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Premature luteinization occurred in eight of the 10 patients (80%) in group A and in two of the 12 patients in group B (16.6%). This result corresponds to the higher mean (+/-SD) progesterone level present in group A patients as compared to those in group B (2.0 +/- 1.2 ng/mL vs. 1.2 +/- 0.6 ng/mL, P=0.03). No pregnancies were achieved in group A, whereas the pregnancy rate per cycle observed in group B was 33.3% (4/12). On the day of hCG administration, the maximum mean (+/-SD) estradiol level was significantly lower (P<0.0001) in group A (210.6 +/- 37.9 pg/mL) than in group B (600.3 +/- 253.8 pg/mL). The treatment duration and the number of FSH ampules used did not differ between the groups.
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Recently, we identified a human follicular fluid protein(s) (FP) which inhibited human menopausal gonadotropin (hMG)-induced rat ovarian weight gain and FSH-induced aromatase. Here, we assessed FP activity from ovulatory patients who were either untreated (n = 7) or received clomiphene (n = 9; 150 mg/day on cycle days 5-9) or hMG (n = 6; 150 IU/day on cycle day 3). Aspirations were performed when one follicular diameter exceeded 20 mm. FP activity was expressed as the percent inhibition of porcine granulosa cell aromatase activity at three concentrations of extracted follicular fluid (range, 1250-10 micrograms; extrapolated to 50 micrograms). Patients receiving hMG or clomiphene had multiple follicles greater than 16 mm in diameter (3.83; 2.66/patient, respectively), while untreated patients had 1 each. FP activity was 14.1 +/- 5.3% (mean +/- SEM) inhibition for untreated, 18.0 +/- 3.4% inhibition for hMG-treated, and 13.7 +/- 5.3% inhibition for clomiphene-treated patients. Follicular fluid estradiol levels from untreated patients (2590 +/- 1221 ng/ml) were greater than estradiol concentrations from hMG-treated (356 +/- 55 ng/ml; P less than 0.01) or clomiphene-treated (1317 +/- 344 ng/ml; P less than 0.05) patients. Progesterone follicular fluid levels were 9.84 +/- 3.3, 5.18 +/- 61, and 11.3 +/- 2.3 micrograms/ml for untreated, hMG-treated, and clomiphene-treated patients, respectively (P less than 0.05). A similar relationship was present with 17-hydroxyprogesterone (untreated, 1.6 +/- 0.2 micrograms/ml; hMG-treated, 0.76 +/- 0.1 micrograms/ml; clomiphene-treated, 2.16 +/- 0.3 micrograms/ml; P less than 0.05). Androstenedione and testosterone follicular fluid levels were similar in all groups (78.9 +/- 23 and 7.09 +/- 2.14 ng/ml, respectively). Untreated patients had a positive correlation between FP and follicular fluid estradiol (r = 0.689; P less than 0.01) and inhibin activity (r = 0.654; P less than 0.05), and a negative correlation between follicular fluid progesterone levels (r = 0.622; P less than 0.05). Patients treated with hMG had a significant negative correlation between FP activity and follicular fluid progesterone levels (r = 0.756; P less than 0.005) and a biphasic correlation with follicular fluid 17-hydroxyprogesterone (r2 = 0.853; P less than 0.0025). Clomiphene-treated patients had biphasic correlations between follicular fluid estradiol and 17-hydroxyprogesterone levels (r2 = 0.853 and P less than 0.0025, and r2 = 0.637 and P less than 0.025, respectively). These findings indicate that the FP activity of the dominant follicle correlates with its state of differentiation, as described by intrafollicular estradiol, progesterone, 17-hydroxyprogesterone levels and inhibin activity. These relationships are in part dependent upon gonadotropin stimulation.
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Evaluation and treatment of various conditions including polycystic ovarian syndrome, hyperprolactinemia, congenital adrenal hyperplasia are discussed as are methods to prevent certain complications of these therapies.
