- Email: [email protected]
Induction of ovulation
volume
102
number
September
American
2
15, 1968
of Obstetrics and Gynecology
Journal
Induction of ovulation An attempt to avoid complications
L.
W.
COX,
R.
I.
COX,B.Sc.,
T.
L.
BLACK,
Adelaide,
South
F.R.C.S.,
F.R.A.C.S.,
F.R.C.0.G
PH.D. M.B.,
B.S.”
Australia
Atte:mpts to induce ovulation in a series of 66 infertile women with human gonadotropins, clomiphene citrate, or both were successful in 91 per cent of cases, and pregnancy resulted in 50 per cent. Daily monitoring of estrogen excretion critical phases of the cycle is believed to be an important factor in avoiding com$lications such as multiple pregnancy and ovarian cyst formation. Some patients who failed to respond to clomiphene or to gonadotropin were treated with combinations which were followed by ovulation, and in one case pregnancy occurred.
T H E s u c c E s s F u L induction of ovulation by human pituitary gonadotropin (HPG), first reported by Gemzell, Diczfalusy, and Tillinger, lo by MER-25 by :Kistner
and SmithI” and by clomiphene citrate by Greenblatt and associates,12 has led to great interest in obstetric and endocrine circles. AS more and more patients are under treatment, complications of various nature have been reported from the use of all stimulating agents. One of the most common complications has been muItiple pregnancy, in some series the incidence being as high as 50 per cent. The fetal wastage due to multiple pregnancy is high, and most experienced workers in this field are attempting some method of dosage control to achieve single pregnancies only. Another common complication is ovarian cyst formation, and when this is
From the Department of Obstetrics and Gynaecology, The University of A.delaide. This study was supported by a gra.nt from the National Health and Medical Research Council of Australia. Clomid was supplied by Wm. S. Merrell Company and some of the human pituitary gonadotropin was prepared by Commonwealth Serum Laboratories, Victoria, Australia. *Fotheringham Research Fellow, Australian Council, Royal College Obstetricians and Gynaecologists.
at
of
177
178
Cox,
Cox,
and
September 15, 1968 Am. j. Obsr. & Gynec.
Black
gross, intraperitoneal bleeding and effusion may occur. Three deaths have been repomrted from this complication.ls~ Ipa 22T~~ cases of severe thromboembolism during treatment, causing death in one and amputation of a limb in another, were reported.170varian enlargement also occurs with clomiphene, but not to such a severe degree unless dosage is prolonged. In an attempt to avoid complications, it has been our practice to try to achieve ovulation with minimal doses of the appropriate agent. Toward this end we have tested the ovarian response with an ovarian stimulation test and on this based our subsequent treatment. Responses are carefully assessed during treatment by steroid analyses and ovarian palpation. We are also recording the results of treatment in patients refractory to conventional dosage with human pituitary gonadotropins and clomiphene by giving combined regimens.
Patients were selected for treatment when infertility due to anovulation was the only impediment to conception. To date we have only attempted treatment in patients with amenorrhea, oligomenorrhea, or infrequent periods and have not tried to stimulate ovulation when menstrual cycles are regular. We have accepted the diagnosis of anovulation on the basis of urinary pregnanediol level being low (below 1.4 mg. per 24 hours) or
RESPONSE
TO :“t:: 110
SHORT
noncyclic when in the range 1.5 to 2.1 mg. per 24 hours. When there is amenorrhea with inadequate ovarian function, levels of estrogen are often low, although in those with some ovarian activity estrogen execretion within the normal follicular phase range is seen. Following the full investigation, the usual first step in management has been the ovarian stimulation test. Ovarian stimulation test. This is similar to the heterologous gonadotropin test proposed by Shearman. A particular standard batch of a preparation of human menopausal gonadotropin (HMG) , is used. Three injections are given on successive days. Collection of a control urine sample and two 24 hour urine samples on the days following the gonadotropin injections allows classification of the response as satisfactory, over, or inadequate (Fig. 1) : 1. Satisfactory. Cases of primary and secondary pituitary failure (estrone rise 5 to 40 ILg per 24 hours). These should respond well to HPG or HMG and possibly to clomiphene. 2. Overresponse. Cases of polycystic ovary (estrone rise over 40 pg per 24 hours). These usually respond to clomiphene and are very difficult to control on gonadotropin treatment. 3. Inadequate responses. Cases usually of ovarian failure. These need very large doses of HPG or HPG and clomiphene sequences
F.S.H. OVER RESPONSE
125
DESTRONE
‘;
Fig. 1. Ovarian furlction test. The shaded area indicates the range of estrone excretion values regarded as a satisfactory response. Arrows indicate FSN injections (Pergonal, 225 1.U. FSH).
Volume Number
102 2
Induction
Treatment
to excite activity, if any (estrone rise 5 pg or less per 24 hours). Using these criteria of selection we have been able to institute effective treatment (that is, proved ovulation) in a high proportion (91 per cent) of individuals in as short a time as possible. Although cases have been selected primarily as those where anovulation has been virtually the only infertility factor, not all of those ovulating have yet achieved pregnancy. IHowever, we submit that with the regimen shown we have achieved a high pregnancy rate when compared. with other series. We emphasize that we have attempted treatment in all women presenting where ovarian tissue was present who had patent tubes and fertile husbands. Estrone assays have been performed by a modification of a method of Brown,Z and pregnanediol assays by gas-liquid chromatography.5
20.
10
of
ovulation
regimens.
Clomiphene citrate. Although not suitable or effective for every anovular woman, the ease of administration, few assays necessary to control dosage, and high efficacy make this the first choice, even in cases where response is not very likely. We have used 3 dosages only, 50, 100, and 150 mg. daily from the fifth to ninth days of the actual or putative menstrual cycle. The doses have been used in succession until ovulation occurred, then the effective dosage maintained for several cycles. Of the 55 patients treated with clomiphene alone, 37 (67 per cent) have ovulated. Although 26 ovulated with the 50 mg. dose, ovulation was not maintained in successive cycles, and the dose was increased to 100 mg. in 10 cases with effect. Another 10 patients ovulated with 100 mg., but one of these became refractory and required 150
PREGNANEDIOL mg./ 24 hr. .
