- Email: [email protected]
The effectiveness of clomiphene citrate in LH surge suppression in women undergoing IUI: a randomized controlled trial
OVARY The effectiveness of clomiphene citrate in LH surge suppression in women undergoing IUI: a randomized controlled trial Hesham Al-Inany, M.D., Ph.D.,a Hamdy Azab, M.D.,a Waleed El-Khayat, M.D.,a Adel Nada, M.D.,a Eman El-Khattan, M.D.,a and Ahmed M. Abou-Setta, M.D., Ph.D.b a
Department of Obstetrics and Gynecology, Cairo University, Cairo, Egypt; and bAlberta Research Centre for Health Evidence, University of Alberta, Edmonton, Alberta, Canada
Objective: To study the effectiveness of clomiphene citrate (CC) in preventing a premature LH surge during controlled ovarian stimulation in women undergoing assisted reproduction. Design: Prospective, randomized, controlled trial. Setting: University hospital. Patient(s): Two-hundred thirty couples with mild male factor, or unexplained infertility. Intervention(s): Couples were randomized to receive human menopausal gonadotrophins (hMG) followed by CC or hMG alone until the day of hCG. Main Outcome Measure(s): The primary outcomes were the incidence of a clinical pregnancy and premature LH rise. Secondary outcomes were the E2 levels, number of mature follicles, and endometrial thickness as determined on the day of hCG. Result(s): The number of patients who had a premature LH surge was significantly lower in the hMG þ CC group (5.45% vs. 15.89%). Additionally, the mean E2 levels (pg/mL) and the number of mature follicles were also significantly higher in the hMG þ CC group (360.3 162.9 vs. 280 110.0 and 2.4 0.97 vs. 1.3 1.1, respectively), although there was no significant difference regarding number of canceled cycles, endometrial thickness, or clinical pregnancy rate. Conclusion(s): The addition of CC to hMG has been proven to be effective in reducing premature LH surges without compromising the pregnancy rate. (Fertil Steril 2010;94:2167–71. 2010 by American Society for Reproductive Medicine.) Key words: COS, IUI, CC, premature LH surge
Intrauterine insemination (IUI) with partner or donor sperm is a commonly practiced method of assisted reproduction. The procedure involves directly introducing washed spermatozoa into the uterine cavity, thereby bypassing several of the natural barriers in the female genital tract (e.g., vagina, cervix) which may be the source of the infertility. In combination with controlled ovarian stimulation (COS), it has proved to be a cost-effective line of treatment for many forms of infertility (1). Its main indications are mild male factor, cervical factor, and cases of unexplained infertility (2, 3). The technical simplicity, associated lower costs, and low incidence of complications make it a natural choice for many couples attempting to conceive (1). Additionally, because most cases of infertility are relatively mild in nature and can be overcome with the proper diagnosis and treatment, many andrologists, gynecologists, and reproductive endocrinologists alike recommend up to six cycles Received September 19, 2009; revised January 24, 2010; accepted January 26, 2010; published online March 16, 2010. H.A.-I. has nothing to disclose. H.A. has nothing to disclose. W.E.-K. has nothing to disclose. A.N. has nothing to disclose. E.E.-K. has nothing to disclose. A.A.-S. has nothing to disclose. Reprint requests: Hesham Al-Inany, M.D., Ph.D. 8-Moustapha Hassanin St, Manial, Cairo 11451, Egypt (E-mail: [email protected]).
0015-0282/$36.00 doi:10.1016/j.fertnstert.2010.01.069
of IUI before embarking on more invasive procedures (e.g., IVF) (2, 4, 5). This has been confirmed by a recent Cochrane review on couples with unexplained infertility, which demonstrated that the success rates with IUI are similar to those achieved with IVF/ intracytoplasmic sperm injection in this patient population (6). Clomiphene citrate (CC) has been the most widely used treatment for fertility enhancement for the past 40 years. Clomiphene was a revolutionary advance in reproductive medicine and quickly became popular for induction of ovulation, owing to its ease of administration and minimal side effects. It acts as a selective estrogen receptor modulator, similarly to tamoxifen and raloxifene. All three drugs are competitive inhibitors of estrogen binding to estrogen receptors and have mixed agonist and antagonist activity depending on the target tissue. Most evidence suggests that the primary site of clomiphene action is the hypothalamus, where it appears to bind to hypothalamic estrogen receptors, thereby blocking the negative feedback effect of circulating endogenous estrogen and resulting in an increase in plasma levels of FSH and LH (7). One of the major challenges facing using gonadotropin stimulation with IUI is the occurrence of a premature LH surge and consequent luteinization before ovarian follicle maturation. It has been suggested that 24%–36% of IUI cycles suffer from premature LH
Fertility and Sterility Vol. 94, No. 6, November 2010 Copyright ª2010 American Society for Reproductive Medicine, Published by Elsevier Inc.