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Although the endometrial thickness on the day of ET was similar for the prostaglandin and conventional groups, the pregnancy and implantation rates for the prostaglandin group were 40.0% and 22.0%, respectively, which was significantly higher than the rates for the conventional group (P < 0.01).
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First-line treatments for unexplained infertility traditionally include clomifene citrate (CC) or unstimulated intrauterine insemination (IUI). A recently published randomized controlled trial considered the effectiveness of CC and IUI in patients with unexplained infertility and found that neither treatment offered a superior live birth rate when compared with expectant management (EM). This paper reports the economic evaluation conducted alongside this trial in order to assess whether health care providers are gaining value for money in this clinical area.
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To compare the ovulation rate between raloxifene and clomiphene citrate (CC) in patients with polycystic ovary syndrome (PCOS).
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This cross-over randomized controlled clinical trial included 90 infertile amenorrheic women with PCOS. After inducing withdrawal bleeding, patients were randomly divided into two equal groups to receive ovulation induction with CC 100 mg/day for 5 days. Group I started treatment the next day after finishing medroxyprogesterone acetate course for a menstrual cycle, and after a washout period of another menstrual cycle, the treatment was shifted to start on day 2 of withdrawal bleeding. Group II received a reversed protocol: late then early treatment. Women were followed up on transvaginal ultrasonography to monitor follicular growth, endometrial thickness and evidence of ovulation. Human chorionic gonadotropin 10 000 IU was given i.m. to trigger ovulation when at least one mature follicle measured ≥18 mm at day 14.
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Ovulation induction (OI) with CC, hMG, or CC+hMG.
In a prospective clinical trial lasting one year, 35 postmenopausal women with severe climacteric symptoms were cyclically treated with conjugated oestrogens (1.25 mg daily). This oestrogen replacement therapy was randomly supplemented with 10 mg of megestrol acetate daily (18 women) or 50 mg of clomiphene citrate (17 women) for 10 days four times a year. Both treatment regimens significantly alleviated climacteric symptoms. At the end of the oestrogen-megestrol acetate treatment no endometrial proliferation or hyperplasia was seen, while at the end of the oestrogen-clomiphene citrate treatment the endometrium was proliferative or hyperplastic in two women and atrophic in the other 15. Regular uterine bleeding occurred in each woman after megestrol acetate but never after clomiphene citrate administration. Break-through bleeding during the oestrogen treatment periods appeared in the megestrol and clomiphene groups in five and eight women, respectively. There were no clinically adverse hormonal or metabolic changes during megestrol acetate or clomiphene citrate treatment periods. Our results provide further evidence that in addition to progestins postmenopausal oestrogen replacement therapy can safely be supplemented with antioestrogen and thereby avoid the bleeding which occurs regularly after progestin withdrawal.
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Although certain beneficial effects were observed in the literature in some of the infertile patients treated with corticosteroids, the overall results did not support daily, low-dose dexamethasone (long-acting corticosteroid) as a clinically useful adjuvant therapy for "low responders" during gonadotropin therapy.
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women of any age, ethnicity and weight with PCOS diagnosed by all current criteria, who are infertile; at least 1000 mg of any type of metformin at any frequency, including slow release and standard release, compared with any type, dose and frequency of clomiphene citrate.
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To determine the histologic development of midluteal corpus luteum (CL) and endometrium in normal fertile women after induction of ovulation with clomiphene citrate (CC). DESIGN, PATIENTS, INTERVENTIONS: Twelve normally cycling women planning to undergo an elective tubal ligation were treated with 50 to 150 mg of CC daily on days 5 through 9 of the cycle. Luteectomy and endometrial biopsy were performed simultaneously 7 days after the urinary luteinizing hormone surge.
T increased significantly from baseline in both groups at 6 and 12 weeks. There was a significantly larger increase in T and mean increase from baseline in CC vs. AZ (571 vs. 408 ng/dL, respectively). Whereas E-2 levels increased in the CC group, they decreased in the AZ group. Though both groups demonstrated an increase in T-to-E-2 ratio from baseline, statistic significance at 6 and 12 weeks was only achieved with AZ. Neither group demonstrated significant changes in seminal parameters or patient-reported outcomes.
