Relationship between seasons and pregnancy rates during intrauterine insemination. A historical cohort

ABSTRACT BACKGROUND: The underlying cause of seasonal infertility in humans is unclear, but is likely to be ­multifactorial. OBJECTIVE: The aim of our study was to compare the pregnancy rates among infertile women who underwent induced ovulation and intrauterine insemination (IUI) with the season in which the fertility treatment was performed. DESIGN AND SETTING: This retrospective cohort study was conducted on 466 patients who were treated in the reproductive endocrinology and infertility outpatient clinic of a tertiary-level women's healthcare and maternity hospital. METHODS: Retrospective demographic, hormonal and ultrasonographic data were obtained from the patients' medical records. Clomiphene citrate or gonadotropin medications were used for induced ovulation. The patients were divided into four groups according to the season (spring, winter, autumn and summer) in which fertility treatment was received. Clinical pregnancy rates were calculated and compared between these four groups. RESULTS: There were no significant differences between the seasonal groups in terms of age, infertility type, ovarian reserve tests, duration of infertility, medications used or length of stimulation. A total of 337 patients (72.3%) were treated with clomiphene citrate and 129 (27.7%) with gonadotropin; no significant difference between these two groups was observed. The clinical pregnancy rates for the spring, winter, autumn and summer groups were 15.6% (n = 24), 8.6% (n = 9), 11.5% (n = 13) and 7.4% (n = 7), respectively (P = 0.174). CONCLUSIONS: Although the spring group had the highest pregnancy rate, the rates of successful IUI did not differ significantly between the seasonal groups.

Clomiphene citrate treatment for late onset hypogonadism: rise and fall

ABSTRACT Objective: Previous series have demonstrated that Clomiphene Citrate (CC) is an effective treatment to increase Total Testosterone (TT) in Late Onset Hypogonadism (LOH) patients. However, what happens to TT levels after ending CC treatment is still debatable. The objective of this study is to evaluate TT levels 3 months after the discontinuation of CC in patients with LOH who were previously successfully treated with the same drug. Materials and Methods: Twenty-seven patients with LOH that were successfully treated (achieved TT levels >11nmol/l) with CC 50mgs daily for 50 days were prospectively recruited in our Andrological outpatient clinic. CC was then stopped for 3 months and TT levels were measured at the end of this period. Results: Mean TT level before discontinuation of CC was 22.7±8.1nmol/L (mean±SD). Three months after discontinuation, mean TT level significantly decreased in all patients, 10.2±3.9nmol/l (p<0.01). Twenty-one patients (78%) decreased TT levels under 11nmol/L. Six patients (22%) had TT levels that remained within the normal recommended range (≥11nmol/l). No statistical significant differences were observed between both groups. Conclusion: In the short term LOH does not seem to be a reversible condition in most patients after CC treatment. More studies with longer follow-up are needed to evaluate the kinetics of TT in LOH.

Clinical Practice Guidance for the Use Of Clomiphene Citrate in Male Hormone Replacement Therapy (HRT).

Introduction: Inhibition of pituitary gonadotropin secretion in men by testosterone (T) is principally mediated by aromatization to estrogen (E), which inhibits hypothalamic secretion of gonadotropin-releasing hormone (GnRH). Material and Methods: Longitudinal clinical investigation unit-based evaluation of the clinical and biochemical response to E-receptor blockade. Initial monotherapy with 50 mg of clomiphene citrate (CC) daily for a period of 9 months, with diurnal morning peak testosterone and luteinizing hormone (LH) levels evaluated at three-month intervals thereafter. Th e patient then resumed hormone replacement therapy (HRT) using T cream with adjuvant CC therapy. Main Outcome Measures were Baseline and stimulated T and LH levels; eff ect on sexual function. Result(S): CC therapy resulted in complete normalization of pulsatile gonadotropin secretion, serum T level, and sexual function. Conclusion(S): Isolated hypogonadotropic hypogonadism (IHH) may result from an acquired defect of enhanced hypothalamic sensitivity to E-mediated negative feedback. Whereas direct T replacement therapy can further suppress endogenous gonadotropin secretion, treating IHH men with gonadotropins can stimulate endogenous T secretion and enhance fertility potential. Reversal of gonadotropin defi ciency with CC was found to have a similar biological eff ect.

