groups (dexamethasone, sprinolactone and cyproterone acetate) were established. In 40 cases of 50 cycles ovulation were detected and 11 pregnancies occurred. The authors achieved the highest ovulation and pregnancy rate in the group treated with cyproterone acetate. The highest progesterone and the lowest testosterone levels were measured in the same group. According to our investigations adjuvant antiandrogen treatment with cyproterone acetate advisable in the cases of hyperandrongenic conditions.

Adult↗
PubMed2006

The influence of body weight on response to ovulation induction with gonadotrophins in 335 women with World Health Organization group II anovulatory infertility.

OBJECTIVE: To assess the influence of body weight on the outcome of ovulation induction in women with World Health Organization (WHO) group II anovulatory infertility. DESIGN: The combined results of two studies in which either a highly purified urinary follicle-stimulating hormone or highly purified urinary menotrophin were compared with recombinant follicle-stimulating hormone. SETTING: Thirty-six fertility clinics. POPULATION: A total of 335 women with WHO group II anovulatory infertility failing to ovulate or conceive on clomifene citrate. METHODS: Ovarian stimulation using a low-dose step-up protocol. MAIN OUTCOME MEASURES: The effects of body weight on ovarian response, ovulation rate and pregnancy rate after one treatment cycle. RESULTS: With increasing body mass index (BMI), a higher threshold dose of gonadotrophins was required and there were more days of stimulation; yet, despite a greater concentration of antral follicles, there were fewer intermediate and large follicles. There was no difference in the rates of ovulation and clinical pregnancy in relation to body weight. CONCLUSIONS: Body weight affects gonadotrophin requirements but not overall outcome of ovulation induction in women with anovulatory polycystic ovary syndrome and a BMI of less than 35 kg/m2.

Adult↗
PubMed1989

Ovulation induction with intravenous gonadotropin-releasing hormone.

The efficacy of ovulation induction with the use of pulsatile gonadotropin-releasing hormone (GnRH) therapy was examined in 21 infertile women. Seventeen had hypothalamic amenorrhea (HA) and 4 polycystic ovary syndrome (PCO). All patients were treated as outpatients. GnRH was infused in a pulsatile mode by means of portable auto-infusion pumps connected to an indwelling intravenous catheter inserted into a forearm vein. The doses varied from 1.8 to 5 micrograms/pulse with a frequency of 90 minutes. Ovulation occurred in 52 out of 64 cycles (81.2%). Ten (47.6%) of the 21 patients became pregnant. Seven patients had normal term deliveries and 3 aborted spontaneously. With regard to the 17 patients with HA, ovulation occurred in 93.7% of treatment cycles and 6 women became pregnant. In the case of the PCO patients, ovulation was achieved in 6 out of 15 cycles (40%) and 2 women became pregnant. There was no overstimulation or any other serious complication. In conclusion, therapy with GnRH provides an elevated probability of therapeutic success, especially in HA.

Adult↗
PubMed1993

The luteal phase after ovulation induction with human menopausal gonadotropin and one versus two doses of a gonadotropin-releasing hormone agonist.

OBJECTIVE: To use a GnRH agonist (GnRH-a) to induce ovulation after priming with exogenous hMG. DESIGN: Prospective, randomized double-blind protocol using one or two doses of intranasal nafarelin. SETTING: Office-based ovulation induction program. PATIENTS, INTERVENTIONS: Infertile women not conceiving after use of clomiphene citrate for at least 6 months who were given hMG and nafarelin. No luteal support was given. MAIN OUTCOME MEASURES: Serum concentrations of FSH, LH, E2, and P acutely and at 6 days after GnRH-a administration. Duration of the luteal phase was assessed. RESULTS: Ovulation with elevation of both FSH and LH was achieved. The two-dose regimen was more effective than one dose for sustained LH release. Luteal phase P values and luteal phase duration were both less than usually seen with gonadotropin hCG therapy in the absence of luteal phase support. CONCLUSIONS: Ovulation induction with GnRH-a after hMG priming produces unacceptable luteal phase cycles in the absence of hormonal support.