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There is evidence that obesity may increase the general risk of miscarriage. However, there is insufficient evidence to describe the effect of obesity on miscarriage in specific groups such as those conceiving after assisted conception.
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Review of published literature and expert opinions. Intended as a meta-analysis, but no quality studies met the inclusion criteria.
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We performed cytological examinations on 863 of the 969 patients (89.3%). In the final diagnosis, 4 patients had carcinoma in situ (0.5%) and 1 patient had microinvasive carcinoma (0.1%). Therefore, it is important to perform cytological examinations on infertility out-patient s, and conduct routine cytological examinations when infertility treatment is being continued over long periods. The detection rate for the 18 patients who required detailed examination did not differ between primary and secondary infertility, or with the period of infertility or the factor causing infertility. The follow up after conization should be done carefully, and the patient should be encouraged to become pregnant as early as possible. Unlike fertile women, in infertile women, conization should be performed, even in the case of carcinoma in situ, provided: There is a specialist well-experienced in cytology, colposcopy, and histology; the patient and family are fully satisfied with the physician's explanation; the physician can maintain good contact with the patient and family and continue to provide adequate follow up treatment, and the lesion is in the ectocervix, and the whole lesion can be removed by conization without leaving intact foci.
Fifty-two men with idiopathic infertility were recruited in this randomized controlled trial. They were randomly assigned into 2 treatment groups, group 1 (n = 20) and group 2 (n = 32), who received L-carnitine 25 mg/day and clomiphene citrate 2 gr/day, respectively, for a period of 3 months.
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Eighty-five women were allocated to receive rFSH as part of a multicentre clinical trial. rFSH was administered in a chronic low-dose step-up protocol. The primary end-point was an ongoing pregnancy within 12 months. A logistic model was built using clinical, ultrasonographic and endocrine parameters to predict the response to rFSH treatment, adjusted for the number of cycles performed.
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Corpus luteal function was assessed by estimating pregnanediol 3-alpha-glucuronide (PdG) in three midluteal-phase urine samples collected from 85 women attending the infertility clinic. The previously established cut off limits based on PdG estimations were useful in detecting anovulation in 23 cases, corpus luteal adequacy in 42 cases and corpus luteum deficiency (CLD) in 20 cases. In 8 women CLD could be corrected with 50 mg of clomiphene citrate (CC) therapy whereas 6 women required 100 mg of CC and 3 pregnancies were achieved. This rapid screening method is thus useful in segregating a large number of women according to their ovulatory status and in the subsequent treatment of CLD.
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Forty-one women undergoing donor insemination with cryopreserved sperm for either isolated male factor or male factor plus ovulatory dysfunction corrected by clomiphene citrate.
Uterine ornithine decarboxylase (ODC) activity is reported to increase after estrogen administration to fetal, neonatal, immature, and adult rats, suggesting that it may be a useful marker in studies of the development of estrogen responsiveness. Standard conditions were validated for enzyme assay of uterine cytosols from 5-day-old rats, and it was demonstrated that full activity was retained after freezing cytosol in liquid N2. Maximal activity, obtained 6 h after the injection of 10 micrograms estradiol (E2) to 5-day-old rats, was also elicited by the same dose of mestranol, ethynylestradiol, diethylstilbestrol, or moxestrol. Progesterone, testosterone, and low doses of the antiestrogens clomiphene and tamoxifen failed to alter background ODC levels, while high antiestrogen doses induced small increases in enzyme activity. The glucocorticoid prednisolone lowered ODC activity. Dose-response curves established that E2 was more effective in increasing adult ODC levels (ED50 = 0.2 micrograms/kg E2) than neonatal ODC levels (ED50 = 2 micrograms/kg E2). Time-course measurements were conducted over 24 h in control and E2-injected animals on postnatal days 5, 10, 14, 20, and 28 and in 60-day-old ovariectomized adults. While an age-dependent decrease in control and 6 h E2-induced ODC levels was observed, there was an unexpected progressive development by day 28 of a second peak of E2-induced ODC at 15-18 h. The 6 h neonatal and 6 and 15-18 h adult ODC peaks had apparent Km values for ornithine near 0.2 mM. The potential origin of the second peak and its relationship to other uterine events are discussed.