Effects of perinatal period administration of clomiphene citrate in sexual behavior, organ weights and hormone concentration of Wistar male and female rats / Efeito da administração do citrato de clomifeno durante o período perinatal no comportamento sexual, peso dos órgãos e concentração hormonal de ratos Wistar machos e fêmeas

The effects of prenatal exposure to clomiphene citrate in sexual behavior, organ weight and hormone concentrations of male and female rats was evaluated. The animals received four doses of clomiphene citrate 2 mg/mL each during the prenatal period (21 days of gestation DG21) on days 1 (DN1), 2 (DN2) and 3 (DN3) after the birth of the puppies. The treatment led to the development of polycystic ovaries in 70% of the females, masculinization of female sexual behavior and changes in sexual behavior of males evidenced by the reduction in the number of ejaculations. In regards to hormone levels, a decrease in the FSH levels in male offspring was observed. It was concluded that clomiphene citrate interferes with the reproductive capacity of male and female rats and female sexual orientation when prenatally administered.

Foram investigados os efeitos da exposição perinatal ao citrato de clomifeno no comportamento sexual, peso dos órgãos e concentração hormonal de ratos machos e fêmeas. Os animais receberam quatro doses de 2 mg/mL de citrato de clomifeno, no período perinatal (21 dias de gestação DG21), nos dias 1 (DN1), 2 (DN2) e 3 (DN3) após o nascimento dos filhotes. O tratamento causou desenvolvimento de ovário policístico em 70% das fêmeas, masculinização do comportamento sexual das fêmeas e alteração do comportamento sexual dos machos evidenciado pela redução no número de ejaculações. Em relação aos níveis hormonais, observou-se diminuição de FSH na prole masculina. Concluiu-se que o citrato de clomifeno interfere na capacidade reprodutiva de ratos machos e fêmeas, e na orientação sexual de fêmeas, quando administrado perinatalmente.

Minimal Stimulation Using Gonadotropin Combined with Clomiphene Citrate or Letrozole for Intrauterine Insemination

PURPOSE: To evaluate the efficacy of minimal stimulation using discretely administered gonadotropin combined with clomiphene citrate (CC) or letrozole (LTZ) for intrauterine insemination (IUI) cycles. MATERIALS AND METHODS: Total 257 IUI cycles from 158 infertile couples were assessed. A CC dose of 100 mg/day (n=126 cycles) or a LTZ dose of 5 mg/day (n=131 cycles) was administered on days 3-5 of the menstrual cycle for 5 days. Each group received human menopausal gonadotropin at a dose of 150 IU by two or three alternative day: CC combined with alternate-day regimen for 2 or 3 days (CC+300, n=37; CC+450, n=89) and LTZ combined with alternate-day regimen for 2 or 3 days (LTZ+300, n=36; LTZ+450, n=95). RESULTS: The clinical pregnancy rate was comparable between the CC and LTZ groups (18.3% vs. 13.0%, p=0.243). The clinical pregnancy rate also showed no significant difference among the 4 groups (21.6% vs. 16.9% vs. 11.1% vs. 12.6%, p=0.507). The multiple pregnancy rate was significantly higher in LTZ compared to CC group (37.5% vs. 8.7%, p=0.028) and in the LTZ+450 compared to CC+450 group (50% vs. 13.3%, p=0.038). Overall, there were 15 cases of ovarian hyperstimulation syndrome (OHSS), with the prevalence being significantly lower in the LTZ compared to CC group (1.5% vs. 10.3%, p=0.003). OHSS was more prevalent in the CC+450 compared to the LTZ+450 group (12.4% vs. 1.1%, p=0.002). CONCLUSION: Our findings suggest that minimal stimulation using two alternate-day gonadotropin with LTZ decreases the development of OHSS and multiple pregnancies, while maintaining comparable pregnancy rates in IUI cycles.

