Ste&ovu&ind&2 ND

Step by Step®
OVULATION
INDUCTION
Step by Step®
OVULATION
INDUCTION
Second Edition
Editor
Surveen Ghumman
MD FICOG FICMCH
Senior Consultant
IVF and Reproductive Medicine Unit
Max Super Specialty Hospitals
Panchsheel and Saket, New Delhi, India
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Step by Step® Ovulation Induction
First Edition: 2006

Second Edition: 2014
ISBN 978-93-5152-087-0
Printed at
Dedicated to
Sandeep
Whose support and encouragement has been pivotal in enabling
me to accomplish every venture of mine
Contributors
Abha Majumdar MD Neerja Goel MD

Consultant and Head Professor
Center of IVF and Human Department of
Reproduction Obstetrics and Gynecology
Sir Ganga Ram Hospital University College of Medical
New Delhi, India Sciences and Guru Teg Bahadur
Hospital
New Delhi, India
Deepak Chawla MD
Consultant and Head
Department of Ultrasound Reeti Sahani MD (Radiology)
Sir Ganga Ram Hospital Senior Consultant
New Delhi, India Radiology and Imaging Sciences
Indraprastha Apollo Hospital
New Delhi, India
Lalita Badhwar MD
Senior Consultant
Ritika Kaur MD
Department of
Resident
Obstetrics and Gynecology Department of
Indraprastha Apollo Hospitals Obstetrics and Gynecology
New Delhi, India Maharishi Markandeshwar
Institute of Medical Sciences
Monika Gupta and Research
MD DNB MNAMS MICOG Ambala, Haryana, India
Assistant Professor
Department of Shashi Prateek
Obstetrics and Gynecology MD FICOG FICMCH
Hamdard Institute of Professor and Head
Medical Sciences and Department of
Research Obstetrics and Gynecology
HAHC Hospital Subharti Medical College
New Delhi, India Meerut, Uttar Pradesh, India
viii Step by Step Ovulation Induction
Shweta Mittal Surveen Ghumman

MD FNB (Reproductive Medicine) MD FICOG FICMCH
Consultant Senior Consultant
Center of IVF and IVF and Reproductive
Human Reproduction Medicine Unit
Sir Ganga Ram Hospital Max Super Specialty Hospitals
New Delhi, India Panchsheel and Saket
New Delhi, India
Preface to the Second Edition
In the recent years, the subject of infertility has changed

completely as far as protocols and management are
concerned. The rapidly progressive research and innovations
in this field are difficult to keep up with. Like the First Edition,
the Second Edition of this book attempts to roadmap these
latest therapies defining their current relevance to treatment
in a stepwise form. Not only is it practical but also touches
and introduces the readers to the latest research done in the
field in a manner that it can be translated into application in
their day-to-day practice. All chapters have flow charts and
tables to make reading simplified.
Five new chapters have been added which include,
Premature Luteinization, Ovarian Stimulation for the Poor
Responder, Hypogonadotropic Hypogonadism and Ovulation
Induction, Role of Androgens in Ovulation Induction, and
Mild Ovarian Stimulation. Androgens are a recent addition to
ovulation induction. Mild ovarian stimulation are now being
used extensively where cost is a major deterrent. Premature
luteinization has been discussed extensively as it has an
important role in any stimulation protocol and is often ill-
understood.
The older chapters have been updated with recent
information in a manner that it can be easily applied in day-
to-day practice.
In this age of information overload, this book is an
attempt to integrate information into a practical management
protocol that is rational, logical and rewarding to the reader.
This book attempts to bring forth practical information with
recent advances in ovulation induction and attempts to solve
x Step by Step Ovulation Induction
dilemmas in management of infertile couples bringing the

reader closer to the desired goal—a successful pregnancy in
these patients.
I hope, it is helpful to those who read it and can be applied
in day-to-day practice, which is the purpose with which this
book was written.
Surveen Ghumman
Preface to the First Edition
In the recent years, there has been a revolution in the field

of ovulation induction as new concepts and therapies are
coming up into picture each year with the explosive amount
of research being done in this field. This has left many
practicing infertility specialists puzzled over the options and
their indication. This book attempts to roadmap these latest
therapies, defining their current relevance to treatment, in a
simplified, easy-to-follow protocol for the practicing infertility
specialists. At the same time, besides giving practical tips, it
also touches on the latest research work done in the field. Most
chapters are accompanied by flow charts for managements
providing guidance in a step-by-step manner.
Over the last many years, my interest in infertility
deepened to the extent of organizing my research and clinical
work around this subject. This book is a summary of the
clinical and research work done in ovulation induction by
me over the years.
An attempt has been made to touch every aspect related
to the subject in such a manner that would be understood by
all. The chapters on clomiphene, resistance to clomiphene,
gonadotropins and GnRH analogs solve the practical
dilemmas many practicing clinicians are faced with. Problems
of hyperprolactinemia, endometrial receptivity, luteal phase
defect and fertility in older women are encountered frequently
when treating an infertile patient. These have been dealt with
extensively in separate chapters. The chapter on polycystic
ovarian syndrome highlights recent advances especially with
insulin sensitizers.
Besides medical therapy, it also details on the technique
of laparoscopic ovarian drilling as a surgical treatment for
xii Step by Step Ovulation Induction
ovulation induction. This is becoming an important option

with the increase in usage of laparoscopic surgery.
Multifetal pregnancy reduction technique has been
discussed keeping in view the fact that it is an option for
which the treating infertility clinician often has to counsel.
The chapter on ultrasound gives an extensive review of the
role of color Doppler in cycle assessment during ovulation
induction—a must-know subject for the practicing infertility
professionals.
The book attempts to cover all aspects of ovulation
induction, current stimulation protocols, their indication in
clinical situations and their complications. It is a guide to
problem solving needed while handling such patients. This
subject is changing explosively with newer recombinant
gonadotropins and long-acting preparations being introduced.
I hope this book will solve the dilemmas of many and you
may enjoy reading it as much as I did while writing it.
Surveen Ghumman
Acknowledgments
I thank all the contributors, for their well-researched chapters

and for sparing their invaluable time and intellectual skills.
I have thoroughly enjoyed interacting with all the authors
during this academic venture.
I would also like to acknowledge the invaluable
contribution of Dr Neerja Goel, my teacher and guide.
She has been instrumental in guiding and encouraging me
through all my academic exercises.
The unstinting support, help and encouragement that I
received from my husband went a long way in bringing this
book together and making this dream a reality. I would also
like to thank my parents and my daughters for all the help
they gave.
Although this book has my name on it, but it is the
combined effort of all those who have given it the face it has.
Contents
1. Anovulation and Tests for Ovulation 1

Surveen Ghumman, Ritika Kaur
• Tests for Ovulation 4
2. Oral Ovulogens 14
Surveen Ghumman
• Clomiphene 14
• Tamoxifen 24
• Letrozole 25
3. Clomiphene Resistance—What Next? 31

Surveen Ghumman
• Management of Clomiphene
Failure or Resistance 32
4. Gonadotropins 50
Surveen Ghumman
• Follicle Stimulating Hormone 51
• Recombinant LH 65
• Human Chorionic Gonadotropin 66
5. Role of GnRH Agonists and Antagonists in

Assisted Reproductive Technology 71
Surveen Ghumman
• GnRH Agonist (GnRHa) 71
• GnRH Antagonists 80
• Gonadotropin-releasing Hormone 86
6. Mild Ovarian Stimulation 92

Surveen Ghumman
• Role of GnRH Antagonist in
Mild Stimulation 93
xvi Step by Step Ovulation Induction
• Clomiphene, Gonadotropins and

GnRH Antagonist 94
• Mild vs Conventional Protocols 94
7. Premature Luteinization 106

Surveen Ghumman, Monika Gupta
• Diagnosis 106
• Incidence 107
• Causes 107
• Effect on Reproductive Outcomes 108
• Prevention 109
8. Polycystic Ovarian Syndrome and

Insulin Sensitizers 114
Surveen Ghumman
• Diagnosis 114
• Insulin Resistance 115
• Clinical Presentation 118
• Treatment 119
• Treatment in those who do not
Desire Pregnancy 133
9. Surgical Ovulation Induction 141