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surge. This might negatively influence treatment outcome and can result in procedure cancellation. Obviously, this represents both an economic and a psychologic burden for patients (8, 9) and an additional hurdle for clinicians to overcome. Several strategies have been proven to be effective for preventing the occurrence of premature LH surges during ovarian stimulation. The gold standard is the use of pituitary down-regulation with a GnRH agonist, but it is associated with an explicit need for additional doses of gonadotropins and increased cost of care. Recently, GnRH antagonists have emerged as a strong competitor, with documented improvements in pregnancy rates (9, 10). Other interventions have been tried with varying degrees of success, including ethinyl E2 plus norethindrone (11) and mifepristone (12). Earlier work has proved that CC and oral contraceptive pill pretreatment were able to suppress LH in minimal-stimulation IVF cycles (13). Therefore, the use of CC with IUI would be a natural progression if it can be proved to prevent premature LH surges in COS/IUI cycles. The rationale is that its antiestrogenic effect may suppress premature LH rise while maintaining a positive influence on ovarian follicle development. The use of CC for this indication would open the door for very friendly stimulation protocols in COS/IUI and IVF cycles.
Ovarian stimulation was monitored every other day by vaginal US starting from day 5 of stimulation. When the leading follicle reached a mean diameter of 18 mm, 10,000 IU hCG (Choriomon; IBSA) was administered and IUI scheduled 34–36 hours later. On the day of hCG injection, patients had a serum assay of LH and E2 as well as US measurement of endometrial thickness. IUI was canceled if fewer than two or more than five follicles with a mean diameter of 16 mm were present, to optimize the chance for pregnancy and reduce the risk of multiple pregnancy, respectively. Canceled cases were not given hCG but were instructed to have timed intercourse. All patients received luteal phase support in the form of 100 mg micronized progesterone (Uterogestan; October Pharma, Cairo, Egypt), three tablets daily in two divided doses starting the day after insemination and continued for 18 days. Serum hCG levels were determined 14 days after insemination. Progesterone supplementation was continued for a further 2 weeks in the pregnant patients.
Outcome Measures Clinical pregnancy was defined as a rise in the serum hCG level on serial determinations R2 days apart coupled with an intrauterine gestation with fetal heart pulsations demonstrated by transvaginal US at 6–7 weeks’ gestation. The primary outcome measures for this trial were the incidence of a clinical pregnancy and premature LH rise. Premature LH rise was defined as LH R10 mIU/mL on the day of hCG injection. Secondary outcomes were the E2 levels, number of mature follicles, and endometrial thickness as determined on the day of hCG.
MATERIALS AND METHODS This was a prospective, randomized, controlled study carried out during the period from January 2008 to July 2009 at the Department of Obstetrics and Gynecology, Kasr El-Aini Teaching Hospital, Cairo University. Institutional Review Board approval was obtained, and informed consents from participants were attained before randomization. The study protocol was registered at the Australian New Zealand Clinical Trial Registry (ACTRN12607000568415) in accordance with the Declaration of Helsinki and the recommendations of the Committee of Medical Journal Editors.
Patient Population All patients were subjected to careful history taking, general examination, and local gynecologic examination. Inclusion criteria were mild male factor or unexplained infertility, women partner aged <39 years with regular menstrual cycles, body mass index <32 kg/m2, normal uterine cavity and fallopian tubes as documented by ultrasound (US), hysterosalpingography, and/ or laparoscopy, and normal hormonal profile including FSH, LH, TSH, T, and PRL levels. Mild male factor infertility was defined as the presence of abnormal semen parameters but with >5% normal morphology and >5 106/mL motile spermatozoa recovered after sperm preparation. Couples were excluded if they were diagnosed with infertility due to other causes, significant cardiovascular, pulmonary, renal, neurologic, or hepatic problems, or presence of ovarian cyst >2 cm before stimulation. Two-hundred thirty infertile couples were randomized using a computergenerated random number table. Allocation concealment was performed using sequentially numbered, opaque, sealed envelopes. At the time of inclusion, the attending consultant opened an envelope describing the allocation to either the intervention or the control group. Couples assigned to the intervention group received CC þ hMG, and couples assigned to the control group received hMG only.
Statistical Analysis To prevent a type II error, we performed an a priori sample size calculation. Prior data indicated that the premature LH surge rate among the hMG-only group was 20%. If the true rate for the hMG þ CC group is 5%, we would need to study 75 couples in each arm to be able to reject the null hypothesis that the rates for the experimental and control groups are equal with a probability of 80%. The type I error probability associated with this test of this null hypothesis is .05. We used an uncorrected chi-squared statistic to evaluate this null hypothesis. Additionally, to compensate for discontinuations, we recruited 115 women in each arm. Data are expressed as mean SD or percentage where applicable. Independent samples were compared using the Student t test. The chi-squared test and Fisher exact test were used for categoric data. A P value of < .05 was considered to indicate statistical significance. Statistical analysis was done using Arcus Quickstat version I (Research Solutions Ltd, UK).