Adult↗
PubMed1997

Ovulation induction in a woman with premature ovarian failure resulting from a partial deletion of the X chromosome long arm, 46,X,del(X)(q22).

OBJECTIVE: To report successful ovulation induction in a woman with premature ovarian failure (POF) resulting from a partial Xq deletion. DESIGN: An uncontrolled study. SETTING: University hospital. PATIENT(S): A 27-year-old woman with 46,X,del(X)(q22) who had hypergonadotropic secondary amenorrhea. INTERVENTION(S): Injections of hMG (225 IU/d) for 8 consecutive days after endogenous gonadotropin suppression with a long-acting GnRH agonist (900 micrograms/d) for 12 weeks, together with cyclic sex steroid replacement therapy. MAIN OUTCOME MEASURE(S): Serum concentrations of E2 and P as well as ultrasonography. RESULT(S): Folliculogenesis and ovulation. CONCLUSION(S): Ovulation induction is possible in patients with POF caused by X chromosome aberrations.

Adult↗
PubMed1996

Simplified ultralong protocol of gonadotrophin-releasing hormone agonist for ovulation induction with intrauterine insemination in patients with endometriosis.

The present study was designed to assess the usefulness of the simplified ultralong protocol of gonadotrophin-releasing hormone agonist (GnRHa) for ovulation induction with intrauterine insemination (IUI) in patients with various stages of endometriosis. A prospective randomized trial was set up to compare the simplified ultralong protocol (ULP) and the long protocol (LP) of GnRHa for ovulation induction with IUI in patients with endometriosis. There was no evidence of other factors in infertility in any patient. In the ULP group (39 patients), 4 weeks after a single injection of 3.75 mg Decapeptyl had been given, daily s.c. administration of 0.1 mg Decapeptyl was initiated and continued for at least 2 weeks prior to ovarian stimulation. In the LP group (41 patients), daily s.c. administration of 0.1 mg Decapeptyl was initiated from the mid-luteal phase of the cycle preceding the stimulation cycle. After 14 days of administration, ovarian stimulation was started if pituitary desensitization had been achieved. The amount of gonadotrophins required, number of days of gonadotrophin administration, serum oestradiol response, and the number of mature follicles were comparable in both groups. The clinical pregnancy rate per cycle was significantly higher in the ULP group at 48.7% (19/39) compared with 26.8% (11/41) in the LP group. The miscarriage rates were 21.1% (4/19) in the ULP group and 18.2% (2/11) in the LP group. In patients with stage I or II endometriosis, there was no significant difference between the two groups with respect to clinical pregnancy rate per cycle (47.4 versus 35.0%). In patients with stage III or IV endometriosis, the clinical pregnancy rate per cycle was significantly higher in the ULP group at 50.0% (10/20) compared with 19.0% (4/21) in the LP group. This study suggests that a simplified ULP of GnRHa could give better chances of achieving pregnancy in endometriosis patients undergoing assisted reproductive technologies and that this protocol may be more useful in patients with an advanced stage of endometriosis.

Adult↗
PubMed2006

Recombinant versus highly-purified, urinary follicle-stimulating hormone (r-FSH vs. HP-uFSH) in ovulation induction: a prospective, randomized study with cost-minimization analysis.

BACKGROUND: Both recombinant FSH (r-FSH) and highly-purified, urinary FSH (HP-uFSH) are frequently used in ovulation induction associated with timed sexual intercourse. Their effectiveness is reported to be similar, and therefore the costs of treatment represent a major issue to be considered. Although several studies about costs in IVF have been published, data obtained in low-technology infertility treatments are still scarce. METHODS: Two hundred and sixty infertile women (184 with unexplained infertility, 76 with CC-resistant polycystic ovary syndrome) at their first treatment cycle were randomized and included in the study. Ovulation induction was accomplished by daily administration of rFSH or HP-uFSH according to a low-dose, step-up regimen aimed to obtain a monofollicular ovulation. A bi- or tri-follicular ovulation was anyway accepted, whereas hCG was withdrawn and the cycle cancelled when more than three follicles greater than or equal to 18 mm diameter were seen at ultrasound. The primary outcome measure was the cost of therapy per delivered baby, estimated according to a cost-minimization analysis. Secondary outcomes were the following: monofollicular ovulation rate, total FSH dose, cycle cancellation rate, length of the follicular phase, number of developing follicles (>12 mm diameter), endometrial thickness at hCG, incidence of twinning and ovarian hyperstimulation syndrome, delivery rate. RESULTS: The overall FSH dose needed to achieve ovulation was significantly lower with r-FSH, whereas all the other studied variables did not significantly differ with either treatments. However, a trend toward a higher delivery rate with r-FSH was observed in the whole group and also when results were considered subgrouping patients according to the indication to treatment. CONCLUSION: Considering the significantly lower number of vials/patient and the slight (although non-significant) increase in the delivery rate with r-FSH, the cost-minimization analysis showed a 9.4% reduction in the overall therapy cost per born baby in favor of r-FSH.