OESTRONE 60.
pg /
24 hr.
40
20
H.I.T. 20.000 ” liud..n
. .
"0
15 ttt
Fig.
2. “Short”
FSH
5
course:
arrows indicate Pergonal, Positive
hemagglutination-inhibition
20
. 25
. . . .t 30
35
40
45
.1 55
50
t lo
urina.ry excretion FSH; broad test positive
225 I.U.
179
of estrone
and
pregnanediol
is shown.
arrows, Pregnyl units as shown. H.I.T. at a titer
of 20,000
I.U.
HCG
per
Fine 20,000: liter.
180 Cox, ‘20x, and Black
mg. in later cycles. Only one other patient ovulated with 150 mg. These results are seen in Table II. One patient ovulated twice with 100 mg. but has failed to respond to clomiphene since. One patient is of interest in whom we have had the opportunity to study the results of discontinuing clomiphene therapy. She had been amenorrheic for 4 years and had two out of four ovular cycles on clomiphene (dose 50 then 100 mg.) and following this has spontaneously ovulated five times during six cycles. As we encountered no serious side effects with any of these doses, it appears reasonable to use 50 mg. for those overresponding to the ovarian function test and 100 mg. for all others. The only multiple pregnancy was one monovular twin which occurred following clomiphene, the dosage being 100 mg. daily. The father of the child was himself a twin. Short gonadotrofiin course. This is in effect the addition of 1 to 2 injections of human chorionic gonadotropin (HCG) following 3 to 4 injections of HMG.G Although almost all patients had 3 injections of HMG in the ovarian stimulation test, only those responding at a satisfactory level were given HCG to complete the ovulation stimulation (Fig. 2). Even when ovulation was achieved with these women, for economy and convenience a trial was made of clomiphene before returning to further courses of FSH. If it were not for the cost of the procedure, we would have persisted with this regimen, varying dosage according to hormonal response in each individual. We consider this course to be much easier than the long FSH course and more generally applicable. Another short course has been evolved by Crooke, Butt, and Bertrand,S where one injection of FSH and HCG is followed 8 to 9 days later by HCG. Though convenient, the total dose of hormones used by them is generally much in excess of our short course. Long gonadotropin course. This entails about 8 or 9 injections of FSH followed by 1 or 2 of HCG to trigger ovulation (Fig. 3). We have followed a regimen suggested by
20
PREGNANEDIOL mg. / 24 hr.
40,
OESTRONE pg ,‘24 hr.
20
0a
5
10
15
20
25
30
35
40
45
ttttttttt
Fig. 3. “Long” FSH course: urinary excretion of estrone and pregnanediol is shown. Fine arrows indicate injections 2 mg. of FSH; broad arrows, Pregnyl units as shown. H.I.T. 20,000: Positive hemagglutination-inhibition test positive at a titer of 20,000 I.U. HCG per liter.
Brown” and later reported,‘l in which by daily monitoring of estrogen excretion an apparently normal physiologic response has been achieved. In our series, only one multiple (binovular twin) pregnancy has occurred in 10 cases where FSH was used, and we attribute this partly to the strict observation of estrone levels and clinical findings of ovarian enlargement and our diminution of dosage or cancellation of injections if overstimulation appeared to be occurring. Perhaps our caution has been extreme, with fewer pregnancies resulting in this series. Since the short course proved successful, we have limited the use of the long course to those patients who showed persistent underresponse both to the short course and to clomiphene or to patients whose responses were difficult to control. Combinations of clomiphene and gonadotropins. CLOMIPHENE AND HCG. The use of combined therapy is in an early exploratory stage, but results suggest that effective ovulation induction
When
procedures
clomiphene
can
result.
alone
at 150 mg. per
Volume 102 Number 2
Induction
20
three cycles and pregnancy followed. have also given clomiphene in one cycle followed in the next cycle with an course. In particular, these sequences produced ovulation in 2 patients who not respond to either clomiphene, 150 in repeated cycles, or long courses of in high dosage (Fig. 5) . This sequence be investigated further in resistant cases.
PREGNANEDIOL mg. /24hr.
10
1
0
OESTRONE pg / 24 hr.
60
of ovulation
181
We and FSH have did mg. FSH will
I-
Complications 40
20
0 LIIILI 0 5
10
ccccic
15
t 8 x
20
25
30
35
401
45
H.I.T. 40.000
Fig. 4. Clomiphene indicates injection Positive
at a titer
citrate followed by :HCG. C 150 mg. of Clomid; broad arrow, an of IPregnyl 3,000 units. H.I.T. 20,000: hemagglutination-inhibition test positive of 20,000 I.U. HCG per liter.
day for 5 days does not result in ovulation, it may produce a rise in estrogen output showing that a partial response has resulted. Menstruation may even follow. Where sufficiently high estrogen levels result, suggesting that adequate follicular development has occurred, an injection of HCG (initially 3,000 I.U.) 5 days following clomiphene treatment can be effective in producing ovulation. Similar courses to this were suggested by Carey3 and have been published by Kistner.15 In our series, one patient conceived in her first course (Fig. 4). Clomiphene plus HCG treatment is best considered as, a second regimen if clomiphene alone is ineffective in producing ovulation. CLOMIPHENE AND FSH AND HCG. Acting on the hypothesis that clomiphene may have two actions : to stimulate the hypoth,alamicpituitary apparatus and to sensitize thse ovary to FSH, we have tried a combination of methods. Clomiphene and FSH have been given simultaneously. Ovulation occurred in
Particular care is required in gonadotropin treatment to avoid overstimulation and complications. It has been our experience that each patient varies in sensitivity to follicle stimulating hormone, to HCG for triggering ovulation and to HCG required to maintain a corpus luteum. The sensitivity of the patient at each of these three stages is not necessarily parallel. One patient, for instance, required the low dose of 1 ampule of on 4 days to stimulate follicular Pergonal” development, but the relatively high dose of 6,000 I.U. HCG to trigger ovulation. The ovaries are always palpated before attempting to trigger ovulation in combined regimens. Estrogen output does not always indicate ovarian enlargement or when ovarian cysts are developing. Cyst formation up to 3 to 4 cm. in diameter may not cause any symptoms and would not be detected unless pelvic examination is performed. Sometimes there is tenderness in the region of the ovary and a “bloated” feeling of the abdomen. Larger cysts have formed in 2 patients under our care and the patients have required homspitalization. The first patient we treated excreted high levels of estrone (600 pg daily) and a cyst of one ovary was palpable of a size to reach up to the umbilicus, while she had severe pain. It regressed spontaneously.4 Another patient with normal steroid excretion (estrone 15.6 pg daily at ovulation peak) developed first one cystic ovary (6 to 8 cm. diameter) which ruptured and then the other in the same luteal
phase.