RESULTS Two-hundred forty-five infertile couples were screened for inclusion, with 230 couples randomized in a 1:1 ratio to receive hMG þ CC or hMG alone for ovarian stimulation. Each couple was included only once in this trial to prevent a possible unit-of-analysis error in interpreting the results.
TABLE 1 Basic characteristics of the study population. Variable
Ovulation Induction and IUI Protocols On day 3 of the cycle a basal US scan was done and a blood sample was taken for hormonal profile assessment. All subjects received a fixed dose of 75 IU highly purified human menopausal gonadotropin (Merional; IBSA, Lugano, Switzerland), regardless of the response starting from the third day of cycle for 5 days. Subsequently, women randomized to the CC þ hMG group received 50 mg CC (Clomid; Aventis pharma S.AE, Global Napi Pharmaceuticals, Cairo, Egypt) three times daily starting from the fourth day of hMG and continued until the day of hCG injection. Women randomized to the hMG-only group maintained hMG injections until the day of hCG injection.
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Age (y) Duration of infertility (y) Cause of infertility Unexplained infertility Mild male factor Body mass index (kg/m2)
Group I (n [ 115)
Group II (n [ 115)
P value
27.3 4.7 3.1 1.9
28.4 2.7 2.4 1.6
NS NS
61 (53%) 54 (47%) 28.5 1.6
58 (50.4%) 57 (49.6%) 28.1 3.1
NS NS NS
Note: NS ¼ nonsignificant. Al-Inany. CC prevents LH surge. Fertil Steril 2010.
Vol. 94, No. 6, November 2010
FIGURE 1 Flow chart of participating patients.
Al-Inany. CC prevents LH surge. Fertil Steril 2010.
Baseline characteristics of the two groups were similar, with no statistical difference in mean female age, duration of infertility, or body mass index (Table 1). Out of the 115 couples randomized to receive hMG þ CC, five cycles were canceled owing to inadequate response (n ¼ 4) or hyperresponse (n ¼ 1) (Fig. 1). In the hMG-only group, eight cycles were canceled owing to inadequate response (n ¼ 6) or hyperresponse (n ¼ 2). The number of days CC was administered in group I ranged between 2 and 5 days with a mean of 3.1 days. On the day of hCG administration, mean E2 levels (pg/mL) were significantly higher in the hMG þ CC group than in the hMG-only Fertility and Sterility
group (360.3 162.9 vs. 280 110.0; P<.05). The number of mature follicles R16 mm also was significantly higher for the hMG þ CC group (2.4 0.97 vs. 1.3 1.1; P<.05). Additionally, the number of patients who had a premature LH surge was significantly less in the hMG þ CC group (5.22% vs. 14.78%; P<.001). Even so, these advantages with the additional use of CC did not correlate with additional clinical benefits, with no significant differences demonstrated between the two groups regarding number of canceled cycles, endometrial thickness, and clinical pregnancy rate (Table 2). There was only one case of multiple pregnancy (twin), in the hMG þ CC group.
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TABLE 2 Cycle characteristics. Variable No. of canceled cycles Inadequate response Hyperresponse Basal LH (mIU/mL) Basal FSH (mIU/mL) Days of stimulation E2 at time of hCG (pg/mL) LH on day of hCG (mIU/mL) for cases with no premature LH surge No. of follicles R16 mm No. of patients with premature LH surge Endometrial thickness (mm) No. of clinical pregnancies
Group I (n [ 115)
Group II (n [ 115)
P value
5/110 4/5 1/5 6.4 2.2 6.7 2.5 7.2 1.8 360.3 162.9 7.3 1.8
8/107 6/8 2/8 5.8 2.4 7.2 4.8 8.1 1.3 280 110.0 7.8 2.2
NS NS NS NS NS NS < .05 NS
2.4 0.97 6 (5.45%) 5.9 0.7 11 (10%)
1.3 1.1 17 (15.89%) 4.9 1.9 9 (8.41%)
< .05 < .001 NS NS
Al-Inany. CC prevents LH surge. Fertil Steril 2010.