Adult↗
PubMed1987

Response to repetitive cycles of ovulation induction in the same women.

It has been theorized that the administration of human menopausal gonadotropin (hMG) in consecutive menstrual cycles will result in a poor follicular response in the second cycle. To examine this, 50 women undergoing ovulation induction in two consecutive cycles were assessed, using in each the same induction regimen during the initial 5 days. The remainder of each cycle was individualized according to their response. Nine women were anovulatory, 19 were oligoovulatory, and 22 ovulated regularly in unstimulated cycles. In repeat cycles only 3 of 50 had poor follicular development and did not receive human chorionic gonadotropin (hCG); all were anovulatory. Forty-two of 50 of the first cycles had continually rising estradiol (E2), while 43 of 47 of the second cycles had rising E2 patterns. Grouping the peak E2 prior to hCG in the ranges less than 300, 300-699, 700-1099, and greater than or equal to 1100 pg/ml, peaks in the second cycle were similar in 25 of 50, lower in 16, and higher in 9. Only 3 of 9 anovulatory women had similar peaks, as compared to 22 of 41 of the oligoovulatory and regularly ovulating women. Comparing the second to the first cycle, the day of hCG was within 1 day in 28 of 50 women, 2 or more days less than the first cycle in 6, and 2 or more days greater than the first cycle in 11. We conclude that in a successive cycle of ovulation induction (i) the follicular response is impaired in anovulatory women, but (ii) in oligoovulatory or regularly ovulating women, clinically significant differences in the estradiol response do not occur.

Chorionic Gonadotropin↗
PubMed1980

Effect of clomiphene citrate on corticosteroid-binding globulin and serum progesterone levels during ovulation induction.

Mid-luteal phase serum progesterone, cortisol, and corticosteroid-binding globulin concentrations were measured in 46 conception cycles and in 19 ovulatory, non-conception cycles in patients with spontaneous ovulation and following ovulation induction with clomiphene citrate (Clomid) or human menopausal gonadotropin. Significant elevations (P less than 0.05) of serum corticosteroid-binding globulin were noted in patients under therapy with Clomid. This effect was not secondary to elevated serum estrogen levels. This alteration in serum binding protein levels appears to be secondary to a direct effect of Clomid on hepatic synthesis and may have significance in relation to progesterone binding and metabolism during ovulation induction with Clomid.

Adrenal Cortex Hormones↗
PubMed1998

Comparison of low-technology and high-technology monitoring of clomiphene citrate ovulation induction.

OBJECTIVE: To determine whether newer monitoring techniques, including urinary detection of the LH surge and vaginal ultrasound, offer an advantage over basal body temperature (BBT) charts alone in achieving pregnancy using clomiphene citrate (CC). DESIGN: Randomized clinical trial. SETTING: Infertility patients in an academic research environment. PATIENT(S): Forty-five women undergoing ovulation induction with CC. INTERVENTION(S): The women were assigned randomly to receive either low- or high-technology ovulation monitoring for a total of 3 ovulatory cycles. Both groups were followed with BBT charts. The high-technology group also was monitored with urinary LH kits and vaginal ultrasound. MAIN OUTCOME MEASURE(S): Cycle fecundity rates for each technique were compared statistically with use of life-table analysis. RESULT(S): Forty-five patients were studied during a total of 134 cycles. The overall cycle fecundity rate was 8%, 10% (8 of 81 cycles) for the low-technology monitoring group and 6% (3 of 53 cycles) for the high-technology monitoring group. These rates were not statistically significant when evaluated by Fisher's exact test (P = .53) or when using life-table analysis and a log-rank test (P = .48). CONCLUSION(S): These data suggest that, for initial attempts at ovulation induction with CC in unselected patients, high-technology monitoring of ovulation offers no increase in fecundity over low-technology monitoring.