Treatment
was
resumed
after
“Human postmenopausal gonadotropin prepared by Instituto Farmacologico Serono, Rome, Italy, each ampule containing 75 I.U. of FSH and 75 I.U. of ICSH.
182
Cox,
Cox,
and
September
Black
Am. J. Obst.
3,
1968
& Gynec.
PREGNANEDIOL mg. / 24 hr.
OESTRONE pg /
5 CEckt
Fig. 5. Combined 2 mg. of FSH; nation-inhibition
10
24hr.
15
20
ji k 8ZZ:: a6
25 1
30
0
!, 5:
-
5
10
ccCFh
15 il 88 z:8
20
i i o"l: "c=
25
30
35
40
‘
I 8 m
FSH and clomiphene citrate: C indicates 150 mg. of Glomid; broad arrows, Fregnyl units as shown. H.I.T. 20,000: Positive test positive at a titer of 20,000 I.U. HCG per liter.
an interval with slightly reduced dosage of FSH and HCG and ovulation occurred with no further complications. Following these 2 cases, we tended to stop treatment or reduce dosage in any cycle when cystic ovaries were palpable or abnormally rising levels of estrone were found. Ovarian cysts causing pain have occurred on 2 recent occasions, one being 6 cm. and the other 3 to 4 cm. in diameter. Observation in the hospital overnight sufficed. The incidence of multiple pregnancy (one case of twins in each of gonadotropin and clomiphene series), while higher than the normal incidence, is still lower than most other ovulation induction series. This may be coincidental but is probably due to our caution in attempting to avoid overstimulation. CSUltS
Pregnancy must be considered the only certain criterion of success. However, the diagnosis of ovulation can be made by the
fine arrows, bemaggluti-
excretion of urinary pregnanediol exceeding 2.1 mg. per 24 hours at any time 3 to 10 days prior to menstruation, provided this is at least double the follicular phase levels. It is not possible to be entirely sure whether luteinization of a follicle rather than ovulation is occurring. The results with each method are set out in Tables I to IV, with similar cases grouped together. It is interesting to note that most of the patients who did not ovulate with clomiphene citrate were able to ovulate when gonadotropins were used. Our clinical impression has been that when pregnancy occurs it does so early in the series of ovular cycles in any one patient. The average number of ovular cycles taken to achieve pregnancy was 2.1 cycles in the clomiphene series of patients. Some patients have required prolonged treatment over many cycles before ovulation occurs, and others have remained under treatment for months with ovulation occurring regularly. Perhaps these patients have been unrewarding because undiscovered infertility factors are operating in them.
Volume Number
102 2
induction
Comment
I. Re;sults of ovulation
inductio’n
Treatment Clomid alone FSH Combinations
55 42 11
Total “Some
Table alone
66” patients
had
different
II. Ovulation
37 24 8
67 57 73
22 9 2
60
91
33
treatment
in separate
induction
40 21 18 50 cycles.
with clomid
55 patients treated 16 ovulate wi.th 50 mg. dose 10 ovulate with 50 mg. then require 100 mg. to maintain 9 ovulate with 100 mg. 1 ovulates with 100 mg. then requires 150 mg. to maintain 1 ovulates with 150 mg. 37 Total
ovulating
(67%).
Table III. Ovulation and gonadotropins
-- Treatment Clomid Clomid and HCG Total Clomid FSH
and
had
clomiphene
No. of patients treated
Cycles
Ouulatory cycles
55
228
101
and combinations
of clomiphene
No. of patients ovulativ 37
Pregnancy
Abortion
Delivered
Proceeding to other treatment
Withdrew
22
5
9
17
4
8
18
9
5
1
0
0
0
4
55s
246
110
41
23
5
9
7
8
55* patients
with
-
3 55
Total *Some
induction
183
ported series of cases remain small, and they arise from a small number of highly efficient groups of research workers and clinicians. Gemzell and RooP who pioneered the long course of FSH have an impressive record of pregnancies, but their latest report is of 23 multiple births in 43 pregnancies, an incidence of over 50 per cent of multiple pregnancy. Crooke, Butt, and Bertrand,g who have had the main experience in Great Britain, have reported 16 pregnancies in 20 cases. They use a method which involves increasing the dosage in subsequent cycles, depending on the response in the previous cycle. Four sets of twins occurred, one with overresponse and the other 3 where a familial tendency to twins was present on the husband’s side. Brown,2l ” having developed reliable and rapid estrogen assays, modified the Gemzell dosage and monitored daily the result of the previous day’s injection. We have adopted a similar regimen, and our results have followed parallel lines. The necessity to maintain luteal function also becomes evident with such stimulation at near physiologically normal levels. We have fo,und the patients’ sensitivity to triggering ovulation with HCG varies widely and must also be carefully monitored. Liggins and Ibbertson16 apparently followed the same principles, but a number of multiple pregnancies followed, including the much publicized quintuplets. Although the evidence is gradually being accumulated,
The use of human pituitary gonadotropins and ovulati.on stimulating drugs has transformed the treatment of infertility. As yet the management of these cases has lbeen restricted to a few research centers. It may be possible within the next few years for refinements of techniques of investigation and therapy to permit the transfer of this interesting field from the precinct of the research endocrine unit to the practice of th,e interested specia&st practitioner. As yet the reTable
of ovulation
different
15 261 treatment
9 119 in separate
cycles.