DISCUSSION The results of this prospective, randomized, controlled trial clearly demonstrate the beneficial effects of the addition of CC to hMG during ovarian stimulation to prevent a premature LH surge from occurring. Climphene citrate reduced the incidence of premature LH surge while providing better follicle maturation compared with the use of hMG alone. Our hypothesis is that this effect could be either due to the antiestrogenic properties of CC or related to a central hypothalamic effect. However, it appears that these antiestrogenic properties did not affect the stimulatory effect of gonadotropins. This was obvious by the fact that the mean E2 levels were even higher in the CC group as was the number of mature follicles. Additionally, there was no difference in the endometrial thickness between the two groups. Clomiphene citrate was given in the present study three times daily, which can be considered to be a high dose, a novel approach which was not tested before: We started with a high dose of CC primarily because most of our participants were above average weight (Table I) The clinical pregnancy rate per cycle was 10% in the CC group and 8.4% in the control group. The pregnancy rates are within the range of success rates reported (8%–18%) for conventional COS/ IUI studies per stimulated cycle (14–16). However, other studies have reported a much higher pregnancy rate per cycle (20%–35%) using the antagonist protocol to prevent premature LH surge (10, 17). We believe that the lower pregnancy rate in the present study reflects the intentionally patient-friendly minimal-stimulation protocol that was used throughout the trial. A more aggressive stimulation protocol would be expected to produce a higher pregnancy rate, but with an associated higher incidence of complications (e.g., multiple pregnancy, ovarian hyperstimulation syndrome). The use of interventions to avoid a premature LH surge during ovarian stimulation has a number of advantages. Such interventions reduce the strict requirements for timing of hCG injection and insemination, thus decreasing the demands for extensive monitoring. They lower the risk of cycle cancellation and provide more flexibility (16). Another advantage, which is more controversial, is the improvement in clinical pregnancy rate. Some authors have
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suggested that the antagonist protocol improves the pregnancy rate (10, 17), but others have not seen this improvement in results (16). A recent meta-analysis of randomized controlled trials demonstrated a significantly higher probability of a clinical pregnancy following the use of an antagonist protocol in women undergoing IUI (odds ratio 1.56, 95% CI 1.05–2.33). The increased pregnancy rate was suggested to be related to the fact that these interventions give the opportunity to continue the administration of gonadotropins until a greater number of ovulatory follicles are recruited. Moreover, it is well known that premature luteinization is associated with a less favorable outcome, because of poor oocyte quality and decreased fertilization and implantation rates (18, 19). In the present trial, CC has proved to be effective in reducing premature LH surges. However, because we were performing serum analyses only on the day of the hCG injection, a minor number of cases with premature LH surges may have been missed. Clinically this was unlikely, but to account for this possible occurrence, future trials should monitor for the surge earlier. Regarding endometrial thickness, our findings match with those reported by other investigators who found thinner endometrial thickness with the use of CC when measured on late proliferative days (20). The endometrial thickness reported in the present study included those who were excluded from the study (four cases in group I and six in group II). The endometrial thickness would be slightly thicker on excluding these cases from the calculation. Even after excluding these cases, the endometrial thickness was less than generally reported in the medical literature, and this may explain the reduced pregnancy rates in our study. This thin endometrium could be the result of the high dose of CC that we used throughout the study. In conclusion, the present study demonstrates a novel protocol for COS/IUI cycles that may be modified and attempted in IVF cycles. The protocol is simple and safe and appears to be very cost-effective. Further trials are needed to improve the pregnancy rate, which may be achieved by refining the dose of CC and choosing the best time to start CC administration.
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REFERENCES 1. Cohlen BJ. Should we continue performing intrauterine inseminations in the year 2004? Gynecol Obstet Invest 2005;59:3–13. 2. Mansour RT, Serour GI, Aboulghar MA. Intrauterine insemination with washed capacitated sperm cells in the treatment of male factor, cervical factor and unexplained infertility. Asia Oceania J Obstet Gynaecol 1989;15:151–4. 3. Dickey RP, Taylor SN, Lu PY, Sartor BM, Rye PH, Pyrzak R. Effect of diagnosis, age, sperm quality, and number of preovulatory follicles on the outcome of multiple cycles of clomiphene citrate–intrauterine insemination. Fertil Steril 2002;78:1088–95. 4. Aboulghar MA, Mansour RT, Serour GI, Al-Inany HG. Diagnosis and management of unexplained infertility: an update. Arch Gynecol Obstet 2003;267:177–88. 5. Khalil MR, Rasmussen PE, Erb K, Laursen SB, Rex S, Westergaard LG. Homologous intrauterine insemination. An evaluation of prognostic factors based on a review of 2473 cycles. Acta Obstet Gynecol Scand 2001;80:74–81. 6. Pandian Z, Bhattacharya S, Vale L, Templeton A. In vitro fertilisation for unexplained subfertility. Cochrane Database Syst Rev 2005; CD003357. 7. Kerin JF, Liu JH, Phillipou G, Yen SS. Evidence for a hypothalamic site of action of clomiphene citrate in women. J Clin Endocrinol Metab 1985;61:265–8. 8. Cohlen BJ, te Velde ER, van Kooij RJ, Looman CW, Habbema JD. Controlled ovarian hyperstimulation and intrauterine insemination for treating male subfertility: a controlled study. Hum Reprod 1998;13: 1553–8.