There was no statistically significant difference in clinical pregnancy rate per cycle between the groups (8.5, 10, and 9.2 % for Group I, II, and III, respectively, p = 0.86). In further analyses related to endometrial thickness, no significant difference was also found in pregnancy rate among the groups.
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Two tertiary-referral infertility clinics associated with the Division of Reproductive Sciences, University of Toronto.
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Despite a plethora of tests of ovarian reserve, there is no perfect test to predict pregnancy. Recent evidence points that anti-Müllerian hormone and antral follicle count may be better than other tests, although other tests continue to be used and form the basis of exclusion of women from fertility treatments. This systematic review concentrated on dynamic tests of ovarian reserve [clomifene citrate challenge test (CCCT), gonadotrophin-releasing hormone agonist stimulation test (GAST) and exogenous FSH ovarian reserve test (EFORT)] and assessed their predictability in terms of fertility outcomes. The study did not restrict itself to women undergoing IVF. The diagnostic odds of abnormal CCCT for non-pregnancy were 2.11 (95% confidence interval, 1.04-4.29) at FSH >10 IU/l (day 3 or 10). The diagnostic accuracy of GAST and EFORT could not be determined due to inconsistencies in the way these tests were conducted. This systematic review and meta-analysis was limited by heterogeneity in terms of the population sampled and the index and reference tests. There is an urgent need for consensus on the performance of these tests and the definition of normality, if their use is to be continued. However, given the present level of evidence, these tests should be completely abandoned.
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Fertility was evaluated in 53 female patients with late-onset adrenal hyperplasia (LAH) due to 21-hydroxylase deficiency. The majority of patients (n = 33) were seen for isolated postpubertal hirsutism, 9 patients consulted for sterility, and 11 for irregular menstrual cycles. At the time of diagnosis, the ages of patients ranged from 15-40 yr (mean +/- SD, 24.6 +/- 5.2). No patient had major signs of virilization. The plasma 17-hydroxyprogesterone level was higher than normal in all patients (26.8 +/- 18.9 nmol/L; range, 3.4-139.4) and dramatically increased to 140.1 +/- 80.6 nmol/L (range, 35.2-324.2) after ACTH treatment. Plasma androgen levels were high (testosterone, 3.25 +/- 2.03 nmol/L; delta 4-androstenedione, 13.65 +/- 5.60 nmol/L). Plasma basal and LHRH-stimulated values were normal for FSH and high for LH. Basal and TRH-stimulated plasma PRL levels were normal. Among these 53 LAH patients, only 20 desired a pregnancy. These had a total of 38 pregnancies. Ten patients became pregnant before the diagnosis of LAH and without any treatment; they had a total of 18 pregnancies, 12 of which were successful. Moreover, 19 normal pregnancies without any spontaneous abortion were carried to term by 14 of 16 hydrocortisone-treated patients. One patient needed the association of one cure of clomiphene citrate. Hypofertility in LAH patients seems, therefore, to be relative. Its mechanism is hormonal, with anovulation or dysovulation, due to the continuous steroid feedback of adrenal origin on the hypothalamo-pituitary axis. Hydrocortisone is the appropriate treatment in most cases, reducing adrenal androgen overproduction and relieving hypothalamic-pituitary gonadotropin function, thereby making possible cyclic ovarian activity and ovulations.
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ISRCT No: 71762042.