3
1
0
0
0
0
44
24
5
9
4
8
184
Cox,
Cox,
and
Table IV. Ovulation
Long FSH normal response Long FSH overRSpOnSe
Long FSH underresponse Short FSH normal response Short FSH overresponse Short FSH underresponse Modified short FSH Total without Clomid FSH and Ciomid Total
Seprembez 15, 1968 Am. J. Obst. c Gynec.
Black
induction
with
gonadotropins
12
11
50
48
32
6
3
3
6
1
2
2
10
9
3
0
0
0
1
1
4
0
4
0
0
0
0
0
4
0
14
8
24
20
13
2
0
2
12
0
6
1
7
2
2
I
0
0
5
0
8
0
8
4
0
0
0
0
a
0
3
2
10
9
2
0
0
0
3
.-.I__ 0
42”
24
113
92
52
9
3
5
3
3
15
14
9
1
0
0
128 106 in separate cycles.
61
10
3
42* ‘Some patients had different
27 treatment
it is now reasonably clear that daily monitoring at critical phases of treatment is necessary if overstimulation is to be avoided. The alternative method of Crooke, Butt, and Bertrand3 is also safe. Twin pregnancy may not be serious, but high multiplicity is. Ovarian enlargement and development of cysts and their rupture cause pain and intraperitoneal hemorrhage. The 3 deaths reported in the literature, emphasize the danger. Although the large cyst which developed in our first treated case dispersed spontaneously, we treated all cases thereafter with extreme caution. We may have missed the chance of producing ovulation sometimes because we omitted injections due to high estrone levels. Many clomiphene series are larger than ours, but in most of these the percentage of success is lower. A probable reason is that most clinics have concentrated on either FSH or clomiphene to the exclusion of the other, hence treat all cases offering with whatever is the available preparation. By choosing
5
31
2
0 31
0 --
2
either clomiphene or gonadotropins, depending partly on their response to a stimulation test, and later in series, by using combinations of the two, a favorable pregnancy success rate has been attained. There seems little doubt from the records, a. large series being reviewed by Kistner,13 that patients with cystic or polycystic ovary respond more frequently and more strongly to this substance. Our observations with the ovarian stimulation test confirm this. It is interesting to speculate in these cases as to where the clomiphene acts. Does it increase the pituitary secretion of FSH, thus allowing full ripening of the follicle, or does it enhance the ovarian response to a lower level of FSH being secreted? Little effect on “total gonadotropic activity” has been found in patients showing good ovarian response to clomiphene.” The final answer to this question must await more sensitive and accurate gonadotropin assays, so that we can follow not only ovarian response but pituitary activity through each cycle.
Volume Number
102 2
There is great value in the short FSH course fcmr both diagnosis and therapy. Many of these women have been infertile f!Dr many years, and 110 time should be wasted on empirical treatment. As the cost of materials, assays, and time for supervision is high, it is most important not to be extravagant in any respect. To monitor the results requires intelligent cooperation by the patient. in cclletting urine for assay, so that time again becomes important; we have lost two prcmising cases from treatment because they were offered a child by adoption before successive ovulations occurred.
REFEREINCES
Bell, E. T., Loraine, J. A., Harkne,ss, R. A., and Foris, G. L.: J. Obst. & Gynaec. Brit. Comm. 73: 766, 1966. 2. Brown, J. B.: Personal communications, 1959, 1963. 3. Carey, II. M.: Personal communication, 1966. 4. Cox, L. W., and Cox, R. I.: South Australian Clin. 7: 49, 1966. 5. Cox, R. I.: J. Chromatography 12: 242, 1963. 6. Cox, R. I., Cox, L. W., and Black, T. L.: Lancet :2: 888, 1966. 7. Cox, R. I., Cox, L. W., and Black, T. L.: J. Endocrinol. 38: x, 1967. 8 Crooke, A. C., Butt, W. R., and Bertrand, P. V.: Lan’cet 2: 514, 1966. A. C., Butt, W. R., and Bertrand, 9. Crooke, P. V.: Acta endocrinol., Suppl. 111: 3, 1966. 10. Gemzell, C. A., Diczfalusy, E., and Tillinger, K. G.: J. Clin. Endocrinol. 18: 1333, 1958. 11. Gemzell, C., and ROOS, P.: AM. J. OBST. & GYNEC. 94: 490, 1966. R. B., Barfield, W. E., Jungck, 12. Greenblatt, E. C., and Ray, A. W.: J. A. M. A. 178: 101, 1961.
Induction
of ovulation
185
Many improvements in ovulation induction procedures can be expected in the next few years. Better criteria for the selection of patients, new drugs, and simpler courses of treatment with more accurate dosage ccntrol will be developed and we hope that the complications of ovarian cysts, multiple pregnancies, and high abortion rates will be greatly reduced. Since
this
paper
was
an ovulatory
submitted,
rate of 98 per per cent have of patients.
cent been
and pregnancy achieved with
13.
Kistner,
W.:
Obst.
14.
873, 1965. Kistner, R. W., and Smith,
1.
15.
16. 17. 18. 19.
R.
&
Gynec.
rate this
Surv.
of 76 series
20:
0. W.: Fertil. & Steril. 12: 121, 1961. Kistner, R. W.: Fe&l. & Steril. 17: 569, 1966. Liggins, G. C., and Ibbertson, H. K.: Lancet 1: 114, 1966. Mazes, M., Bogokowsky, H., Antebi, E., Lunenfeld, B., Rabau, E., Serr, D. M., David, A., and Salomy, M.: Lancet 2: 1213, 1965. Muller, P.: Les gonadotrophins en gynecologie, Paris, 1962, Masson et Cie, quoted by Vande Wiele and Turksoy. Neuwirth, R. S., Turksoy, R. M., and Vande Wiele, R. L.: AM. J. OBST. & GYNEC. 91: 977, 1965.
20. Shearman, R. P.: Brit. M. J. 2: 1115, 1964. S. L., Brown, J. B., Johnstone, J. 21. Townsend,
22.
W., Adey, F. D., Evans, J. H., and Taft, H. P.: J. Obst. & Gynaec. Brit. Comm. 73: 529, 1966. Vande Wiele, R. L., and Turksoy, R. M.: J. Clin. Endocrinol. 25: 369, 1965.