Minimal Stimulation Using Gonadotropin Combined with Clomiphene Citrate or Letrozole for Intrauterine Insemination

PURPOSE: To evaluate the efficacy of minimal stimulation using discretely administered gonadotropin combined with clomiphene citrate (CC) or letrozole (LTZ) for intrauterine insemination (IUI) cycles. MATERIALS AND METHODS: Total 257 IUI cycles from 158 infertile couples were assessed. A CC dose of 100 mg/day (n=126 cycles) or a LTZ dose of 5 mg/day (n=131 cycles) was administered on days 3-5 of the menstrual cycle for 5 days. Each group received human menopausal gonadotropin at a dose of 150 IU by two or three alternative day: CC combined with alternate-day regimen for 2 or 3 days (CC+300, n=37; CC+450, n=89) and LTZ combined with alternate-day regimen for 2 or 3 days (LTZ+300, n=36; LTZ+450, n=95). RESULTS: The clinical pregnancy rate was comparable between the CC and LTZ groups (18.3% vs. 13.0%, p=0.243). The clinical pregnancy rate also showed no significant difference among the 4 groups (21.6% vs. 16.9% vs. 11.1% vs. 12.6%, p=0.507). The multiple pregnancy rate was significantly higher in LTZ compared to CC group (37.5% vs. 8.7%, p=0.028) and in the LTZ+450 compared to CC+450 group (50% vs. 13.3%, p=0.038). Overall, there were 15 cases of ovarian hyperstimulation syndrome (OHSS), with the prevalence being significantly lower in the LTZ compared to CC group (1.5% vs. 10.3%, p=0.003). OHSS was more prevalent in the CC+450 compared to the LTZ+450 group (12.4% vs. 1.1%, p=0.002). CONCLUSION: Our findings suggest that minimal stimulation using two alternate-day gonadotropin with LTZ decreases the development of OHSS and multiple pregnancies, while maintaining comparable pregnancy rates in IUI cycles.

Twenty-five milligrams of clomiphene citrate presents positive effect on treatment of male testosterone deficiency - a prospective study

INTRODUCTION: Male testosterone deficiency is associated with bad sexual function and quality of life (QoL). The aim of this study was to determine whether a daily dose of 25 mg clomiphene citrate (CC) is effective in stimulating the endogenous testosterone production pathway and to address the applicability of this medication as a therapeutic option for symptomatic hypogonadism. MATERIALS AND METHODS: This was a prospective study. Men with low sexual desire and testosterone levels (T) below 400 ng/dL were selected to receive CC. Blood samples were obtained to determine baseline measurements of serum T, estradiol, LH, lipid profile and fasting plasma glucose. Each patient was treated with a daily dose of 25 mg CC for at least 3 months. Patients were asked if they experienced any side effects related to the use of CC and if they experienced any improvement in their sexual profile. Paired samples T-test was utilized to analyze responses to therapy. RESULTS: Our cohort consisted of 125 men with hypogonadism and low libido. Mean age was 62 years (± 11.1 years). Serum T levels ranged from 309 ng/dL (baseline, mean value) to 642 ng/dL (3 months after CC initiation, mean value) (p < 0.001). Serum cholesterol levels ranged from 197 to 186 mg/dL (p = 0.003). There were no statistically significant differences when comparing pre and post-treatment HDL-Cholesterol, triglycerides, fasting plasma glucose and prolactin. All men reported improvements in the post-treatment QoL scores. No serious adverse events were recorded. CONCLUSIONS: The CC was effective in stimulating the endogenous production of testosterone. A lower level of total cholesterol was verified after three months of treatment. This medication should be considered as a therapeutic option for some patients with symptomatic male testosterone deficiency.