Lalita Badhwar, Surveen Ghumman
• Mechanism of Action 142
• Indications 142
• Techniques 142
10. Hypogonadotropic Hypogonadism and

Ovulation Induction 155
Surveen Ghumman
• Causes 155
• Clinical Presentation 157
• Diagnosis 157
• Treatment 158
Contents xvii
11. Hyperprolactinemia 170
• Prolactin and Ovarian Function 171
• Incidence 171
• Etiology 171
• Clinical Features of Hyperprolactinemia 173
• Diagnostic Evaluation 175
• Treatment of Hyperprolactinemia 177
12. Role of Androgens in Ovulation Induction 188

Shashi Prateek, Surveen Ghumman
• Impact of Androgens on
Reproductive Outcome 189
13. Ovarian Reserve and Fertility in

Older Women 200
Neerja Goel, Surveen Ghumman
• Age and Fertility 201
• Management of Older Women with a
Fertility Problem 202
• Treatment of Patients with
Reduced Ovarian Reserve 210
14. Ovarian Stimulation for the

Poor Responder 215
Surveen Ghumman
• Prediction 216
• Treatment 216
15. Endometrial Receptivity—A Vital Role 231

Surveen Ghumman
• Histological Changes 235
• Biochemical and Molecular Changes 235
• Endometrial Vascular Changes 241
• Role of Chronic Endometritis in
Endometrial Receptivity 241
xviii Step by Step Ovulation Induction
• Current Strategies to Assess Endometrial

Receptivity 245
• Treatment of Poor Uterine Receptivity 249
• Endometrial Preparation for
Frozen Embryo Transfer 253
16. Luteal Phase Defect 260

Surveen Ghumman, Neerja Goel
• Pathophysiologic Mechanism 260
• Diagnosis of Luteal Phase Inadequacy 262
• Treatment of Luteal Phase Defect 264
17. Complications of Ovulation Induction 276

Surveen Ghumman
• Ovarian Hyperstimulation Syndrome 277
• Management of OHSS 282
• Multiple Pregnancy 293
• Ovarian Cancer and Ovulation Induction 294
18. Selective Multifetal Pregnancy Reduction 299

Shweta Mittal, Deepak Chawla, Abha Majumdar
• Methods of Multifetal Pregnancy Reduction 300
19. Ultrasonography and Color Doppler

Imaging in Ovulation Induction 309
Reeti Sahani
• Examination Technique 309
• Color Doppler Imaging (CDI) 312
Index 331
cHAPTER
1
Anovulation and
Tests for Ovulation
Disorders of ovulation account for approximately 30–40%

of the problems identified in infertile women. They may
present with oligomenorrhea or amenorrhea. Classification of
ovulatory problems was done by WHO into 3 groups:
• Group I Hypothalamic pituitary failure (Hypo
gonadotropic hypogonadism).
• Group II Hypothalamic pituitary dysfunction
(Normogonadotropic, e.g. PCOD).
• Group III Ovarian failure (Hypergonadotropic
hypogonadism).
Usually treatment is simple and effective. However, not all
cases of anovulation are amenable to treatment by ovulation
induction.1 It is the cause of anovulation that will determine
whether ovulation induction is possible (Tables 1.1 and 1.2).
Before taking up a patient for ovulation induction
a complete investigation for confirmation and cause of
Ch-01.indd 1 18-01-2014 12:01:54

2 Step by Step Ovulation Induction
Table 1.1: Causes of anovulation suitable for ovulation

induction treatment1
Hypothalamic
Low concentration of gonadotropin-releasing hormone (hypogonadism)
Weight or exercise related amenorrhea
Kallmann syndrome
Stress
Idiopathic
Pituitary
Hyperprolactinemia
Pituitary failure (hypogonadotropic hypogonadism)
Sheehan’s syndrome
Craniopharyngioma or hypophysectomy
Cerebral radiotherapy
Ovarian
Polycystic ovaries
Other endocrine
Hypothyroidism
Congenital adrenal hyperplasia
Table 1.2: Causes of anovulation not suitable for ovulation induction

treatment1
Ovarian failure
Idiopathic
Radiotherapy or chemotherapy
Surgical removal
Genetic
Autoimmune
Chromosomal
Turner’s syndrome (45,X)
Ch-01.indd 2 18-01-2014 12:01:55

Anovulation and Tests for Ovulation 3
anovulation should be carried out (Table 1.3). This is
necessary to determine which ovulation inducing drugs are
to be used, in how much dose and whether any adjuvants are
needed.
Table 1.3: Investigations for anovulation1

Investigation When done Interpretation
Progesterone Midluteal phase of >3 ng/ml—confirms ovulation
cycle (day 21 of 28 > 10 ng/ml—shows adequate
day) luteal phase
Follicle- Early follicular phase >10 IU/L indicates reduced
stimulating ovarian reserve
hormone > 40 IU/L indicates ovarian
failure
< 5 IU/L may indicate pituitary
or hypothalamic problem
Luteinizing Early follicular phase > 10 IU/L indicates polycystic
hormone ovaries
< 5 IU/L may indicate pituitary
or hypothalamic problem
Testosterone Any time in cycle >2.4 nmol/L indicates
polycystic ovaries
> 5 nmol/L suggests congenital
adrenal
hyperplasia; check DHEAS and
17-OHP
Prolactin Any time in cycle (but >100 ng/ml indicates pituitary
not after exercise or adenoma
stress) < 100 ng/ml—other causes of
hyperprolactinemia
Thyroid- Any time in cycle High thyroid stimulating
stimulating if woman has hormone indicates
hormone symptoms or signs of hypothyroidism
hypothyroidism or has
hyperprolactinemia
Contd...
Ch-01.indd 3 18-01-2014 12:01:55

Contd...
Investigation When done Interpretation
Transvaginal Day 2—baseline scan Identifies polycystic ovaries
ultrasound Day 9 onward— Ovulation documentation
scan follicular monitoring
MRI/CT of If two prolactin levels Identifies macroadenomas
pituitary >100 ng/ml
Karyotype Primary amenorrhea Identifies karyotypic
and premature abnormalities—for example,
menopause Turner’s syndrome (45, X)
translocations, and androgen
insensitivity syndrome (46, XY)
Body mass Oligomenorrhea or BMI > 30 suggests polycystic
index amenorrhea ovary syndrome BMI < 20
suggests hypogonadotropic
hypogonadism
Tests for Ovulation

Clinically ovulation is indicated by regular menstrual cycles,
midcycle pain and changes in cervical mucus. There are
many methods of confirming ovulation. They are all based on
the effects of hormonal events taking place in the body during
ovulation. These tests are also used to assess the effectiveness
of any ovulation induction treatment.
Basal Body Temperature (BBT)

It is body temperature under basal conditions at rest. For
practical purposes BBT is measured each morning before
arising from bed with an oral glass thermometer, having an
expanded scale, typically ranging from 96ºF to 100ºF and
marked in tenths of a degree. Irregular sleep patterns and
smoking can interfere with tests results.
Ch-01.indd 4 18-01-2014 12:01:55

BBT recordings are based on the thermogenic properties of
progesterone. As levels rise after ovulation, BBT also increases.
BBT varies between 97ºF and 98ºF during the follicular
phase of the cycle. The thermogenic shift in BBT occurs
when progesterone concentrations rise above approximately
5 ng/ml, 1 to 5 days after LH surge and up to 4 days after ovulation.2
The temperature rise is usually abrupt but may be gradual
and difficult to define. BBT generally falls to its lowest level
on the day before ovulation, but the nadir in BBT cannot
be reliably identified until after the temperature rises and
remains elevated.3 It then increases by 0.4 – 0.8° over the
average preovulatory temperature during the luteal phase
and falls again to baseline levels just before or after the onset
of menses. A biphasic pattern usually is readily evident. A
normal luteal phase documents temperature elevation for 11
days at least. Menses begin 12 days or more after the rise
in temperature. In pregnancy BBT remains elevated because
of the sustained production of progesterone by the corpus
luteum stimulated by human chorionic gonadotropin.
Advantages
1. Relatively low cost.
2. BBT recordings can also reveal an abnormally long
follicular phase or short luteal phase.
Disadvantages
1. Increases stress.
2. Women may menstruate regularly and predictably but do
not exhibit a clearly biphasic BBT pattern.
3. The most fertile period passes once the rise in temperature
is seen. BBT tracings are useful when recordings are
viewed in retrospect to show ovulatory pathology.
Ch-01.indd 5 18-01-2014 12:01:55