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9. Cantineau AE, Cohlen BJ. The prevalence and influence of luteinizing hormone surges in stimulated cycles combined with intrauterine insemination during a prospective cohort study. Fertil Steril 2007;88: 107–12. 10. Allegra A, Marino A, Coffaro F, Scaglione P, Sammartano F, Rizza G, et al. GnRH antagonistinduced inhibition of the premature LH surge increases pregnancy rates in IUI-stimulated cycles. A prospective randomized trial. Hum Reprod 2007;22: 101–8. 11. Letterie GS. Inhibition of gonadotropin surge by a brief mid-cycle regimen of ethinyl estradiol and norethindrone: possible role in in vitro fertilization. Gynecol Endocrinol 2000;14:1–4. 12. Escudero EL, Boerrigter PJ, Bennink HJ, Epifanio R, Horcajadas JA, Olivennes F, et al. Mifepristone is an effective oral alternative for the prevention of premature luteinizing hormone surges and/or premature luteinization in women undergoing controlled ovarian hyperstimulation for in vitro fertilization. J Clin Endocrinol Metab 2005;90:2081–8. 13. Branigan EF, Estes MA. Minimal stimulation IVF using clomiphene citrate and oral contraceptive pill pretreatment for LH suppression. Fertil Steril 2000;73:587–90. 14. Goverde AJ, McDonnell J, Vermeiden JP, Schats R, Rutten FF, Schoemaker J. Intrauterine insemination or in-vitro fertilisation in idiopathic subfertility and male subfertility: a randomised trial and cost-effectiveness analysis. Lancet 2000; 355:13–8.
15. Matorras R, Diaz T, Corcostegui B, Ramon O, Pijoan JI, Rodriguez-Escudero FJ. Ovarian stimulation in intrauterine insemination with donor sperm: a randomized study comparing clomiphene citrate in fixed protocol versus highly purified urinary FSH. Hum Reprod 2002;17:2107–11. 16. Lambalk CB, Leader A, Olivennes F, Fluker MR, Andersen AN, Ingerslev J, et al. Treatment with the GnRH antagonist ganirelix prevents premature LH rises and luteinization in stimulated intrauterine insemination: results of a double-blind, placebo-controlled, multicentre trial. Hum Reprod 2006;21: 632–9. 17. Ragni G, Alagna F, Brigante C, Riccaboni A, Colombo M, Somigliana E, et al. GnRH antagonists and mild ovarian stimulation for intrauterine insemination: a randomized study comparing different gonadotrophin dosages. Hum Reprod 2004;19:54–8. 18. Manzi DL, Dumez S, Scott LB, Nulsen JC. Selective use of leuprolide acetate in women undergoing superovulation with intrauterine insemination results in significant improvement in pregnancy outcome. Fertil Steril 1995;63:866–73. 19. Loumaye E. The control of endogenous secretion of LH by gonadotrophin-releasing hormone agonists during ovarian hyperstimulation for in-vitro fertilization and embryo transfer. Hum Reprod 1990;5: 357–76. 20. Nakamura Y, Ono M, Yoshida Y, Sugino N, Ueda K, Kato H. Effects of clomiphene citrate on the endometrial thickness and echogenic pattern of the endometrium. Fertil Steril 1997;67:256–60.
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Department of Obstetrics and Gynecology, Cairo University, Cairo, Egypt; and bAlberta Research Centre for Health Evidence, University of Alberta, Edmonton, Alberta, Canada
Objective: To study the effectiveness of clomiphene citrate (CC) in preventing a premature LH surge during controlled ovarian stimulation in women undergoing assisted reproduction. Design: Prospective, randomized, controlled trial. Setting: University hospital. Patient(s): Two-hundred thirty couples with mild male factor, or unexplained infertility. Intervention(s): Couples were randomized to receive human menopausal gonadotrophins (hMG) followed by CC or hMG alone until the day of hCG. Main Outcome Measure(s): The primary outcomes were the incidence of a clinical pregnancy and premature LH rise. Secondary outcomes were the E2 levels, number of mature follicles, and endometrial thickness as determined on the day of hCG. Result(s): The number of patients who had a premature LH surge was significantly lower in the hMG þ CC group (5.45% vs. 15.89%). Additionally, the mean E2 levels (pg/mL) and the number of mature follicles were also significantly higher in the hMG þ CC group (360.3 162.9 vs. 280 110.0 and 2.4 0.97 vs. 1.3 1.1, respectively), although there was no significant difference regarding number of canceled cycles, endometrial thickness, or clinical pregnancy rate. Conclusion(s): The addition of CC to hMG has been proven to be effective in reducing premature LH surges without compromising the pregnancy rate. (Fertil Steril 2010;94:2167–71. 2010 by American Society for Reproductive Medicine.) Key words: COS, IUI, CC, premature LH surge
Intrauterine insemination (IUI) with partner or donor sperm is a commonly practiced method of assisted reproduction. The procedure involves directly introducing washed spermatozoa into the uterine cavity, thereby bypassing several of the natural barriers in the female genital tract (e.g., vagina, cervix) which may be the source of the infertility. In combination with controlled ovarian stimulation (COS), it has proved to be a cost-effective line of treatment for many forms of infertility (1). Its main indications are mild male factor, cervical factor, and cases of unexplained infertility (2, 3). The technical simplicity, associated lower costs, and low incidence of complications make it a natural choice for many couples attempting to conceive (1). Additionally, because most cases of infertility are relatively mild in nature and can be overcome with the proper diagnosis and treatment, many andrologists, gynecologists, and reproductive endocrinologists alike recommend up to six cycles Received September 19, 2009; revised January 24, 2010; accepted January 26, 2010; published online March 16, 2010. H.A.-I. has nothing to disclose. H.A. has nothing to disclose. W.E.-K. has nothing to disclose. A.N. has nothing to disclose. E.E.-K. has nothing to disclose. A.A.-S. has nothing to disclose. Reprint requests: Hesham Al-Inany, M.D., Ph.D. 8-Moustapha Hassanin St, Manial, Cairo 11451, Egypt (E-mail: [email protected]).