Moduladores seletivos do receptor estrogênico: novas moléculas e aplicações práticas / Selective estrogen receptor modulators: new molecules and practical uses

Os moduladores seletivos do receptor de estrogênio são moléculas que se ligam ao receptor estrogênico com ações agonistas e antagonistas, em tecidos específicos. Eles apresentam efeitos estrogênicos e antiestrogênicos em vários órgãos, o que lhes permite diferentes atuações clínicas específicas. As diferenças nas estruturas moleculares conferem propriedades diferentes de ligação ao receptor-alvo, resultando em diferenças nos efeitos terapêuticos e adversos. Desde a descoberta dos primeiros compostos, há 50 anos, vários outros têm sido estudados e são usados frequentemente por ginecologistas, oncologistas e mastologistas. O raloxifeno é aprovado para a prevenção e o tratamento de osteoporose na pós-menopausa e para o câncer de mama receptor de estrogênio positivo; o tamoxifeno, para prevenção e tratamento do câncer de mama receptor de estrogênio positivo na pós-menopausa; e o clomifeno, primeiro modulador seletivo com receptor de estrogênio a ser estudado e empregado clinicamente, para infertilidade. Outras moléculas como bazedoxifeno, lasofoxifeno e arzoxifeno vêm sendo estudadas e vêm se mostrando como alternativas eficazes, algumas com menos efeitos colaterais

Selective estrogen receptor modulators are molecules that bind to estrogen receptor with agonistic and antagonistic actions in specific tissues. They exert estrogenic and anti-estrogenic effects in several organs, allowing them to perform differently in specific clinical situations. The differences in molecular structures provide different binding properties to the target receptor, resulting in differences in therapeutic and adverse effects. Since the discovery of the first compounds 50 years ago, several others have been studied and are often used by gynecologists and oncologists, and mastologists. Raloxifene is approved for preventing and treating osteoporosis in postmenopausal women and for treating estrogen receptor-positive breast cancer; tamoxifen is used for preventing and treating estrogen receptor-positive postmenopausal breast cancer; and clomiphene, the first selective estrogen receptor modulator to be studied and clinically employed, is used for infertility treatment. Other molecules such as bazedoxifene, lasofoxifene and arzoxifene have been studied and shown to be effective alternatives, some with fewer side effects

The salivary ferning test and ovulation in clomiphene citrate-stimulated cycles.

OBJECTIVE: To determine the day of ovulation by the salivary ferning test in clomiphene citrate-treated women. DESIGN: A descriptive study. SETTING: Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. SUBJECT: Seventy-five infertile women with regular menstrual cycles. MATERIAL AND METHOD: Infertile women were given 100 mg of clomiphene citrate for five days and collected their saliva samples daily until seven days after ovulation. Transvaginal ultrasound was performed daily to detect ovulation. The salivary ferning formation was examined by a normal light microscope and graded from 1-3, according to its extent and intensity. MAIN OUTCOME MEASURE: The salivary ferning score, the peak salivary ferning day, and the day of ovulation detected by ultrasound. RESULTS: The patients' age and cycle length (mean +/- SD) were 32.9 +/- 3.7 years and 28.4 +/- 1.3 days. The peak salivary ferning day corresponded with the ultrasound ovulation day in only 7.1%. There were two peaks of median salivary ferning scores; one was two days prior ovulation and the other was five days post ovulation. There was no correlation between the peak salivary ferning day and day of ovulation detected by ultrasound (r = 0.102, p > 0.05). CONCLUSION: In clomiphene citrate-stimulated cycles, the saliva ferning test does not seem to associate with ovulation.

Effect of clomiphene citrate on sperm density in male partners of infertile couples.