102
number
September
American
2
15, 1968
of Obstetrics and Gynecology
Journal
Induction of ovulation An attempt to avoid complications
L.
W.
COX,
R.
I.
COX,B.Sc.,
T.
L.
BLACK,
Adelaide,
South
F.R.C.S.,
F.R.A.C.S.,
F.R.C.0.G
PH.D. M.B.,
B.S.”
Australia
Atte:mpts to induce ovulation in a series of 66 infertile women with human gonadotropins, clomiphene citrate, or both were successful in 91 per cent of cases, and pregnancy resulted in 50 per cent. Daily monitoring of estrogen excretion critical phases of the cycle is believed to be an important factor in avoiding com$lications such as multiple pregnancy and ovarian cyst formation. Some patients who failed to respond to clomiphene or to gonadotropin were treated with combinations which were followed by ovulation, and in one case pregnancy occurred.
T H E s u c c E s s F u L induction of ovulation by human pituitary gonadotropin (HPG), first reported by Gemzell, Diczfalusy, and Tillinger, lo by MER-25 by :Kistner
and SmithI” and by clomiphene citrate by Greenblatt and associates,12 has led to great interest in obstetric and endocrine circles. AS more and more patients are under treatment, complications of various nature have been reported from the use of all stimulating agents. One of the most common complications has been muItiple pregnancy, in some series the incidence being as high as 50 per cent. The fetal wastage due to multiple pregnancy is high, and most experienced workers in this field are attempting some method of dosage control to achieve single pregnancies only. Another common complication is ovarian cyst formation, and when this is
From the Department of Obstetrics and Gynaecology, The University of A.delaide. This study was supported by a gra.nt from the National Health and Medical Research Council of Australia. Clomid was supplied by Wm. S. Merrell Company and some of the human pituitary gonadotropin was prepared by Commonwealth Serum Laboratories, Victoria, Australia. *Fotheringham Research Fellow, Australian Council, Royal College Obstetricians and Gynaecologists.
at
of
177
178
Cox,
Cox,
and
September 15, 1968 Am. j. Obsr. & Gynec.
Black
gross, intraperitoneal bleeding and effusion may occur. Three deaths have been repomrted from this complication.ls~ Ipa 22T~~ cases of severe thromboembolism during treatment, causing death in one and amputation of a limb in another, were reported.170varian enlargement also occurs with clomiphene, but not to such a severe degree unless dosage is prolonged. In an attempt to avoid complications, it has been our practice to try to achieve ovulation with minimal doses of the appropriate agent. Toward this end we have tested the ovarian response with an ovarian stimulation test and on this based our subsequent treatment. Responses are carefully assessed during treatment by steroid analyses and ovarian palpation. We are also recording the results of treatment in patients refractory to conventional dosage with human pituitary gonadotropins and clomiphene by giving combined regimens.
Patients were selected for treatment when infertility due to anovulation was the only impediment to conception. To date we have only attempted treatment in patients with amenorrhea, oligomenorrhea, or infrequent periods and have not tried to stimulate ovulation when menstrual cycles are regular. We have accepted the diagnosis of anovulation on the basis of urinary pregnanediol level being low (below 1.4 mg. per 24 hours) or
RESPONSE
TO :“t:: 110
SHORT
noncyclic when in the range 1.5 to 2.1 mg. per 24 hours. When there is amenorrhea with inadequate ovarian function, levels of estrogen are often low, although in those with some ovarian activity estrogen execretion within the normal follicular phase range is seen. Following the full investigation, the usual first step in management has been the ovarian stimulation test. Ovarian stimulation test. This is similar to the heterologous gonadotropin test proposed by Shearman. A particular standard batch of a preparation of human menopausal gonadotropin (HMG) , is used. Three injections are given on successive days. Collection of a control urine sample and two 24 hour urine samples on the days following the gonadotropin injections allows classification of the response as satisfactory, over, or inadequate (Fig. 1) : 1. Satisfactory. Cases of primary and secondary pituitary failure (estrone rise 5 to 40 ILg per 24 hours). These should respond well to HPG or HMG and possibly to clomiphene. 2. Overresponse. Cases of polycystic ovary (estrone rise over 40 pg per 24 hours). These usually respond to clomiphene and are very difficult to control on gonadotropin treatment. 3. Inadequate responses. Cases usually of ovarian failure. These need very large doses of HPG or HPG and clomiphene sequences
F.S.H. OVER RESPONSE
125
DESTRONE
‘;
Fig. 1. Ovarian furlction test. The shaded area indicates the range of estrone excretion values regarded as a satisfactory response. Arrows indicate FSN injections (Pergonal, 225 1.U. FSH).
Volume Number
102 2
Induction
Treatment
to excite activity, if any (estrone rise 5 pg or less per 24 hours). Using these criteria of selection we have been able to institute effective treatment (that is, proved ovulation) in a high proportion (91 per cent) of individuals in as short a time as possible. Although cases have been selected primarily as those where anovulation has been virtually the only infertility factor, not all of those ovulating have yet achieved pregnancy. IHowever, we submit that with the regimen shown we have achieved a high pregnancy rate when compared. with other series. We emphasize that we have attempted treatment in all women presenting where ovarian tissue was present who had patent tubes and fertile husbands. Estrone assays have been performed by a modification of a method of Brown,Z and pregnanediol assays by gas-liquid chromatography.5
20.
10
of
ovulation
regimens.
Clomiphene citrate. Although not suitable or effective for every anovular woman, the ease of administration, few assays necessary to control dosage, and high efficacy make this the first choice, even in cases where response is not very likely. We have used 3 dosages only, 50, 100, and 150 mg. daily from the fifth to ninth days of the actual or putative menstrual cycle. The doses have been used in succession until ovulation occurred, then the effective dosage maintained for several cycles. Of the 55 patients treated with clomiphene alone, 37 (67 per cent) have ovulated. Although 26 ovulated with the 50 mg. dose, ovulation was not maintained in successive cycles, and the dose was increased to 100 mg. in 10 cases with effect. Another 10 patients ovulated with 100 mg., but one of these became refractory and required 150
PREGNANEDIOL mg./ 24 hr. .