Adult↗
PubMed1992

The outcome of in vitro fertilization and embryo transfer in women with polycystic ovary syndrome failing to conceive after ovulation induction with exogenous gonadotropins.

OBJECTIVE: To assess the outcome of in vitro fertilization and embryo transfer (IVF-ET) in women with refractory polycystic ovarian syndrome (PCOS). DESIGN: Retrospective case series with an age-matched control group. SETTING: Ovulation induction and IVF programs in a tertiary referral center. PATIENTS AND INTERVENTIONS: Nine patients with PCOS who failed standard ovulation induction treatment (clomiphene citrate plus greater than or equal to 6 ovulatory human menopausal gonadotropin [hMG] cycles) underwent 19 cycles of IVF-ET. Forty age-matched tubal factor patients who completed 40 cycles of IVF-ET served as a control group. OUTCOME MEASURES: Demographic features and IVF-ET cycle characteristics were compared using Student's t-test and Fisher's exact test. RESULTS: Cycles of IVF-ET in patients with PCOS were associated with higher estradiol levels (5,222 versus 4,009 pmol/L), lower hMG requirements (15.8 versus 19.6 vials), greater numbers of oocytes (7.6 versus 5.6), and lower fertilization rates (56% versus 75%) compared with tubal factor cycles (P less than 0.05). However, the number of embryos transferred (3.9 versus 4.0) and the clinical pregnancy rate per embryo transfer (24% versus 25%) did not differ significantly between the two groups. CONCLUSION: These results suggest that conception failure after six or more ovulatory hMG cycles in patients with PCOS does not adversely affect subsequent IVF performance.

Adult↗
PubMed1998

Ovulation induction with pulsatile GnRH in a patient with anovulation of hypothalamic origin and central diabetes insipidus.

Patients with diabetes insipidus (DI) are at high risk for dehydration, hypernatremia and hemodynamic instability. Ovarian hyperstimulation syndrome (OHSS) likewise has negative effects on electrolyte balance. If ovulation induction is required in a patient with DI, there is thus a strong argument for avoiding techniques that increase the risk of OHSS. This paper reports the results of ovulation induction in a patient with anovulation of hypothalamic origin and central (vasopressin deficit) DI. Ovulation was induced with pulsatile gonadotropin-releasing hormone (GnRH), which induces single-ovule cycles and which does not increase the risk of OHSS. The patient successfully achieved pregnancy after seven ovulatory cycles.

Adult↗
PubMed2001

The role of infertility nurses in ovulation induction programmes.

The role of the infertility nurse is continually expanding and changing to meet the demands of couples undergoing assisted reproduction. This article examines the responsibilities infertility nurses have in ovulation induction programmes in fertility clinics today. A simple questionnaire was sent to all fertility units listed in The Patients' Guide to DI and IVF Clinics. There was a response rate of 71%. Specialist infertility units had a higher number of nurses available to carry out various tasks within the fertility programme compared with other types of staff. Members of the nursing staff were involved in initial consultation, transvaginal ultrasound scanning, intrauterine inseminations, administration of medication, sperm preparation and pregnancy tests. Infertility nurses played a major role in ovulation induction programmes. In 39% of units, nurses performed intrauterine inseminations alone, in 23% of units they made decisions as to the requirement for human chorionic gonadotrophin administration, and in over 77% of units transvaginal scans were done by nurses. This role could be even broader, assuming adequate training is provided and undertaken. The extended role of infertility nurse practitioners allows more continuity of care and better understanding of patients' needs and results in the involvement of fewer people in the overall care.

Female↗