Infertility is on the rise in today's world. A subnormal sperm count is frequently encountered in infertile couples. Clomiphene citrate, 1-[p-(beta-diethyl aminoethoxy) phenyl]-1,2-diphenyl chloroethylene, is an orally active nonsteroidal agent distantly related to diethylstilbestrol. It is thought to stimulate pituitary gonadotropin release by excluding estradiol from hypothalamic receptor sites. This interaction neutralizes the normal negative feedback control of estrogen and results in enhanced secretion of LH-RH, FSH-RH and gonadotropins. Testosterone is produced by the Leydig cells in response to LH secretion. The concentration of testosterone in the tubular environment is believed to maintain the gametogenic function of the testis. Clomiphene citrate in the dose of 25 mg daily for 25 days with five days rest was administered to 25 extreme oligozoospermic men (group I) and 40 moderate oligozoospermic men (group II) the cycle being continued for three months). Repeat semen analysis was done at the end of three months and all the routine seminal parameters were reevaluated. The data thus obtained was analyzed using Student's paired 't' test. The mean sperm count in Group I increased from 3.84 +/- 0.32 to 8.2 +/- 1.58 (P < 0.05) and in Group II from 13.05 +/- 0.48 to 24.55 +/- 1.73 (P < 0.001). The mean motile sperm count in Group I increased from 1.74 +/- 0.25 to 3.92 +/- 0.83 (P < 0.05) and in Group II from 8.27 +/- 0.40 to 10.05 +/- 0.56 (P < 0.01). Thus clomiphene citrate exerts its effect on spermatogenesis by raising the endogenous serum FSH, LH and testosterone levels to initiate and maintain gametogenesis (10). Researchers opined that this increase in endogenous gonadotrophins manifests itself in improving the sperm count, sperm motility and to certain extent morphology of the sperms, when there is no end-organ pathology.

Metformina en el tratamiento de la anovulación asociada a insulino-resistencia / Use of metformin on anovulation associated insulin-resistance

Se presentan 18 casos de pacientes infértiles anovulatorias en que se efectuó el diagnóstico de insulino resistencia y fueron tratadas con metformina. Once pacientes se embarazaron, 7 con metformina y 4 al asociar citrato de clomifeno. Seis pacientes tuvieron parto de término, 2 presentaron aborto de primer trimestre y 3 embarazos están en curso. De los 6 embarazos de término, 2 presentaron diabetes gestacional. Se revisa la literatura y se discute la conveniencia de mantener el tratamiento con metformina durante el embarazo para prevenir diabetes gestacional.

Terapia con metformina y embarazo en pacientes con síndrome de ovario poliquístico / Metformin therapy for polycystic ovary syndrome during pregnancy

Estudio prospectivo de seguimiento de 15 pacientes con síndrome de ovario poliquístico (SOP) e hiperinsulinemia que se embarazaron con el uso de metformina, y que se siguieron hasta el parto. Diez continuaron metformina durante el embarazo, hasta las 14 semanas y cinco hasta las 32 semanas. Las 5 pacientes que usaron más tiempo el medicamento no desarrollaron diabetes gestacional a diferencia de las que lo tomaron hasta las 14 semanas que presentaron diabetes gestacional en tres de diez. No encontramos abortos en estas pacientes, y tampoco presentaron problemas con el medicamento. No hubo malformaciones en los recién nacidos.

Relationship between ovarian volume, BMI and follicular number and clomiphene response in polycystic ovary syndrome