Luteal Serum Progesterone Levels

Progesterone levels generally remain below 1 ng/ml during
the follicular phase, rise slightly on the day of the LH surge
(1–2 ng/ml) and steadily thereafter, peak 7 to 8 days after
ovulation, and then decline over the days preceding menses.
Any level greater than 3 ng/ml provides reliable objective
evidence that ovulation has occurred.4 It is usually performed
in the midluteal phase around day 21 of menstrual cycle.
Serum progesterone levels have also been used to
measure the adequacy of luteal function. Accurate judgment
requires daily serum progesterone determination because the
corpus luteum progesterone secretion is pulsatile in nature,
closely correlating with distinct pulses in pituitary LH release.
Levels ranging from as low as 2 ng/ml to as high as 40 ng/
ml can be observed, within brief intervals of time.5 However,
daily estimations are both costly and impractical. Sampling
during the morning hours when progesterone concentrations
are generally high and less erratic may be helpful.6 A sum
of 3 measurements obtained between the 5th and 9th day
after ovulation totaling 30 ng/ml or more have also been
recommended.7 A single measurement greater than 10 ng/
ml at day 21 of menstrual cycle is often used. However,
random serum progesterone concentrations defy confident
interpretation of adequacy of luteal phase and have little
value beyond documenting ovulation.
Advantages
1. Simple
2. Reliable
3. Minimally invasive
4. Widely available
5. Assesses adequacy of luteal phase also.
Ch-01.indd 6 18-01-2014 12:01:55

Disadvantages
1. False-negative or-positive due to fluctuating levels.
2. Multiple samples required for accuracy.
Midcycle LH Surge
It is a relatively brief event, typically lasting for 48 and 50
hours. LH has a short half-life and is rapidly cleared via the
urine. Ovulation predictor kits turn positive when the urinary
LH concentration exceeds a threshold level normally seen
only during the LH surge. The threshold level for the Elisa
kit is 40 mIU/ml.
Methods
LH surge can be detected by the following methods:
1. ELISA: It is the commonly used method.
2. RIA: It is very accurate.
3. Slide test.
Principle of ELISA Test

It contains 2 antibodies one directed against a subunit which
is attached to enzyme alkaline phosphates and the other
against the b subunit which is attached to test pad. When
LH is present in urine, a sandwich is formed and the enzyme
is available to convert a noncolored substance to chromo
gen (blue). The color intensity produced is proportional to the
concentration of LH in the urine sample.
Time of test: The first morning void would be an ideal speci
men to test because it is typically the most concentrated.
However, results correlate best with the serum LH peak when
testing is performed in the late afternoon or early evening
hours (4.00 to 10.00 pm), probably because LH surges often
Ch-01.indd 7 18-01-2014 12:01:55

begin in the early morning hours and are not detected in

urine until several hours later.2 Twice daily testing decreases
the frequency of false-negative results.
Precautions:
1. Testing must be done on a daily basis as test is positive on
only a single day, occasionally on two consecutive days.
2. Patients should be advised to avoid drinking large volumes
of fluids a short time before they plan to test as results are
sensitive to the volume of fluid intake.
Interpretation: Ovulation generally follows within 14 to 26
hours after detection of the urine LH surge and almost always
within 48 hours.8 The period of greatest fertility includes the
day of LH surge detection and the following 2 days. The day
after the first positive test generally is the one best for timed
intercourse and artificial insemination.8,9
Accuracy of test: The accuracy of many ovulation predictor
kits available varies. The kits predict ovulation with greater
than 90% probability.9,10 The positive and negative predictive
values of these tests are 90% and 96%, respectively. If the
urine is checked twice a day sensitivity increases to 97–99%.
About 5–10% of women do not produce positive results either
because of failed recognition by the antibody used or because
their peak urinary LH concentration does not rise above the
threshold set by the kit manufacturers. True false-positive
tests are rare but equivocal results are not and can be both
confusing and frustrating. About 28.7% of patients undergoing
ultrasound-monitored IUI (intrauterine insemination) cycle
had a spontaneous LH surge before ovulation triggering
was scheduled. This could affect pregnancy rates following
IUI. Hence, LH surge may have a more important role than
ultrasound monitoring in timing IUI or coitus.11
Ch-01.indd 8 18-01-2014 12:01:55

False-positive: False-positive results may occur with intake of
these drugs.
1. Oral contraceptive pill
2. Danazol
3. Exogenous hCG
4. hMG
5. Clomiphene citrate.
Advantages
1. Noninvasive
2. Widely available
3. Not time consuming
4. Predict when ovulation will occur unlike other methods
which are analyzed in retrospect
5. Helps to define the length of the follicular and luteal phase
and to identify other cycle abnormalities.
Disadvantages
1. Tedious
2. False-negative results because of short duration of LH
surge.
3. Accuracy is affected by fluid intake.
Endometrial Biopsy
Endometrial biopsy is a test of ovulation based on the charac
teristic histological changes in the endometrium resulting
from the action of progesterone. During the follicular phase of
the menstrual cycle, the endometrium exhibits a proliferative
pattern, reflecting the growth stimulated by rising levels of
estrogen derived from the dominant ovarian follicle. During
the luteal phase, progesterone secreted by the corpus luteum
causes the secretory transformation of the endometrium.
Ch-01.indd 9 18-01-2014 12:01:55

Anovulatory women are always in the follicular phase and have

a proliferative endometrium which can become hyperplastic
with extended exposure to a constant estrogen growth
stimulus. The histologic features of the secretory endometrium
change, with the duration of progesterone exposure. The
experienced pathologists can “date” the endometrium,
providing a retrospective estimate of how many days have
passed since ovulation occurred. The observed date can then
be compared to the actual date of sampling. In recent years
it has been more accurately defined prospectively, by the
number of days elapsed since the detection of the LH surge
or ultrasound observation of follicular collapse. Histologic
and sampling dates that agree, within a 2-day interval, have
generally been considered normal. Dates more than 2 days
“out of phase” in two consecutive cycles is the standard
criterion for the diagnosis of luteal phase deficiency.12 The
best time for the biopsy is controversial. Some advocate the
premenstrual phase, when the endometrium might best reflect
the cumulative effects of corpus luteum function, while others
have argued that the midsecretory phase, coinciding with the
putative implantation window, is more relevant being able
to identify abnormalities of endometrial maturation which
may go undetected.13 A careful and systematic study has
revealed that normal variations in histologic characteristics
among individuals, between cycles in individuals and among
different observers are simply too great to reliably define a
specific luteal day or even a narrow interval of days.
To conclude the body of the available evidence supports
the conclusion that the traditional endometrial histologic
dating is not a valid diagnostic tool. Consequently, endo
metrial dating cannot be used to guide the clinical manage
ment of women with reproductive failure and should no lon
ger be regarded as an important element of their evaluation.
Ch-01.indd 10 18-01-2014 12:01:55

Advantages
1. Simple office procedure.
2. Few complications.
Disadvantages
1. Invasive.
2. Costly.
3. Not very accurate: Numerous studies and analyzes have
described significant intraobserver and interobserver
variations in histologic interpretation that are great enough
to affect diagnosis and management in 20 to 40% of indi
vidual women.14
Ultrasonography
Although not providing definite positive proof that ovulation
actually occurred, serial transvaginal ultrasound examinations
offer details about the size and number of preovulatory
follicles and provide the most accurate estimate of when
ovulation occurs (See Chapter 14).
In its final stages of development, the preovulatory follicle
grows at a predictable pace, approximately 2 mm per day
(range of 1–3 mm/day). After ovulation, the follicle abruptly
decreases in size, its margins become less distinct, the density
of internal echoes increases and fluid in cul-de-sac is seen
Table 1.4.15 Abnormal patterns of follicle development can
Table 1.4: Signs of ovulation on ultrasonography