OESTRONE 60.
pg /
24 hr.
40
20
H.I.T. 20.000 ” liud..n
. .
"0
15 ttt
Fig.
2. “Short”
FSH
5
course:
arrows indicate Pergonal, Positive
hemagglutination-inhibition
20
. 25
. . . .t 30
35
40
45
.1 55
50
t lo
urina.ry excretion FSH; broad test positive
225 I.U.
179
of estrone
and
pregnanediol
is shown.
arrows, Pregnyl units as shown. H.I.T. at a titer
of 20,000
I.U.
HCG
per
Fine 20,000: liter.
180 Cox, ‘20x, and Black
mg. in later cycles. Only one other patient ovulated with 150 mg. These results are seen in Table II. One patient ovulated twice with 100 mg. but has failed to respond to clomiphene since. One patient is of interest in whom we have had the opportunity to study the results of discontinuing clomiphene therapy. She had been amenorrheic for 4 years and had two out of four ovular cycles on clomiphene (dose 50 then 100 mg.) and following this has spontaneously ovulated five times during six cycles. As we encountered no serious side effects with any of these doses, it appears reasonable to use 50 mg. for those overresponding to the ovarian function test and 100 mg. for all others. The only multiple pregnancy was one monovular twin which occurred following clomiphene, the dosage being 100 mg. daily. The father of the child was himself a twin. Short gonadotrofiin course. This is in effect the addition of 1 to 2 injections of human chorionic gonadotropin (HCG) following 3 to 4 injections of HMG.G Although almost all patients had 3 injections of HMG in the ovarian stimulation test, only those responding at a satisfactory level were given HCG to complete the ovulation stimulation (Fig. 2). Even when ovulation was achieved with these women, for economy and convenience a trial was made of clomiphene before returning to further courses of FSH. If it were not for the cost of the procedure, we would have persisted with this regimen, varying dosage according to hormonal response in each individual. We consider this course to be much easier than the long FSH course and more generally applicable. Another short course has been evolved by Crooke, Butt, and Bertrand,S where one injection of FSH and HCG is followed 8 to 9 days later by HCG. Though convenient, the total dose of hormones used by them is generally much in excess of our short course. Long gonadotropin course. This entails about 8 or 9 injections of FSH followed by 1 or 2 of HCG to trigger ovulation (Fig. 3). We have followed a regimen suggested by
20
PREGNANEDIOL mg. / 24 hr.
40,
OESTRONE pg ,‘24 hr.
20
0a
5
10
15
20
25
30
35
40
45
ttttttttt
Fig. 3. “Long” FSH course: urinary excretion of estrone and pregnanediol is shown. Fine arrows indicate injections 2 mg. of FSH; broad arrows, Pregnyl units as shown. H.I.T. 20,000: Positive hemagglutination-inhibition test positive at a titer of 20,000 I.U. HCG per liter.
Brown” and later reported,‘l in which by daily monitoring of estrogen excretion an apparently normal physiologic response has been achieved. In our series, only one multiple (binovular twin) pregnancy has occurred in 10 cases where FSH was used, and we attribute this partly to the strict observation of estrone levels and clinical findings of ovarian enlargement and our diminution of dosage or cancellation of injections if overstimulation appeared to be occurring. Perhaps our caution has been extreme, with fewer pregnancies resulting in this series. Since the short course proved successful, we have limited the use of the long course to those patients who showed persistent underresponse both to the short course and to clomiphene or to patients whose responses were difficult to control. Combinations of clomiphene and gonadotropins. CLOMIPHENE AND HCG. The use of combined therapy is in an early exploratory stage, but results suggest that effective ovulation induction
When
procedures
clomiphene
can
result.
alone
at 150 mg. per
Volume 102 Number 2
Induction
20
three cycles and pregnancy followed. have also given clomiphene in one cycle followed in the next cycle with an course. In particular, these sequences produced ovulation in 2 patients who not respond to either clomiphene, 150 in repeated cycles, or long courses of in high dosage (Fig. 5) . This sequence be investigated further in resistant cases.
PREGNANEDIOL mg. /24hr.
10
1
0
OESTRONE pg / 24 hr.
60
of ovulation
181
We and FSH have did mg. FSH will
I-
Complications 40
20
0 LIIILI 0 5
10
ccccic
15
t 8 x
20
25
30
35
401
45
H.I.T. 40.000
Fig. 4. Clomiphene indicates injection Positive
at a titer
citrate followed by :HCG. C 150 mg. of Clomid; broad arrow, an of IPregnyl 3,000 units. H.I.T. 20,000: hemagglutination-inhibition test positive of 20,000 I.U. HCG per liter.
day for 5 days does not result in ovulation, it may produce a rise in estrogen output showing that a partial response has resulted. Menstruation may even follow. Where sufficiently high estrogen levels result, suggesting that adequate follicular development has occurred, an injection of HCG (initially 3,000 I.U.) 5 days following clomiphene treatment can be effective in producing ovulation. Similar courses to this were suggested by Carey3 and have been published by Kistner.15 In our series, one patient conceived in her first course (Fig. 4). Clomiphene plus HCG treatment is best considered as, a second regimen if clomiphene alone is ineffective in producing ovulation. CLOMIPHENE AND FSH AND HCG. Acting on the hypothesis that clomiphene may have two actions : to stimulate the hypoth,alamicpituitary apparatus and to sensitize thse ovary to FSH, we have tried a combination of methods. Clomiphene and FSH have been given simultaneously. Ovulation occurred in
Particular care is required in gonadotropin treatment to avoid overstimulation and complications. It has been our experience that each patient varies in sensitivity to follicle stimulating hormone, to HCG for triggering ovulation and to HCG required to maintain a corpus luteum. The sensitivity of the patient at each of these three stages is not necessarily parallel. One patient, for instance, required the low dose of 1 ampule of on 4 days to stimulate follicular Pergonal” development, but the relatively high dose of 6,000 I.U. HCG to trigger ovulation. The ovaries are always palpated before attempting to trigger ovulation in combined regimens. Estrogen output does not always indicate ovarian enlargement or when ovarian cysts are developing. Cyst formation up to 3 to 4 cm. in diameter may not cause any symptoms and would not be detected unless pelvic examination is performed. Sometimes there is tenderness in the region of the ovary and a “bloated” feeling of the abdomen. Larger cysts have formed in 2 patients under our care and the patients have required homspitalization. The first patient we treated excreted high levels of estrone (600 pg daily) and a cyst of one ovary was palpable of a size to reach up to the umbilicus, while she had severe pain. It regressed spontaneously.4 Another patient with normal steroid excretion (estrone 15.6 pg daily at ovulation peak) developed first one cystic ovary (6 to 8 cm. diameter) which ruptured and then the other in the same luteal
phase.