Polycystic ovary syndrome [PCOS] is one of the most common causes of anovulation in women during reproduction years. In this syndrome the first choice for ovulation induction is clomiphene citrate. Approximately 15-25% of patients have been shown to be resistant to even high levels clomiphene and fail to ovulate. To assess the relationship between ovarian unresponsiveness to clomiphene and some clinical and paraclinical factors in PCOS, a prospective, randomized clinical trial was performed on patients referring to the Royan Institute between May 1998 to May 2000. Fifty three PCOS patients with at least 5 successive years of infertility and an age range of 25-35 years were randomly selected. All patients suffered from oligomenorrhea, hirsutism and in all patients baseline concentrations of FSH, LH, testosterone, FBS, fasting insulin, androstandione, 17-alpha-hydroxy progesterone and DHEAs were determined. In all patients the body mass index [BMI], ovarian volume and the number of follicles in each ovary were measured. After transvaginal sonography on 3rd day of menstrual cycle, the patients were treated with clomiphene citrate in 2 cycles. In the first cycle 100 mg/day clomiphene citrate was administered from day 5 to day 9 of the cyle and if no response, the second cycle included 150 mg/day clomiphene citrate and the rate of ovulation was studied. With respect to ovulation the patients were divided in 2 groups, group 1 with ovulation and group 2 without ovulation Usingt student test, the two groups were statistically compared. The ovarian volumes were 8.6 +/- 4.3ml [Mean +/- SD] and 8.74?3.7ml in groups 1 and 2, respectively. The BMI in the 2 groups were 28.0 +/- 3.8 and 29.72 +/- 4.36 [mean +/- SD], respectively. No siginficant difference were observed between the 2 groups in these cases. However, 72.4% of patients in group 1 and 45.8% in group 2 had <10 follicles in each ovary [p < 0.05]. There results suggest no correlation between ovarian volume or BMI and response to clomiphene. However, our findings are highly suggestive of a correlation between number of primary follicles in each ovary and responsiveness to clomiphene, and thus measurement of primary follicle number in ovaries may be a predictive factor for clomiphene responsiveness

A experiência de iniciar um programa de fertilizaçäo in vitro em Hospital Universitário / The experience of initiating an assisted reproduction program in a university hospital

OBJETIVO: Analisar as mudanças ocorridas durante os seis primeiros anos de funcionamento do programa de fertilizaçäo "in vitro" do Departamento de Tocoginecologia/CAISM/UNICAMP. TIPO DE ESTUDO: Estudo descritivo, retrospectivo, que avaliou as características dos casais participantes, as modificaçöes técnicas ocorridas e a evoluçäo dos resultados nesses seis anos. MÉTODOS: Analisaram-se os resultados obtidos em períodos durante os quais utilizaram-se técnicas semelhantes. RESULTADOS: A primeira gavidez obteve-se somente no terceiro ano do programa após aproximadamente 100 ciclos de tratamento. Houve uma melhora progressiva nos resultados do programa segundo todos os indicadores utilizados, culminando com 20 por cento de recém nascidos em casa por ciclo iniciado e 30 por cento por ciclo de transferência. CONCLUSöES: O processo de instalaçäo de um programa de FIV bem sucedido em hospital público de ensino é lento e difícil. A avaliaçäo contínua é indispensável para introduzir as mudanças que levem ao sucesso.

O emprego do citrato de clomifeno e gonadotrofina de mulher menopausada como alternativa de hiperestimulaçäo ovariana em pacientes com resposta idiopática inadequada na fertilizaçäo in vitro / Clomiphene citrate and gonadotropins of woman in menopause as an alternative approach to ovarian hyperstimulation in idiopatic poor response for in vitro fertilization