1. Margins of follicle become indistinct
2. Increase in density of internal echoes in follicle
3. Irregularity of follicle
4. Abrupt decrease in size of follicle
5. Fluid in cul-de-sac
Ch-01.indd 11 18-01-2014 12:01:55

also be observed. The follicle may grow at an abnormal pace,

collapse when still relatively small (atresia), or continue to
grow or fail to rupture, persisting as a cyst for days after the
LH surge (luteinized unruptured follicle).16 3D ultrasound
monitoring is a new introduction and is more closer to
physiological monitoring.17
Each of the available tests is useful and no one test is
necessarily the best. Some are very simple, noninvasive, and
inexpensive, and others are more complicated, invasive and
costly. Pregnancy is the only sure positive proof of ovulation.
References
1. Fairley DH, Taylor A. Anovulation. Br Med J. 2003;327:546-9.
2. Luciano AA, Peluso J, Koch El, Maier D, Kuslis S, Davison
E. Temporal relationship reliability of the clinical, hormonal,
and ultrasonographic indices of ovulation in infertile women.
Obstet Gynecol. 1986;75:412-6.
3. Quagliarello J, Arny M. Inaccuracy of basal body temperature
charts in predicting urinary luteinizing hormone surges. Fertil
Steril. 1990;45:334-7.
4. Wathen NC, Perry L, Lilford RJ, Chard T. Interpretation of
single progesterone measurement in diagnosis of anovulation
and defective luteal phase: Observations on analysis of the
normal range. Br Med J. 1984;288:7-9.
5. Fillcori M, Butler JP, Crowley WF. Neuroendocrine regulation
of the corpus luteum in the human: Evidence for pulsatile
progesterone secretion. J Clin Invest. 1984;73:1638-47.
6. Syrop CH, Hammond MG. Diurnal variations in midluteal
serum progesterone measurements. Fertil Steril. 1987;47:67-70.
7. Jordan J, Craig K, Clifton DK, Soules MR. Luteal phase defect:
The sensitivity and specificity of diagnostic methods in
common clinical use. Fertile Steril. 1994;62:54-62.
8. Miller PB, Soules MR. The usefulness of a urinary LH kit
ovulation prediction during menstrual cycles of normal
women. Obstet Gynecol. 1996;87:13-7.
Ch-01.indd 12 18-01-2014 12:01:55

9. Martinez AR, Bernardus RE, Vermeiden JP, Schoemaker J. Time
scheduled of intrauterine insemination after urinary lutenizing
hormone surge detection and pregnancy results Gynecol
Endocrinol. 1994;8:1-5.
10. Nielsen MS, Barton SD, Hatasaka HH, Stanford JB. Comparisons
of several one step home urinary luteinizing hormone detection
test kits to OvuQuick. Fertil Steril. 1998;76:384-7.
11. Antaki R, Dean NL, Lapensée L, Racicot MH, Ménard S,
Kadoch IJ. An algorithm combining ultrasound monitoring
and urinary luteinizing hormone testing: a novel approach
for intrauterine insemination timing. J Obstet Gynaecol
Can. 2011;33(12):1248-52.
12. Duggan MA, Brashert P, Ostor A, Scurry J, Billson V, Kneafsey P,
Difrancesco L. The accuracy and interobserver reproducability
of endometrial dating. Pathology. 2001;33:292-7.
13. Casteibaum AJ, Wheeler J, Coutiferis CB, Mastroianni L, Lessey
BA Jr. Timing of the endometrial biopsy may be critical for
the accurate diagnosis of luteal phase deficiency. Fertil Steril.
1994;61:443-7.
14. Scott RL, Snyder RR, Strickland DM, Tyburski CC, Bagnall JA,
Reed KR, et al. The effect of interobserver variation in dating
endometrial histology on the diagnosis of luteal phase defects.
Fertil Steril. 1988;50:888-92.
15. de Crespigny LC, O’Herlihy C, Robinson HP. Ultrasonic
observation of the mechanism of human ovulation. Am J
16. Matijevic R, Grigic O. Predictive value of ultrasound
monitoring of menstrual cycle. Curr Opin Obstet Gynecol.
2005;17(4):405-10.
17. Murtinger M, Aburumieh A, Rubner P, Eichel V, Zech MH,
Zech MH. Improved monitoring of ovarian stimulation using
3D transvaginal ultrasound plus automated volume count.
Reprod Biomed Online. 2009;19(5):695-9.
Ch-01.indd 13 18-01-2014 12:01:55

cHAPTER
2
Oral Ovulogens
Surveen Ghumman
Clomiphene
Clomiphene citrate (CC) is an orally active nonsteroidal
triphenylethylene derivative approved for clinical trials in
1967. It has both estrogen agonist and antagonist effects by
acting on a and b estrogen receptors. It is used in clinical
practice as an antagonist, as the agonist properties manifest
only when endogenous estrogen levels are very low (Fig. 2.1).
The commercially available preparation is a racemic mixture
of two sterochemicals in the ratio of 38% zuclomiphene
or less active cis-isomer, and 62% enclomiphene or active
transisomer which is responsible for the ovulation induction
property of clomiphene.1
After oral administration, it undergoes enterohepatic
circulation and may be found in serum up to 30 days.
Enclomiphene is cleared rapidly, while zuclomiphene has
a long half-life. The two clomiphene isomers have mixed
estrogenic and antiestrogenic effects with zuclomiphene
having a greater estrogenic activity than enclomiphene. Only
Ch-02.indd 14 18-01-2014 12:03:25

Oral Ovulogens 15
Fig. 2.1: Mechanism of action
51% of the oral dose is excreted after 5 days. Significant levels

of plasma concentration of zuclomiphene can be detected
even after one month but there is no evidence of important
clinical significance as it is less active isomer.
In normally ovulating woman clomiphene increases GnRH
pulse frequency, but in anovulatory PCOS women it increases
the pulse amplitude as frequency is already very high.
Indications for Use

1. Anovulation or infrequent ovulation as in PCO (WHO
category II).
Ch-02.indd 15 18-01-2014 12:03:26

2. Infertility for causes other than ovulatory to time IUI or

increase number of oocytes.
3. Luteal phase defects.
4. Unexplained infertility.
The mechanism of inadequate corpus luteum can be
due to insufficient FSH stimulation during follicular phase.
Clomiphene acts by removing any dysfolliculogenesis.
In patients of unexplained infertility, controlled ovarian
stimulation increases the level of ovarian steroids and may
overcome the subtle deficiencies that these women may
have. It also increases the number of oocytes available in one
cycle.
Contraindications
1. Liver disease
2. Ovarian cyst
3. Development of visual symptoms on administration of
drug
4. Ovarian failure
5. Hypothalamic pituitary failure (WHO Group I)—as
clomiphene requires an intact hypothalamic-pituitary
ovarian axis for its action.
Prerequisites before Clomiphene Therapy

1. History and examination to determine duration and cause
of infertility.
2. Evaluation of male partner.
3. Prolactin level assessment—as abnormal levels will
require additional treatment besides clomiphene.
4. Thyroid function test—as specific treatment is needed.
Ch-02.indd 16 18-01-2014 12:03:26

Oral Ovulogens 17
5. Pituitary function assessment by baseline hormonal
evaluation—as clomiphene requires a functional
hypothalamic pituitary ovarian axis for results.
6. Liver function tests.
7. Adrenal function assessment—if hirsutism and other
evidence of androgen excess are present.
8. Determination of ovarian tissue responsiveness to gonado
tropins.
9. Tubal factor evaluation—Done only if there is suspicion
or evidence of tubal factor involvement, otherwise it is
evaluated only on failure of clomiphene treatment. It may
also be recommended in women above 35 years to avoid
wasting time on ineffective treatment as fertility is rapidly
declining.
Dose
Clomiphene is started from day 2 to 5 of the spontaneous or
progestin induced menstrual cycle and in amenorrheic patients;
it can be started immediately if pregnancy is ruled out. Giving
clomiphene on day 5 results in increased gonadotropins at
the time when the dominant follicle is being selected. Starting
it earlier stimulates multiple follicular development which is
ideal in order to obtain more than one oocyte. Outcome is
similar, if it is started on any day between 2 and 5 of the cycle.2
The starting dose of clomiphene is 50 mg for 5 consecutive
days (Fig. 2.2). More sensitive patients may be started with a
lower dose of 25 mg. Dose can be increased every month by
50 mg up to 250 mg till ovulation occurs. However, it is seen
that cumulative conception rate does not increase substantially
beyond a dose of 150 mg due to the adverse effect of
clomiphene on cervical mucus and endometrium (Table 2.1).3
Recommendation: FDA recommends a maximum induction

dose of 150 mg/day as there is not much advantage thereafter.
Ch-02.indd 17 18-01-2014 12:03:26