0015-0282/$36.00 doi:10.1016/j.fertnstert.2010.01.069
of IUI before embarking on more invasive procedures (e.g., IVF) (2, 4, 5). This has been confirmed by a recent Cochrane review on couples with unexplained infertility, which demonstrated that the success rates with IUI are similar to those achieved with IVF/ intracytoplasmic sperm injection in this patient population (6). Clomiphene citrate (CC) has been the most widely used treatment for fertility enhancement for the past 40 years. Clomiphene was a revolutionary advance in reproductive medicine and quickly became popular for induction of ovulation, owing to its ease of administration and minimal side effects. It acts as a selective estrogen receptor modulator, similarly to tamoxifen and raloxifene. All three drugs are competitive inhibitors of estrogen binding to estrogen receptors and have mixed agonist and antagonist activity depending on the target tissue. Most evidence suggests that the primary site of clomiphene action is the hypothalamus, where it appears to bind to hypothalamic estrogen receptors, thereby blocking the negative feedback effect of circulating endogenous estrogen and resulting in an increase in plasma levels of FSH and LH (7). One of the major challenges facing using gonadotropin stimulation with IUI is the occurrence of a premature LH surge and consequent luteinization before ovarian follicle maturation. It has been suggested that 24%–36% of IUI cycles suffer from premature LH
Fertility and Sterility Vol. 94, No. 6, November 2010 Copyright ª2010 American Society for Reproductive Medicine, Published by Elsevier Inc.
2167
surge. This might negatively influence treatment outcome and can result in procedure cancellation. Obviously, this represents both an economic and a psychologic burden for patients (8, 9) and an additional hurdle for clinicians to overcome. Several strategies have been proven to be effective for preventing the occurrence of premature LH surges during ovarian stimulation. The gold standard is the use of pituitary down-regulation with a GnRH agonist, but it is associated with an explicit need for additional doses of gonadotropins and increased cost of care. Recently, GnRH antagonists have emerged as a strong competitor, with documented improvements in pregnancy rates (9, 10). Other interventions have been tried with varying degrees of success, including ethinyl E2 plus norethindrone (11) and mifepristone (12). Earlier work has proved that CC and oral contraceptive pill pretreatment were able to suppress LH in minimal-stimulation IVF cycles (13). Therefore, the use of CC with IUI would be a natural progression if it can be proved to prevent premature LH surges in COS/IUI cycles. The rationale is that its antiestrogenic effect may suppress premature LH rise while maintaining a positive influence on ovarian follicle development. The use of CC for this indication would open the door for very friendly stimulation protocols in COS/IUI and IVF cycles.
Ovarian stimulation was monitored every other day by vaginal US starting from day 5 of stimulation. When the leading follicle reached a mean diameter of 18 mm, 10,000 IU hCG (Choriomon; IBSA) was administered and IUI scheduled 34–36 hours later. On the day of hCG injection, patients had a serum assay of LH and E2 as well as US measurement of endometrial thickness. IUI was canceled if fewer than two or more than five follicles with a mean diameter of 16 mm were present, to optimize the chance for pregnancy and reduce the risk of multiple pregnancy, respectively. Canceled cases were not given hCG but were instructed to have timed intercourse. All patients received luteal phase support in the form of 100 mg micronized progesterone (Uterogestan; October Pharma, Cairo, Egypt), three tablets daily in two divided doses starting the day after insemination and continued for 18 days. Serum hCG levels were determined 14 days after insemination. Progesterone supplementation was continued for a further 2 weeks in the pregnant patients.
Outcome Measures Clinical pregnancy was defined as a rise in the serum hCG level on serial determinations R2 days apart coupled with an intrauterine gestation with fetal heart pulsations demonstrated by transvaginal US at 6–7 weeks’ gestation. The primary outcome measures for this trial were the incidence of a clinical pregnancy and premature LH rise. Premature LH rise was defined as LH R10 mIU/mL on the day of hCG injection. Secondary outcomes were the E2 levels, number of mature follicles, and endometrial thickness as determined on the day of hCG.