OBJETIVO: Avaliar os efeitos do esquema de estimulaçäo ovariana com citrato de clomifeno (CC)/gonadotrofina de mulher menopausada (hMG) nos resultados da fertilizaçäo in vitro e transferência de embriöes (FIVETE) em um grupo de pacientes que apresentaram resposta ovariana inadequada em ciclos prévios de FIVETE estimulados com um análogo do GnRH e gonadotrofinas (protocolo longo). MÉTODO: Os resultados de FIVETE em ciclos estimulados com CC/hMG e com o protocolo longo de uma mesma paciente foram comparados. Oito pacientes (grupo I) que apresentaram uma resposta ovariana idiopática inadequada (idade: < 38 anos, FSH<15 mU/mL, E2<60pg/mL, ciclos menstruais regulares e ausência de cirurgia ovariana) ao protocolo longo em 11 ciclos de FIVETE (grupo Ia), foram estimuladas com CC/hMG em 20 ciclos (grupo Ib). Administrou-se CC 100 mg/dia por 5 dias a partir do 3§ dia do ciclo e o hMG 150 UI/dia foi iniciado no 5§ dia, sendo a dose modificada de acordo com a resposta da paciente. Dezenove ciclos de 15 pacientes com resposta ovariana adequada ao protocolo longo, durante o mesmo intervalo de tempo, foram incluídas neste estudo como grupo controle (grupo II). Casais com fator masculino de infertilidade foram excluídos. RESULTADOS: As pacientes avaliadas näo apresentaram diferença em termos de idade, duraçäo da infertilidade e do índice de massa corpórea. Embora a duraçäo do estímulo ovariano tenha sido similar nos 3 grupos: 10,1 + 0,76, 10,9 + 0,34 e 10,3 + 0,21 dias para os grupos Ia, Ib e II, respectivamente, o número médio de ampolas de hMG utilizado no grupo Ib (13,6 + 1,36) foi significativamente menor (p<0.001) quando comparado aos grupos Ia e II (49,9 + 3,20, 43,7 + 2,73; respectivamente). A taxa de cancelamento foi de 36,4 por cento, 25,0 por cento e 0 por cento (grupos Ia, Ib e II; respectivamente), näo revelando diferença entre os grupos Ia e Ib. Os números médios de oócitos MII inseminados e fertilizados foram de 4,9 + 0,8 e 1,3 + 0,4 no grupo Ia e de 4,4 + 0,3 e 2,1 + 0,2 no grupo Ib, näo mostrando diferença entre os grupos. Contudo, os números médios de oócitos MII inseminados e fertilizados no grupo II, 11,4 + 2,0 (p<0.01) e 7,9 + 2,0 (p=0.01), respectivamente, foram significativamente maiores quando comparados aqueles do grupos Ia e Ib...

Esquemas de induçäo da ovulaçäo para inseminaçäo intra-uterina / Ovulation induction in intrauterine insemination

RETROSPECTIVA: A inseminaçao intra-uterina (IIU) é um dos procedimentos de fertilizaçao assistida mais comumente empregados para o tratamento do casal infértil. A induçao da ovulaçao para posterior IIU possibilita melhores taxas de gestaçao, quando comparadas ao ciclo espontâneo. OBJETIVOS: Avaliar três esquemas de induçao de ovulaçao para posterior IIU, observando as vantagens e desvantagens entre os mesmos. CASUISTICA E METODOLOGIA: Um total de 63 casais foram submetidos a 92 ciclos de induçao da ovulaçao e posterior IIU, com diversas etiologias de infertilidade, sendo que as drogas utilizadas foram o citrato de clomifeno, HMG na dosagem de 37,5 UI/dia e HMG na dose de 75 UI/dia. Monitorou-se o ciclo através da avaliaçao da espessura endometrial e desenvolvimento folicular, por meio de ultra-sonografia, e do estradiol sérico. Quando o folículo atingia l7mm administrava-se HCG, na dose de 5000 UI. Após 40 a 42 horas realizava-se a IIU, após capacitaçao espermática por meio do gradiente descontínuo de Percoll. RESULTADOS:Os resultados mostraram taxa de cancelamento e resposta endometrial similar entre os três grupos, enquanto que a resposta folicular foi mais expressiva nos grupos usuários de citrato de clomifeno e HMG na dose de 75 UI/dia. A droga que apresentou menor custo por ciclo foi o citrato de clomifeno, enquanto que a utilizaçao de HMG 75 UI/dia foi a de mais alto custo, compensado pelo fato da taxa de gravidez ser mais elevada. CONCLUSOES: As drogas e dosagens utilizadas apresentaram resposta ovulatória, endometrial e taxa de gestaçao satisfatórias, com vantagens para o citrato de clomifeno em termos de custo e para o HMG na dosagem de 75 UI/dia em termos de desenvolvimento folicular e taxa de gestaçao, com as doses menores nao apresentando custo-benefício satisfatório.