Results
There is an ovulation rate of 80% which decreases with BMI,
age, free androgen index and history of oligomenorrhea.5 The
cycle fecundity is 15% in women who respond to treatment
and increases to 22% if no other infertility factor is present.6
Cycle fecundity for those with unexplained infertility ranges
from 3.4 to 8%.7 This is increased up to 9.5% if IUI is added.
However, a recent Cochrane review (2010) stated that there
is no evidence of clinical benefit of clomiphene citrate for
unexplained fertility.8
Recommendation: If there is no conception after three cycles,

intrauterine insemination is recommended along with clomiphene.
Predictors of Response
It is important to identify women who will be poor responders
in order to timely recommend nonresponders to alternative
treatments. Negative factors would be obesity, hirsutism,
oligomenorrhea, high free androgens and increased mean
ovarian volume. It was found that leptin and free androgen
index were most accurate predictors of response in
normogonadotropic oligomenorrheic women.9
However, there is no accurate way to predict what dose
will be required for an individual woman. In a recent study,
concentrations of En and Zu were analyzed and it was found
that they accumulated throughout treatment but no statistically
significant relationship between En or Zu concentrations, and
the dose required to induce ovulation was established. The
Zu and En concentrations were not different in the patients
who failed to respond, and are not a predictor of the ovulation
response to CC or of the dose requirement.10
Normograms have been used to predict response. Age,
body mass index, free androgen index, and cycle history were
Ch-02.indd 18 18-01-2014 12:03:26

Oral Ovulogens 19
Fig. 2.2: Ovulation induction with clomiphene
Ch-02.indd 19 18-01-2014 12:03:26

Table 2.1: Ovulatory and conception rates with different doses

of clomiphene4
Dose of Successful Cumulative conception rate
clomiphene (mg) ovulation (%) (%)
50 52.1 52.8
100 21.9 20.7
150 12.31 9.8
200 6.9 4.8
250 4.9 2.2
used to assign a likelihood of response for each patient on the

basis of a published nomogram in a study and predicted 80%
nonresponders but could not predict the dose required for
response.11
Duration of Treatment
Duration of treatment can extend to 6 to 12 months but 75%
conceptions occur in the first 3 months.12
Since fecundability declines with age, those women above
35 should not undergo prolonged treatment with clomiphene
citrate and treatment strategy must move on to other forms
earlier after an expanded diagnostic evaluation to exclude
other factors.6
Recommendation: Clomiphene should be used for a maximum

of 6 months consecutively or 12 months in a patient’s lifetime as
75% conceptions occur in the first 3 months. In older women,
alternatives should be opted for earlier.13
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Oral Ovulogens 21
Monitoring
Monitoring can be done as follows:
1. Basal body temperature is simple, inexpensive but tedious
and time consuming.
2. Serum estradiol levels (each follicle secretes 150 to 300
pg/ml per follicle).
3. LH surge by home monitoring urine tests (best performed
by second urination of the day between 7 am and 10 am).
It usually occurs between 5 and 12 days of completion of
treatment.
4. Ultrasonography—Follicular monitoring to be
started on day 9. Optimal follicular parameters
around ovulation are a follicular size of 18 to
20 mm with perifollicular blood flow of 50 to 75% and RI
of 0.4 to 0.48.
5. Midluteal serum progesterone greater than 3 ng/ml is an
evidence of ovulation. A level of progesterone more than
10 ng/ml is taken as an adequate luteal phase. However,
this value is not reliable as progesterone levels are very
variable.
A study comparing cycle fecundity clomiphene cycle
monitored by BBT, LH surge detection and ultrasonography
are found no advantage of one over the other.14
Before starting the next cycle it is useful to do a ‘clomiphene
check’ where previous treatment cycle is reviewed, and
pelvic examination or ultrasound ensures that no residual cyst
is present. In recent years, this practice has been thought to
be unnecessary; however, a regular contact is recommended
to review response to treatment and to ensure an additional
evaluation and alternative treatment is not delayed.6
Antiestrogenic Effect of Clomiphene

It is thought that the antiestrogenic effect on cervical mucus
and endometrium may be responsible for the discrepancy
Ch-02.indd 21 18-01-2014 12:03:26

between ovulation and conception rates in clomiphene

induced cycle.
Cervical Mucus
With clomiphene the quantity of cervical mucus is decreased.
Effect is dose dependant and more readily apparent when the
interval between the last dose of clomiphene and ovulation is
short. However, it is seen that the effect is usually negated by
high serum estradiol levels due to multi-follicular development
or because of end-organ sensitivity. Randomized controlled
trials have proved that cervical mucus is not very significant
as the postcoital test has little predictive value.
Endometrial Growth
Clomiphene inhibits estradiol induction of progesterone
receptors in endometrium. The effect is usually inconsistent
but is important if preovulatory endometrial thickness is
persistently less than 6 mm. In such situation, clomiphene
citrate can be replaced by tamoxifen or letrozole. Tamoxifen
has an estrogen agonist rather than antagonist effect on the
endometrium. Letrozole has no adverse effect on endo
metrium as it acts by decreasing estrogen production rather
than receptor antagonism. Its action is easily reversible
when the drug is stopped. Patients can also be started on
gonadotropins instead of clomiphene.
In recent studies it has been seen that clomiphene affects
endometrium thickness on late proliferative days but not on
mid-secretory days, and does not alter the echogenic pattern
of the endometrium. The endometrial echogenic patterns
in mid-secretory phase of women taking clomiphene who
had conceived, were not significantly different from those of
women who had not conceived.15
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Oral Ovulogens 23
Side Effects and Risks
Minor side effects are seen in 10 to 20% of cases.
1. Hot flushes occur in 10% and are due to central
misperception that endogenous estrogens are low
causing vasomotor symptoms.
2. Nausea and vomiting (2%).
3. Breast discomfort and bloating.
4. Hair loss and dryness.
5. Headache.
6. Visual disturbances (1.6%): Blurred vision, diplopia,
scotoma and light sensitivity may occur and need
cessation of the drug and change of treatment options.
Rarely optic neuropathy develops. Cases of central
retinal vein occlusion (CRVO) have been reported and
clomiphene may predispose to this condition especially
in patients with associated risk factors for CRVO.
Patients should be well informed of this side effect
before commencement of therapy. If visual disturbances
occur, therapy should be terminated and the patient
referred for specialist ophthalmic care.16,17
7. Ovarian cysts (6.4%): They resolve without treatment in
a few weeks.13
8. Ovarian hyperstimulation syndrome (less than 1%):
It can be avoided by establishing and using minimum
effective dose. Severe forms are rarely seen.
9. Multiple pregnancy (5–8%): Usually twins (95%) and
very rarely triplets may be seen.

10. Ovarian cancer: Although earlier studies showed a
3-fold increase in incidence of ovarian cancer, recent
studies showed only a small increase of incidence (OR-
2.43) of borderline serous tumors but not of invasive
cancer.18 A pooled analysis of 8 studies showed that
Ch-02.indd 23 18-01-2014 12:03:26

neither any fertility drug use nor more than 12 months

of use was associated with ovarian cancer. Hence, no
change in prescribing practice is warranted on these
grounds.
11. Congenital malformations are not increased. However,
it was seen that an abnormal karyotype was present in
nearly 50% of women undergoing preovulatory oocyte
retrieval after clomiphene stimulation.19 Clomiphene
has been found to increase interval of time required for
oocytes to reach metaphase I compared with oocytes of
natural cycle. The interval of time required for metaphase
I to reach metaphase II is significantly reduced (2.4 hours
versus 10 hours for natural cycle).20
Despite all the above clomiphene with its ease of
administration, reduced need for monitoring and limited cost
maintains an important place in treatment of anovulation.
Tamoxifen
Tamoxifen is a triphenylethylene derivative with a strong anti
estrogenic activity.
Mechanism of Action
It inhibits estrogen negative feedback on hypothalamus and
pituitary by binding to its receptors in a manner similar to
clomiphene.
Dose
It is administered orally on second or third day of menstrual
cycle in a dose of 20 mg/day for 5 days. The dose can be
increased to 40 mg/day.
Ch-02.indd 24 18-01-2014 12:03:26