MATERIALS AND METHODS This was a prospective, randomized, controlled study carried out during the period from January 2008 to July 2009 at the Department of Obstetrics and Gynecology, Kasr El-Aini Teaching Hospital, Cairo University. Institutional Review Board approval was obtained, and informed consents from participants were attained before randomization. The study protocol was registered at the Australian New Zealand Clinical Trial Registry (ACTRN12607000568415) in accordance with the Declaration of Helsinki and the recommendations of the Committee of Medical Journal Editors.
Patient Population All patients were subjected to careful history taking, general examination, and local gynecologic examination. Inclusion criteria were mild male factor or unexplained infertility, women partner aged <39 years with regular menstrual cycles, body mass index <32 kg/m2, normal uterine cavity and fallopian tubes as documented by ultrasound (US), hysterosalpingography, and/ or laparoscopy, and normal hormonal profile including FSH, LH, TSH, T, and PRL levels. Mild male factor infertility was defined as the presence of abnormal semen parameters but with >5% normal morphology and >5 106/mL motile spermatozoa recovered after sperm preparation. Couples were excluded if they were diagnosed with infertility due to other causes, significant cardiovascular, pulmonary, renal, neurologic, or hepatic problems, or presence of ovarian cyst >2 cm before stimulation. Two-hundred thirty infertile couples were randomized using a computergenerated random number table. Allocation concealment was performed using sequentially numbered, opaque, sealed envelopes. At the time of inclusion, the attending consultant opened an envelope describing the allocation to either the intervention or the control group. Couples assigned to the intervention group received CC þ hMG, and couples assigned to the control group received hMG only.
Statistical Analysis To prevent a type II error, we performed an a priori sample size calculation. Prior data indicated that the premature LH surge rate among the hMG-only group was 20%. If the true rate for the hMG þ CC group is 5%, we would need to study 75 couples in each arm to be able to reject the null hypothesis that the rates for the experimental and control groups are equal with a probability of 80%. The type I error probability associated with this test of this null hypothesis is .05. We used an uncorrected chi-squared statistic to evaluate this null hypothesis. Additionally, to compensate for discontinuations, we recruited 115 women in each arm. Data are expressed as mean SD or percentage where applicable. Independent samples were compared using the Student t test. The chi-squared test and Fisher exact test were used for categoric data. A P value of < .05 was considered to indicate statistical significance. Statistical analysis was done using Arcus Quickstat version I (Research Solutions Ltd, UK).
RESULTS Two-hundred forty-five infertile couples were screened for inclusion, with 230 couples randomized in a 1:1 ratio to receive hMG þ CC or hMG alone for ovarian stimulation. Each couple was included only once in this trial to prevent a possible unit-of-analysis error in interpreting the results.
TABLE 1 Basic characteristics of the study population. Variable
Ovulation Induction and IUI Protocols On day 3 of the cycle a basal US scan was done and a blood sample was taken for hormonal profile assessment. All subjects received a fixed dose of 75 IU highly purified human menopausal gonadotropin (Merional; IBSA, Lugano, Switzerland), regardless of the response starting from the third day of cycle for 5 days. Subsequently, women randomized to the CC þ hMG group received 50 mg CC (Clomid; Aventis pharma S.AE, Global Napi Pharmaceuticals, Cairo, Egypt) three times daily starting from the fourth day of hMG and continued until the day of hCG injection. Women randomized to the hMG-only group maintained hMG injections until the day of hCG injection.
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Age (y) Duration of infertility (y) Cause of infertility Unexplained infertility Mild male factor Body mass index (kg/m2)
Group I (n [ 115)
Group II (n [ 115)
P value
27.3 4.7 3.1 1.9
28.4 2.7 2.4 1.6
NS NS
61 (53%) 54 (47%) 28.5 1.6
58 (50.4%) 57 (49.6%) 28.1 3.1
NS NS NS
Note: NS ¼ nonsignificant. Al-Inany. CC prevents LH surge. Fertil Steril 2010.
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FIGURE 1 Flow chart of participating patients.
Al-Inany. CC prevents LH surge. Fertil Steril 2010.
Baseline characteristics of the two groups were similar, with no statistical difference in mean female age, duration of infertility, or body mass index (Table 1). Out of the 115 couples randomized to receive hMG þ CC, five cycles were canceled owing to inadequate response (n ¼ 4) or hyperresponse (n ¼ 1) (Fig. 1). In the hMG-only group, eight cycles were canceled owing to inadequate response (n ¼ 6) or hyperresponse (n ¼ 2). The number of days CC was administered in group I ranged between 2 and 5 days with a mean of 3.1 days. On the day of hCG administration, mean E2 levels (pg/mL) were significantly higher in the hMG þ CC group than in the hMG-only Fertility and Sterility
group (360.3 162.9 vs. 280 110.0; P<.05). The number of mature follicles R16 mm also was significantly higher for the hMG þ CC group (2.4 0.97 vs. 1.3 1.1; P<.05). Additionally, the number of patients who had a premature LH surge was significantly less in the hMG þ CC group (5.22% vs. 14.78%; P<.001). Even so, these advantages with the additional use of CC did not correlate with additional clinical benefits, with no significant differences demonstrated between the two groups regarding number of canceled cycles, endometrial thickness, and clinical pregnancy rate (Table 2). There was only one case of multiple pregnancy (twin), in the hMG þ CC group.