Inductores de la ovulación, su estado actual y experiencia institucional / Ovulation inductors, present state and instutional experience

Antecedentes. La anovulación o esterilidad por factor endócrino ovárico representa del 20 al 30 por ciento de todas las parejas estériles y aunque en la actualidad existen diversos fármacos capaces de inducir ovulación , siguen siendo el citrato de clomifeno y las gonadotropinas menopáusicas humanas los medicamentos de primera línea para el tratamiento de la esterilidad por factor anovulatorio, como hace 30 años que se inició su uso. Objetivo. En el presente trabajo se analiza el marco teórico para la selección de las pacientes candidatas a uno u otro medicamento, así como los esquemas terapéuticos utilizados, efectos secundarios y resultados tanto de ovulación como de embarazos. Método. Se compararon los resultados promedio de la literatura, con la experiencia institucional de los autores. Resultados. Con el citrato de clomifeno en casos bien seleccionados se obtiene ovulación en aproximadamente 80 por ciento de los casos y embarazo en el 40-50 por ciento; en el INPer se obtuvo en un análisis de 200 casos ovulación en el 72 por ciento y embarazo en el 58 por ciento. Con las gonadotropinas menopáusicas humanas los resultados son mas variables encontrando un promedio en la literatura de ovulación del 70 al 90 por ciento y de embarazo del 25 al 55 por ciento. En el INPer de 128 ciclos de tratamiento se obtuvo ovulación el 75.7 por ciento y embarazo en el 36 por ciento de un grupo de 100 mujeres anovulatorias tratadas

Serun insulin in clomiphene responders and nonresponders with polycystic ovarian disease

Objetivo. Investigar las concentraciones plasmáticas de insulina de mujeres con síndrome de ovario poliquístico (SOP) respondedoras y no respondedoras citrato de clomifeno (CC). Diseño. Estudio abierto y prospectivo. Sitio. Consulta externa de una clínica de esterilidad en una institución médica de tercer nivel. Pacientes. Diez mujeres sanas (grupo 1) y 35 pacientes con SOP clasificadas como respondedoras. (grupo 2 n = 10) o no respondedoras (grupo 3 n = 25) con base en progesterona sérica ò 19 nmol/L en respuesta a la administración repetida de CC en dosis de hasta 250 mg/día por cinco días. Las mujeres fueron subsecuentemente divididas si su índice de masa corporal (IMC) fue menor (N) o mayor (A) a media + 3 desviaciones estándar del grupo. Intervenciones: se obtuvieron muestras de sangre durante una curva de tolerancia oral a 100 g de glucosa (CTOG) tanto en ayuno como cada 30 minutos por 2 horas. Métodos. De cada muestra de sangre se obtuvo suero y en él se midieron glucosa, insulina, testosterona libre (TL), sulfato de dehidroepiandrosterona (DHEA-S) y androstenediona (A). Se calculó el área bajo la curva (ABC) de estas sustancias. Resultados. El grupo 3 tuvo mayor IMC, LH, insulina basal y ABC de insulina que los grupos 1 y 2; la TL fue más alta en los grupos 2 y 3 que en el 1, y la PRL fue mayor en el grupò 2 que en los grupos 1 y 3. Cuando se investigó un IMC ó 25.4 kg/m² (promedio + 1 desviación estándar del grupo 1) 77 por ciento de mujeres con SOP respondieron al CC (10 de 13); con IMC > a 25.4 km/m², ninguna de ellas respondió (n = 22), independientemente del nivel de insulina basal o en ABC. Conclusiones. Se sugiere que el sobrepeso, moderado o excesivo, está más frecuentemente asociado a una respuesta negativa al CC en mujeres con SOP que la hiperinsulinemia