Oral Ovulogens 25
Results
Ovulation is induced in 70 to 75% patients with a pregnancy
rate of 35%. In a recent Cochrane review, no evidence of a
difference in effect was found between clomiphene versus
tamoxifen or clomiphene.21
Advantages
Tamoxifen causes a raised estrogen levels due to multi-
follicular development and a direct action on the ovaries to
enhance estrogen production, hence leading to a favorable
response on the cervical mucus and endometrium. It is an
alternative to clomiphene when there is persistently poor
endometrial response. It also gives better results in patients
with poor cervical mucus score.22
Side Effects
Side effects include hot flushes, nausea, vomiting, headache,
dizziness, liver toxicity, abdominopelvic discomfort,
endometrial hyperplasia and endometrial polyps. Compli
cations, similar to clomiphene include multiple pregnancy,
hyperstimulation and ovarian enlargement.
Antiestrogens have an important role to play as first-line
ovulation induction in infertile women. They are safe with
minimal side effects. However, dose and length of treatment
must be individualized. It is important to identify when they
should be stopped and further treatment with other drugs
initiated.
Letrozole
Letrozole is an aromatase inhibitor used in breast cancer
cases to suppress estrogen. Although it can be used to induce
Ch-02.indd 25 18-01-2014 12:03:26

ovulation, it is not approved by FDA for this purpose. The

use of this drug is not recommended for ovulation induction
currently.
It has no effect on plasma androstenedione and testos
terone and so no accumulation of androgens (Fig. 2.3).
Letrozole has no effect on endometrium and cervical mucus
because of its short half-life and absence of estrogen receptor
depletion. As can be seen in Table 2.2 although the estrogen
levels are lower with letrozole compared to clomiphene the
endometrial response is much better.23 It was also associated
with lower rate of multiple pregnancy.24
Fig. 2.3: Mechanism of action
Ch-02.indd 26 18-01-2014 12:03:27

Oral Ovulogens 27
Table 2.2: Comparison of effect of clomiphene and letrozole23

Endometrial Ovulation E2 levels Number Pregnancy
thickness rate of mature
follicles
Clomiphene 5 mm 67% 1278 pg/ml 1.9
Letrozole 8 mm 87% 392 pg/ml 2.4 30%
Advantages
1. No antiestrogenic effect on endometrial lining and
cervical mucus.
2. Induces monofolliculogenesis and hence does not cause
hyperstimulation.
3. Easily reversible action as half-life is 2 days.
Dose
It is given in a single dose of 2.5 to 5 mg/day from day 3 to 7
for 5 days. Recently single dose of 20 mg on day 3 has given
comparable success rate for ovulation stimulation.25
Side Effects
Hair thinning, nausea, hot flushes, peripheral edema and
fatigue have been reported in 5% patients.
Aromatase inhibitors warrant additional study to establish
their role as treatment drug for ovulation induction and as a
option for clomiphene resistant cases.
References
1. McDonough PG. The clomid twins: Waiting for a single isomer
heaven (Editorial). Fertil Steril. 1997;68:186-7.
2. Wu CH, Wenkel CA. The effect of therapy initiation day on
clomiphene citrate therapy. Fertil Steril. 1989;52:564-8.
Ch-02.indd 27 18-01-2014 12:03:27

3. Kusata E, White DM, Franks S. Modern use of clomiphene

citrate in induction of ovulation. Hum Reprod. Update.
1997;3:359-65.
4. Gysler M, March CM, Mishell DR Jr, Baily EJ. A decade’s
experience with an individualized clomiphene treatment
regimen including its effect on the postcoital test. Fertil Steril.
1982;37:161-7.
5. Imani B, Eijkemans MJ, te Velde ER, Habbema JD, Fauser
BC. Predictors of patients remaining anovulatory
during clomiphene citrate induction of ovulation in
normogonadotropic oligoamenorrheic infertility. J Clin
Endocrinol Metab. 1998;83(7):2361-5.
6. Use of clomiphene citrate in women. The Practice Committee
of American Society of Assissted Reproduction. Fertil Steril.
2006;86(5):S187-93.
7. Fisch P, Casper RF, Brown SE, Wrixon W, Collins JA, Reid
RL, et al. Unexplained infertility: evaluation of treatment with
clomiphene citrate and human chorionic gonadotropin. Fertil
Steril. 1989;51(5):828-33.
8. Hughes E, Brown J, Collins JJ, Vanderkerchove P. Clomiphene
citrate for unexplained subfertility in women. Cochrane
Database of Systematic Reviews. 2010; Issue 1. Art. No.:
CD000057.
9. Imani B, Eijkemans MJ, de Jong FH, Payne NN, Bouchard
P, Giudice LC, et al. Free androgen index and leptin
are the most prominent endocrine predictors of ovarian
response during clomiphene citrate induction of ovulation
in normogonadotropic oligoamenorrheic infertility. J Clin
Endocrinol Metab. 2000;85(2):676-82.
10. Ghobadi C, Amer S, Lashen H, Lennard MS, Ledger
WL, Rostami-Hodjegan A. Evaluation of the relationship
between plasma concentrations of en- and zuclomiphene and
induction of ovulation in anovulatory women being treated
with clomiphene citrate. Fertil Steril. 2009;91(4):1135-40.
11. Ghobadi C, Nguyen TH, Lennard MS, Amer S, Rostami-
Hodjegan A, Ledger WL. Evaluation of an existing nomogram
for predicting the response to clomiphene citrate. Fertil
Steril. 2007;87(3):597-602.
Ch-02.indd 28 18-01-2014 12:03:27

Oral Ovulogens 29
12. Speroff L, Glass R, Kase N. In vitro fertilization. In: Speroff L,
Glass R, Kase N (Eds). Clinical Gynaecological Endocrinology
and Infertility. William and Wilkins: Baltimore, London.
1989;611-9.
13. Rust LA, et al. An individualized graduated therapeutic regimen
for clomiphene citrate. N Engl J Med. 1994;331:771-6.
14. Smith YR, et al. Comparison of low technology and high
technology monitoring of clomiphene citrate ovulation
induction. Fertil Steril. 1998;70:165-8.
15. Dehbashi S, Parsanezhad ME, Alborzi S, Zarei A. Effect of
clomiphene citrate on endometrium thickness and echogenic
patterns. Int J Gynaecol Obstet. 2003;80(1):49-53.
16. Lee VY, Liu DT, Li CL, Hoi-Fan, Lam DS Central retinal vein
occlusion associated with clomiphene-induced ovulation.
Fertil Steril. 2008;90(5):2011.e11-2.
17. Viola MI, Meyer D, Kruger T. Association
between clomiphene citrate and visual disturbances with
special emphasis on central retinal vein occlusion: a review.
Gynecol Obstet Invest. 2011;71(2):73-6.
18. Ness RB, Cramer DW, Goodman MT, Kjaer SK, Mallin K,
Mosgaard BJ, et al. Infertility, fertility drugs and ovarian cancer:
A pooled analysis of case control studies. Am J Epidemiol.
2002;155:217-24.
19. Wramby H, Fredga K, Liedholm P. Chromosome analysis
of human oocyte recovered from preovulatory follicles in
stimulated cycles. N Engl J Med. 1987;316:121-4.
20. Seibel MM, Smith DM. The effect of clomiphene citrate on
human preovulatory oocyte maturation in vivo. J In Vitro Fertil.
1989;6:3-6.
21. Brown J, Farquhar C, Beck J, Boothroyd C, Hughes E.
Clomiphene and anti-oestrogens for ovulation induction in
PCOS. Cochrane Database of Systematic Reviews. 2009; Issue
4. Art No.: CD002249.
22. Annapurna V, Dhaliwal LK, Gopalan S. Effects of two anti-
estrogens, clomiphene citrate and tamoxifen, on cervical
mucus and sperm cervical mucus interaction. Int J Fertil
Women’s Med. 1997;42(3):215-8.
Ch-02.indd 29 18-01-2014 12:03:27