Treatment
was
resumed
after
“Human postmenopausal gonadotropin prepared by Instituto Farmacologico Serono, Rome, Italy, each ampule containing 75 I.U. of FSH and 75 I.U. of ICSH.
182
Cox,
Cox,
and
September
Black
Am. J. Obst.
3,
1968
& Gynec.
PREGNANEDIOL mg. / 24 hr.
OESTRONE pg /
5 CEckt
Fig. 5. Combined 2 mg. of FSH; nation-inhibition
10
24hr.
15
20
ji k 8ZZ:: a6
25 1
30
0
!, 5:
-
5
10
ccCFh
15 il 88 z:8
20
i i o"l: "c=
25
30
35
40
‘
I 8 m
FSH and clomiphene citrate: C indicates 150 mg. of Glomid; broad arrows, Fregnyl units as shown. H.I.T. 20,000: Positive test positive at a titer of 20,000 I.U. HCG per liter.
an interval with slightly reduced dosage of FSH and HCG and ovulation occurred with no further complications. Following these 2 cases, we tended to stop treatment or reduce dosage in any cycle when cystic ovaries were palpable or abnormally rising levels of estrone were found. Ovarian cysts causing pain have occurred on 2 recent occasions, one being 6 cm. and the other 3 to 4 cm. in diameter. Observation in the hospital overnight sufficed. The incidence of multiple pregnancy (one case of twins in each of gonadotropin and clomiphene series), while higher than the normal incidence, is still lower than most other ovulation induction series. This may be coincidental but is probably due to our caution in attempting to avoid overstimulation. CSUltS
Pregnancy must be considered the only certain criterion of success. However, the diagnosis of ovulation can be made by the
fine arrows, bemaggluti-
excretion of urinary pregnanediol exceeding 2.1 mg. per 24 hours at any time 3 to 10 days prior to menstruation, provided this is at least double the follicular phase levels. It is not possible to be entirely sure whether luteinization of a follicle rather than ovulation is occurring. The results with each method are set out in Tables I to IV, with similar cases grouped together. It is interesting to note that most of the patients who did not ovulate with clomiphene citrate were able to ovulate when gonadotropins were used. Our clinical impression has been that when pregnancy occurs it does so early in the series of ovular cycles in any one patient. The average number of ovular cycles taken to achieve pregnancy was 2.1 cycles in the clomiphene series of patients. Some patients have required prolonged treatment over many cycles before ovulation occurs, and others have remained under treatment for months with ovulation occurring regularly. Perhaps these patients have been unrewarding because undiscovered infertility factors are operating in them.
Volume Number
102 2
induction
Comment
I. Re;sults of ovulation
inductio’n
Treatment Clomid alone FSH Combinations
55 42 11
Total “Some
Table alone
66” patients
had
different
II. Ovulation
37 24 8
67 57 73
22 9 2
60
91
33
treatment
in separate
induction
40 21 18 50 cycles.
with clomid
55 patients treated 16 ovulate wi.th 50 mg. dose 10 ovulate with 50 mg. then require 100 mg. to maintain 9 ovulate with 100 mg. 1 ovulates with 100 mg. then requires 150 mg. to maintain 1 ovulates with 150 mg. 37 Total
ovulating
(67%).
Table III. Ovulation and gonadotropins
-- Treatment Clomid Clomid and HCG Total Clomid FSH
and
had
clomiphene
No. of patients treated
Cycles
Ouulatory cycles
55
228
101
and combinations
of clomiphene
No. of patients ovulativ 37
Pregnancy
Abortion
Delivered
Proceeding to other treatment
Withdrew
22
5
9
17
4
8
18
9
5
1
0
0
0
4
55s
246
110
41
23
5
9
7
8
55* patients
with
-
3 55
Total *Some
induction
183
ported series of cases remain small, and they arise from a small number of highly efficient groups of research workers and clinicians. Gemzell and RooP who pioneered the long course of FSH have an impressive record of pregnancies, but their latest report is of 23 multiple births in 43 pregnancies, an incidence of over 50 per cent of multiple pregnancy. Crooke, Butt, and Bertrand,g who have had the main experience in Great Britain, have reported 16 pregnancies in 20 cases. They use a method which involves increasing the dosage in subsequent cycles, depending on the response in the previous cycle. Four sets of twins occurred, one with overresponse and the other 3 where a familial tendency to twins was present on the husband’s side. Brown,2l ” having developed reliable and rapid estrogen assays, modified the Gemzell dosage and monitored daily the result of the previous day’s injection. We have adopted a similar regimen, and our results have followed parallel lines. The necessity to maintain luteal function also becomes evident with such stimulation at near physiologically normal levels. We have fo,und the patients’ sensitivity to triggering ovulation with HCG varies widely and must also be carefully monitored. Liggins and Ibbertson16 apparently followed the same principles, but a number of multiple pregnancies followed, including the much publicized quintuplets. Although the evidence is gradually being accumulated,
The use of human pituitary gonadotropins and ovulati.on stimulating drugs has transformed the treatment of infertility. As yet the management of these cases has lbeen restricted to a few research centers. It may be possible within the next few years for refinements of techniques of investigation and therapy to permit the transfer of this interesting field from the precinct of the research endocrine unit to the practice of th,e interested specia&st practitioner. As yet the reTable
of ovulation
different
15 261 treatment
9 119 in separate
cycles.