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TABLE 2 Cycle characteristics. Variable No. of canceled cycles Inadequate response Hyperresponse Basal LH (mIU/mL) Basal FSH (mIU/mL) Days of stimulation E2 at time of hCG (pg/mL) LH on day of hCG (mIU/mL) for cases with no premature LH surge No. of follicles R16 mm No. of patients with premature LH surge Endometrial thickness (mm) No. of clinical pregnancies
Group I (n [ 115)
Group II (n [ 115)
P value
5/110 4/5 1/5 6.4 2.2 6.7 2.5 7.2 1.8 360.3 162.9 7.3 1.8
8/107 6/8 2/8 5.8 2.4 7.2 4.8 8.1 1.3 280 110.0 7.8 2.2
NS NS NS NS NS NS < .05 NS
2.4 0.97 6 (5.45%) 5.9 0.7 11 (10%)
1.3 1.1 17 (15.89%) 4.9 1.9 9 (8.41%)
< .05 < .001 NS NS
Al-Inany. CC prevents LH surge. Fertil Steril 2010.
DISCUSSION The results of this prospective, randomized, controlled trial clearly demonstrate the beneficial effects of the addition of CC to hMG during ovarian stimulation to prevent a premature LH surge from occurring. Climphene citrate reduced the incidence of premature LH surge while providing better follicle maturation compared with the use of hMG alone. Our hypothesis is that this effect could be either due to the antiestrogenic properties of CC or related to a central hypothalamic effect. However, it appears that these antiestrogenic properties did not affect the stimulatory effect of gonadotropins. This was obvious by the fact that the mean E2 levels were even higher in the CC group as was the number of mature follicles. Additionally, there was no difference in the endometrial thickness between the two groups. Clomiphene citrate was given in the present study three times daily, which can be considered to be a high dose, a novel approach which was not tested before: We started with a high dose of CC primarily because most of our participants were above average weight (Table I) The clinical pregnancy rate per cycle was 10% in the CC group and 8.4% in the control group. The pregnancy rates are within the range of success rates reported (8%–18%) for conventional COS/ IUI studies per stimulated cycle (14–16). However, other studies have reported a much higher pregnancy rate per cycle (20%–35%) using the antagonist protocol to prevent premature LH surge (10, 17). We believe that the lower pregnancy rate in the present study reflects the intentionally patient-friendly minimal-stimulation protocol that was used throughout the trial. A more aggressive stimulation protocol would be expected to produce a higher pregnancy rate, but with an associated higher incidence of complications (e.g., multiple pregnancy, ovarian hyperstimulation syndrome). The use of interventions to avoid a premature LH surge during ovarian stimulation has a number of advantages. Such interventions reduce the strict requirements for timing of hCG injection and insemination, thus decreasing the demands for extensive monitoring. They lower the risk of cycle cancellation and provide more flexibility (16). Another advantage, which is more controversial, is the improvement in clinical pregnancy rate. Some authors have
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CC prevents LH surge
suggested that the antagonist protocol improves the pregnancy rate (10, 17), but others have not seen this improvement in results (16). A recent meta-analysis of randomized controlled trials demonstrated a significantly higher probability of a clinical pregnancy following the use of an antagonist protocol in women undergoing IUI (odds ratio 1.56, 95% CI 1.05–2.33). The increased pregnancy rate was suggested to be related to the fact that these interventions give the opportunity to continue the administration of gonadotropins until a greater number of ovulatory follicles are recruited. Moreover, it is well known that premature luteinization is associated with a less favorable outcome, because of poor oocyte quality and decreased fertilization and implantation rates (18, 19). In the present trial, CC has proved to be effective in reducing premature LH surges. However, because we were performing serum analyses only on the day of the hCG injection, a minor number of cases with premature LH surges may have been missed. Clinically this was unlikely, but to account for this possible occurrence, future trials should monitor for the surge earlier. Regarding endometrial thickness, our findings match with those reported by other investigators who found thinner endometrial thickness with the use of CC when measured on late proliferative days (20). The endometrial thickness reported in the present study included those who were excluded from the study (four cases in group I and six in group II). The endometrial thickness would be slightly thicker on excluding these cases from the calculation. Even after excluding these cases, the endometrial thickness was less than generally reported in the medical literature, and this may explain the reduced pregnancy rates in our study. This thin endometrium could be the result of the high dose of CC that we used throughout the study. In conclusion, the present study demonstrates a novel protocol for COS/IUI cycles that may be modified and attempted in IVF cycles. The protocol is simple and safe and appears to be very cost-effective. Further trials are needed to improve the pregnancy rate, which may be achieved by refining the dose of CC and choosing the best time to start CC administration.
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