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The biological response to anti-estrogens is very variable and depends on the animal species considered, the target organ, the parameter studied, and the experimental conditions. Anti-estrogens can bind specifically, (1) to the estrogen receptor, (2) to the typical anti-estrogen specific binding site, and (3) to low density lipoproteins in the plasma. Using a monoclonal antibody against the estrogen receptor, different immunological characteristics of the anti-estrogen-receptor complex can be observed. This difference could explain some of the different biological effects. Studies using different human mammary cancer cell lines (hormone-dependent) show that anti-estrogens are active in decreasing cell proliferation. Also, anti-estrogens can block proteins specifically produced by these cells. Some of these proteins could act as growth or inhibitory factors. Estrogen sulfates are the main precursors of estradiol in breast tissues and this conversion is significantly decreased by anti-estrogens. It is accepted that the main pathway of action of anti-estrogens is through the estrogen receptor, but recent information suggests the possibility that this is not the only step in the mechanism of action of anti-estrogens.
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To determine the effects of clomiphene citrate (CC) and cyclofenil on cervical mucus (CM) volume and receptivity sampled serially over the periovulatory period.
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The review describes briefly the clinical and endocrinological characteristics of chronic hyperandrogenic anovulation (CHA), as well as ovulation induction by hormone therapy (therapy of first choice) and by classical wedge resection. The main purpose of this study, however, is to compare different laparoscopic treatments of CHA, with emphasis on laser treatments by argon, CO2, Nd:YAG, and frequency-doubled Nd:YAG laser. The overall results of laparoscopic treatments in hormone-therapy-resistant patients with CHA are encouraging and the results are comparable. In the studies considered in this review, ovulation was induced for longer or shorter periods in 21 out of 31 patients (68%) after ovarian biopsy, in 57 out of 73 patients (78%) after electrosurgery, and in 82 out of 118 patients (70%) after laser treatment. Subsequent conception occurred in 44%, 40%, and in 41% of the patients, respectively. Of interest is the fact that some hormone-therapy-resistant patients become sensitive to Clomiphene after laparoscopic treatment, giving an overall percentage of ovulation and an overall pregnancy rate of 89% and 54%, respectively, for electrosurgery, and of 88% and 50%, respectively, for laser treatment. Unfortunately, adhesion formation, a serious complication of surgical treatment of the ovaries, is still a drawback using laparoscopic surgical techniques.
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Chinese Clinical Trial Registry, ChiCTR-IOR-15007358 , registered on 26 October 2015.
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In women with PCOS, no significant difference could be demonstrated between FSH and hMG, in terms of pregnancy rate. However, given similar cost, potential advantages in terms of purity and a possible reduction in OHSS risk, highly purified or recombinant FSH are likely to be widely adopted in the future. Further research should consider live birth as a primary clinical outcome, given concerns over the association between high androgen and LH levels with spontaneous abortion risk.
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A novel approach for the analysis of the cyanobacterial toxin, anatoxin-a (ANA-a), in an environmentally relevant matrix, using laser diode thermal desorption-atmospheric pressure chemical ionization-tandem mass spectrometry (LDTD-APCI-MS/MS) is presented. The ultra-fast analysis time (15 s/sample) provided by the LDTD-APCI interface is strengthened by its ability to remove interference from phenylalanine (PHE), an isobaric interference in ANA-a analysis by MS/MS. Thus the LDTD-APCI interface avoids the time consuming steps of derivatization, chromatographic separation or solid-phase extraction prior to analysis. Method development and instrumental parameter optimizations were focused toward signal enhancement of ANA-a, and signal removal of a PHE interference as high as 500 μg/L. External calibration in a complex matrix gave detection and quantification limit values of 1 and 3 μg/L respectively, as well as good linearity (R(2) > 0.999) over nearly two orders of magnitude. Internal calibration with clomiphene (CLO) is possible and method performance was similar to that obtained by external calibration. This work demonstrated the utility of the LDTD-APCI source for ultra-fast detection and quantification of ANA-a in environmental aqueous matrices, and confirmed its ability to suppress the interference of PHE without sample preparation or chromatographic separation.
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To estimate whether progestin-induced endometrial shedding, before ovulation induction with clomiphene citrate, metformin, or a combination of both, affects ovulation, conception, and live birth rates in women with polycystic ovary syndrome (PCOS).