3
1
0
0
0
0
44
24
5
9
4
8
184
Cox,
Cox,
and
Table IV. Ovulation
Long FSH normal response Long FSH overRSpOnSe
Long FSH underresponse Short FSH normal response Short FSH overresponse Short FSH underresponse Modified short FSH Total without Clomid FSH and Ciomid Total
Seprembez 15, 1968 Am. J. Obst. c Gynec.
Black
induction
with
gonadotropins
12
11
50
48
32
6
3
3
6
1
2
2
10
9
3
0
0
0
1
1
4
0
4
0
0
0
0
0
4
0
14
8
24
20
13
2
0
2
12
0
6
1
7
2
2
I
0
0
5
0
8
0
8
4
0
0
0
0
a
0
3
2
10
9
2
0
0
0
3
.-.I__ 0
42”
24
113
92
52
9
3
5
3
3
15
14
9
1
0
0
128 106 in separate cycles.
61
10
3
42* ‘Some patients had different
27 treatment
it is now reasonably clear that daily monitoring at critical phases of treatment is necessary if overstimulation is to be avoided. The alternative method of Crooke, Butt, and Bertrand3 is also safe. Twin pregnancy may not be serious, but high multiplicity is. Ovarian enlargement and development of cysts and their rupture cause pain and intraperitoneal hemorrhage. The 3 deaths reported in the literature, emphasize the danger. Although the large cyst which developed in our first treated case dispersed spontaneously, we treated all cases thereafter with extreme caution. We may have missed the chance of producing ovulation sometimes because we omitted injections due to high estrone levels. Many clomiphene series are larger than ours, but in most of these the percentage of success is lower. A probable reason is that most clinics have concentrated on either FSH or clomiphene to the exclusion of the other, hence treat all cases offering with whatever is the available preparation. By choosing
5
31
2
0 31
0 --
2
either clomiphene or gonadotropins, depending partly on their response to a stimulation test, and later in series, by using combinations of the two, a favorable pregnancy success rate has been attained. There seems little doubt from the records, a. large series being reviewed by Kistner,13 that patients with cystic or polycystic ovary respond more frequently and more strongly to this substance. Our observations with the ovarian stimulation test confirm this. It is interesting to speculate in these cases as to where the clomiphene acts. Does it increase the pituitary secretion of FSH, thus allowing full ripening of the follicle, or does it enhance the ovarian response to a lower level of FSH being secreted? Little effect on “total gonadotropic activity” has been found in patients showing good ovarian response to clomiphene.” The final answer to this question must await more sensitive and accurate gonadotropin assays, so that we can follow not only ovarian response but pituitary activity through each cycle.
Volume Number
102 2
There is great value in the short FSH course fcmr both diagnosis and therapy. Many of these women have been infertile f!Dr many years, and 110 time should be wasted on empirical treatment. As the cost of materials, assays, and time for supervision is high, it is most important not to be extravagant in any respect. To monitor the results requires intelligent cooperation by the patient. in cclletting urine for assay, so that time again becomes important; we have lost two prcmising cases from treatment because they were offered a child by adoption before successive ovulations occurred.
REFEREINCES
Bell, E. T., Loraine, J. A., Harkne,ss, R. A., and Foris, G. L.: J. Obst. & Gynaec. Brit. Comm. 73: 766, 1966. 2. Brown, J. B.: Personal communications, 1959, 1963. 3. Carey, II. M.: Personal communication, 1966. 4. Cox, L. W., and Cox, R. I.: South Australian Clin. 7: 49, 1966. 5. Cox, R. I.: J. Chromatography 12: 242, 1963. 6. Cox, R. I., Cox, L. W., and Black, T. L.: Lancet :2: 888, 1966. 7. Cox, R. I., Cox, L. W., and Black, T. L.: J. Endocrinol. 38: x, 1967. 8 Crooke, A. C., Butt, W. R., and Bertrand, P. V.: Lan’cet 2: 514, 1966. A. C., Butt, W. R., and Bertrand, 9. Crooke, P. V.: Acta endocrinol., Suppl. 111: 3, 1966. 10. Gemzell, C. A., Diczfalusy, E., and Tillinger, K. G.: J. Clin. Endocrinol. 18: 1333, 1958. 11. Gemzell, C., and ROOS, P.: AM. J. OBST. & GYNEC. 94: 490, 1966. R. B., Barfield, W. E., Jungck, 12. Greenblatt, E. C., and Ray, A. W.: J. A. M. A. 178: 101, 1961.
Induction
of ovulation
185
Many improvements in ovulation induction procedures can be expected in the next few years. Better criteria for the selection of patients, new drugs, and simpler courses of treatment with more accurate dosage ccntrol will be developed and we hope that the complications of ovarian cysts, multiple pregnancies, and high abortion rates will be greatly reduced. Since
this
paper
was
an ovulatory
submitted,
rate of 98 per per cent have of patients.
cent been
and pregnancy achieved with
13.
Kistner,
W.:
Obst.
14.
873, 1965. Kistner, R. W., and Smith,
1.
15.
16. 17. 18. 19.
R.
&
Gynec.
rate this
Surv.
of 76 series
20:
0. W.: Fertil. & Steril. 12: 121, 1961. Kistner, R. W.: Fe&l. & Steril. 17: 569, 1966. Liggins, G. C., and Ibbertson, H. K.: Lancet 1: 114, 1966. Mazes, M., Bogokowsky, H., Antebi, E., Lunenfeld, B., Rabau, E., Serr, D. M., David, A., and Salomy, M.: Lancet 2: 1213, 1965. Muller, P.: Les gonadotrophins en gynecologie, Paris, 1962, Masson et Cie, quoted by Vande Wiele and Turksoy. Neuwirth, R. S., Turksoy, R. M., and Vande Wiele, R. L.: AM. J. OBST. & GYNEC. 91: 977, 1965.
20. Shearman, R. P.: Brit. M. J. 2: 1115, 1964. S. L., Brown, J. B., Johnstone, J. 21. Townsend,
22.
W., Adey, F. D., Evans, J. H., and Taft, H. P.: J. Obst. & Gynaec. Brit. Comm. 73: 529, 1966. Vande Wiele, R. L., and Turksoy, R. M.: J. Clin. Endocrinol. 25: 369, 1965.