23. Mitwally MF, Casper RF. Aromatase inhibition improves

ovarian response to FSH in poor responders. Fertil Steril.
2002;77(4):776-80.
24. Mitwally MF, Biljan MM, Casper RF. Pregnancy outcome after the
use of an aromatose inhibitor for ovarian stimulation. Am J Obstet
Gynecol. 2005;192:381-6.
25. Mitwally MF, Casper RF. Single dose administration of an
aromatose inhibitor for ovarian stimulation. Fertil Steril.
2005;83:229-31.
Ch-02.indd 30 18-01-2014 12:03:27

cHAPTER
3
Clomiphene Resistance—
What Next?
Surveen Ghumman
Many patients do not respond to clomiphene. There may be

a genetic basis to clomiphene resistance and it is seen that
the chance of resistance to clomiphene is almost double in
women with PCOS (polycystic ovary syndrome) harboring
the 680-polymorphism Ser/Ser genotype.1 It is important to
define clomiphene resistance and failure.
Clomiphene Resistance
Clomiphene resistance is failure to ovulate with 3 months use
of clomiphene at 150 mg/day for 5 days. It occurs in 20%
cases more so in PCOS patients.
Clomiphene Failure
Patients who ovulate but fail to conceive after treatment with
3 cycles of clomiphene in a dose of 150 mg/day are cases of
clomiphene failure. It is usually due to excess LH, androgens
or insulin which leads to impaired folliculogenesis, increased
Ch-03.indd 31 18-01-2014 12:03:59

atresia, poor oocyte quality, poor endometrial receptivity and

deficient corpus luteum function. Other potential infertility
factors must be ruled out. On diagnostic laparoscopy, it was
seen that significant pelvic pathology was present in one third
of these patients, 29.3% had minimal pathology and only
32.6% had a normal pelvis.2
Recommendation: Diagnostic laparoscopy should be done to

evaluate the pelvis after failure of 3 to 6 cycles of clomiphene.
Management of Clomiphene
Failure or Resistance
All cases with clomiphene failure need a complete
endocrinal work-up and a diagnostic laparoscopy to rule
out any underlying endocrine disorder or pelvic pathology.
These women may respond to additional or alternative
treatment. A choice of which treatment is to be initiated is
based on patient’s history, laboratory results and observation
of previous unsuccessful clomiphene cycles. These are
alternatives that merit consideration depending on patient’s
age, goals, available resources and risk tolerance.
Weight Loss
Women with central fat have high levels of LH, andros
tenedione, estrone, insulin, triglycerides, very low-density
lipoproteins and lower levels of high- density lipoprotein.
These altered levels cause disturbances in hypothalamic
pituitary ovarian axis. A high waist-hip ratio (more than
0.85) is associated with greater reproductive hormone and
insulin derangement. Even moderate obesity with a body
mass index of more than 27 kg/m2 is associated with a lesser
chance of ovulation.3 Adipose tissue is an active site for
Ch-03.indd 32 18-01-2014 12:03:59

Clomiphene Resistance—What Next? 33
steroid production and metabolism. It converts androgens to
estrogens by aromatase activity (Table 3.1). There is defective
clearance and production of androgens in central obesity.
Increasing BMI is associated with an increased requirement
for clomiphene. Larger doses of clomiphene up to 200
mg/day are required to ensure ovulation in obese women.
Doses of gonadotropin required are also more. Weight loss
improves the clinical and biochemical parameters that are
disordered due to obesity. Loss of 5 to 7% of body weight
is effective in restoring ovulation and leads to changes in
levels of insulin, IGF and SHBG. Exercise and dietary restraint
produce a favorable endocrine status of these patients and
a better ovulation rate with clomiphene.4 There is a higher
conception rate and a lower miscarriage rate. Even surgically
induced weight loss will induce these changes.
Extended Course of Clomiphene Treatment

Clomiphene can be given for up to 7 to 10 days to induce
ovulation in those cases which do not respond to the 5
day regime.5 Up to 50% of women who are resistant to the
standard regime respond to it.
Tamoxifen
It can be tried alone or in combination with clomiphene
especially in cases of poor cervical mucus score and in cases
Table 3.1: Effect of adipose tissue on steroid hormone levels

• Storage of steroid hormones
• Affects insulin secretion from pancreas
• Conversion of estrogen from inactive to active form
• Peripheral conversion of androgens to estrogens
• Changes in level of sex hormone-binding globulin (SHBG)
Ch-03.indd 33 18-01-2014 12:03:59

of poor endometrial response. Tamoxifen causes a raised

estrogen levels due to multi-follicular development and
a direct action on the ovaries to enhance estrogen; hence,
leading to a favorable response on the cervical mucus and
endometrium. It is given in a dose of 20 to 40 mg/day from
day 2 to 5 days.
Aromatase Inhibitors
Letrozole: Letrozole given for 5 days showed a ovulation
rate of 33.3% in clomiphene resistant cases.6 However, if
administered as long protocol (10 days) it can produce more
mature follicles and subsequently more pregnancies than
the short letrozole therapy (5 days) in clomiphene resistant
women with PCOS.7 In clomiphene resistant PCOS patients,
letrozole results were nearly comparable to gonadotropin
therapy with an ovulation rate of 79.3% and pregnancy rate
of 23.4%. It is found to be most effective when baseline
estradiol level was more than 60 pg/ml.8 However, letrozole
is no longer approved for use as an ovulation induction drug.
Anastrazole: Anastrazole in PCOS clomiphene resistant
women had an ovulation rate of 63.4% and a pregnancy rate
of 15.1%, which was found to be comparable to letrozole.9
Glucocorticoids
Dexamethasone 0.5 mg/day or prednisolone 5 mg/day is
added either continuously or in follicular phase from day 5
to 16 to bring down raised levels of DHEAS (>200 µg/dl) in
PCOS patients. It results in an ovulation rate of 80% compared
to 20% in cases given placebo and a cumulative pregnancy
rate which is 10-fold (40% vs 4%). This effect is seen even
Ch-03.indd 34 18-01-2014 12:03:59

in cases where DHEAS is normal.10 The pregnancy rate in
women with unexplained infertility undergoing IUI after
ovulation induction with clomiphene showed a pregnancy
rate of 21.4% vs 4.5% with and without dexamethasone,
respectively.11
A recent Cochrane review (2009) supported these
findings.12 Glucocorticoids diminishes the androgen level
in the microenvironment of the ovary by blunting the night
time peak of ACTH, thus decreasing the adrenal contribution
to circulating androgens. However, the mechanism involves
more than androgen suppression. It may directly effect oocyte
or induce indirect effects on intrafollicular growth factor and
cytokines which may act synergistically with FSH. It may
be continued for 3 to 6 cycles if successful and should be
discontinued if not (ASRM Guidelines 2006).13 There is no
evidence that glucocorticoids have any major side effect in
this dose when used. It is stopped if pregnancy occurs.
Human Chorionic Gonadotropin (hCG)

About 20% of cases, ovulation does not occur in clomiphene
induced cycle because there is a failure of rupture of a
developed follicle. hCG is given in a dose of 5,000 to 10,000
IU when follicle is 18 to 20 mm on ultrasonography, in cases
where there is repeated evidence of unruptured follicle.
It is also helpful in timing intrauterine insemination where
midcycle LH surge may remain falsely undetected because of
its brief duration. Recombinant hCG can be used in a single
dose of 250 µg subcutaneously and has similar pharma
cokinetics as the urinary formulation. All studies show that
other than these two indications there is no difference in
results with or without exogenous hCG.5 Midcycle hCG
administration has no effect on luteal function.14
Ch-03.indd 35 18-01-2014 12:03:59

Suppressive Therapy
Suppression can be done either with oral contraceptives
or GnRH agonists and is used when there are raised LH or
androgen levels as in PCOS women.
Oral Contraceptive
Suppression with oral contraceptives decreases ovarian
androgens, luteinizing hormone, FSH and 17 b-estradiol and
may be responsible for the improved response in patients who
previously were resistant to clomiphene citrate. It restores
normal function in a patient with dysfunctional hypothalamic
pituitary ovarian axis manifesting with anovulation. An
ovulation rate of 70% and a cumulative pregnancy rate of
50% was achieved with such treatment in clomiphene
resistant cases.15
GnRH Agonist
GnRH agonists cause a down regulation of pituitary. It is
given in a dose of 0.1 mg/day from day 21 of previous cycle.
LH and FSH levels are brought down (E2 < 30 pg/ml, LH
< 2.5 IU/l, Progesterone < 2 ng/ml). Then stimulation is
begun with gonadotropins and GnRH agonist dose is reduced
to half. This decreases high basal LH levels, decreases LH
stimulation of ovarian androgen production and eliminates
any premature LH surge.
When combined with a oral contraceptive there is a
dual advantage of a greater and more sustained reduction
of LH, improved luteinizing hormone-to-follicle-stimulating
hormone ratio and lower serum androgens, particularly
dehydroepiandrosterone sulfate. It also prevents estrogen
deficiency which develops on using GnRH agonist without
add back therapy (Fig. 3.1).16 Results are good in clomiphene
resistant cases.17,18
Ch-03.indd 36 18-01-2014 12:03:59

Fig. 3.1: Combined suppressive action of oral contraceptive and GnRH agonist
Dopamine Agonists
Bromocriptine
For patients with raised serum prolactin levels bromocriptine in
a dose up to 2.5 mg bd or tds is used orally or vaginally. Long-
acting slow release or depot preparations are also available.
Ovulatory dysfunction in presence of galactorrhea responds
well to bromocriptine even if prolactin level is normal.19
About 80% patients have restoration of ovulation. However,
a recent study found no advantage of adding bromocriptine
in clomiphene resistant patients with normal prolactin. No
significant differences was seen in ovulation, and serum levels
of follicle-stimulating hormone (FSH), luteinizing hormone
(LH), dehydroepiandrosterone sulfate (DHEAS), progesterone
(P) between treatment and placebo group after treatment.
Serum prolactin levels were reduced.20
Carbergoline
Carbergoline can be used in bromocriptine resistant cases in
a weekly dose of 0.5 to 3 mg orally or vaginally. It has less
side effects, the most common being headache.
Ch-03.indd 37 18-01-2014 12:03:59

Insulin Sensitizers
Metformin: Patients with hyperinsulinemia (fasting insulin
more than 25 IU or a fasting glucose to insulin ratio of less
than 4.5) in PCOS require insulin sensitising drugs like met-
formin which is given in a dose of 1500 mg/day. Some rec-
ommend administration of insulin sensitizers at fasting insulin
level of more than 15 IU. Now postprandial insulin levels are
also taken into account and levels more than 100 IU are sig-
nificant Altered GTT is considered the most reliable method of
establishing insulin resistance. By reducing hyperinsulinemia
metformin causes a reduction in intraovarian androgens. This
also leads to reduction in E2 levels and induces an orderly fol-
licular growth restoring ovulation. Ovulation rates are higher
when combined with clomiphene (76% vs 46% when used
alone).21,22 A recent meta-analysis published in 2008 showed
that pregnancy rates were also increased. The live birthrate
following up to 6 months of treatment with metformin given
along with clomiphene was increased but not so significantly
(26.8%vs 22.5% with clomiphene alone).23
Metformin combined with clomiphene citrate may increase

ovulation rates and pregnancy rates but does not significantly
improve the live birth rate over that of clomiphene citrate alone.
Therefore, the use of metformin in improving reproductive

outcomes in women with PCOS appears to be limited.24
Metformin may be added to clomiphene citrate in women
with clomiphene resistance who are older and who have
visceral obesity.25
Ultrashort metformin pretreatment: Women with clomiphene
resistant PCOS can be started on 1500 mg metformin daily
for 12 days, followed by clomiphene 150 mg daily for
5 days along with metformin. Twelve days of metformin
Ch-03.indd 38 18-01-2014 12:03:59

pretreatment improves ovulation and pregnancy rates in
women with clomiphene-resistant PCOS with 42.5% women
ovulating, and 15% conceiving vs 12.5% women ovulating
but none conceived in the clomiphene only group as seen
in a recent study.26 A Cochrane review 2008 concluded that
more randomized controlled trials are required before short
treatment can be recommended.27
Pioglitazone and Rosiglitazone: Pioglitazone in a dose of
30 to 50 mg/day or Rosiglitazone in a dose of 4 to 8 mg/
day can also be used as monotherapy or in combination with
metformin.28,29 A recent study showed rosiglitazone when
compared to metformin has higher ovulation rates (64.3% vs
36.4%) and pregnancy rates (50% vs 38.5%) in clomiphene-
resistant cases when given at the start of an induced cycle.
These findings suggest that short-term use of rosiglitazone
with clomiphene is more efficacious than short-term use of
metformin with clomiphene in these women.
D-chiroinositol: Administration of D-chiroinositol makes
up deficiency of D-chiroinositol containing phosphoglycan
which mediates action of insulin in these patients. It is given
in a dose of 1200 mg/day for 6 to 8 weeks to correct ovulatory
dysfunction.
N-acetyl cysteine: In clomiphene-resistant PCOS women,
metformin was more effective than N-acetyl cysteine when
added to clomiphene giving significantly higher ovulation and
pregnancy rates (69.1% vs 20.0%, and 22.7% vs 5.3%,
respectively).30
Acarbose
Acarbose is an a-glucosidase inhibitor, used in the
management of type 2 diabetes. Acarbose reduces the
postprandial rise in both serum glucose and insulin levels
Ch-03.indd 39 18-01-2014 12:03:59

by inhibiting a-glucosidase, an enzyme responsible for the

intestinal absorption of carbohydrates. Acarbose was found to
be a safe and effective agent that could be used in cases with
clomiphene-resistant PCOS. It was as effective as metformin
and is given in a dose of 100 mg tid. When compared with
metformin both groups experienced a significant increase
in ovulation and monthly mid-luteal serum progesterone
levels during the 3-month treatment period compared
with pretreatment scores and ovulation rates were similar
between the acarbose and metformin groups. Acarbose may
be an alternative to metformin for women with PCOS and
clomiphene citrate resistance.31
Bezafibrate
Dyslipidemia is commonly observed in PCOS patients.

Bezafibrate is a drug for dyslipidemia acting through
peroxisome proliferator-activated receptors. It was found to
be beneficial for ovulation induction in patients with PCOS
with dyslipidemia who were resistant to clomiphene citrate in
a small study. It was given in a dose of 400 mg/day from day
1 of menses and clomiphene citrate 100 mg/day from day 5
of menses simultaneously until one follicle measuring at least
18 mm in diameter was found by transvaginal ultrasound. Five
of seven patients successfully ovulated. Bezafibrate may be
effective for ovulation induction in CC-resistant PCOS patients
with dyslipidemia. However, larger studies are required.32
Naltrexone
Endogenous opiates may affect various aspects of reproductive
and metabolic function in patients with polycystic ovary
syndrome (PCOS). Naltrexone (50 mg po daily) for 6 months
caused long-term inhibition of the opioid system. In CC-resistant
Ch-03.indd 40 18-01-2014 12:03:59

women with PCOS, there was significant reductions in BMI,
fasting serum insulin, luteinizing hormone (LH), LH/follicle-
stimulating hormone ratio and testosterone improving a broad
range of clinical, endocrine and metabolic derangements
characteristic in PCOS. 10% ovulated only on natrexone. 33%
patients conceived when clomiphene was added showing
that it restored clomiphene sensitivity resulting in a significant
number of pregnancies.33 However, larger studies need to be
conducted to rule out possible teratogenicity of naltrexone.
Gonadotropins
Gonadotropins may be given along with clomiphene to
improve results and are specially indicated in unexplained
infertility and where there is no success with clomiphene.
Sequential treatment is only given if some response is
seen with clomiphene. In cases where no response is seen
with clomiphene, it is better to directly stimulate with
gonadotropins. Treatment is individualized in the same way
as traditional gonadotropin therapy based on transvaginal
sonography and estradiol levels. Clomiphene citrate
is given in a dose of 100 mg from day 2 to day 6. FSH is
started on day 6 in a dose of 75 to 150 IU/day till adequate
follicular development occurs (Fig. 3.2). Adequate follicular
Fig. 3.2: Clomiphene and gonadotropin regime
Ch-03.indd 41 18-01-2014 12:03:59

development is taken as estradiol more than 500 pg/ml or

one follicle equal to or more than 14 mm mean diameter. The
aim is monofollicular development and not superovulation
in these anovulatory infertile women.13 Since clomiphene
increases LH, FSH is preferred to hMG. Along with FSH, GnRH
antagonist can be added to suppress premature LH surge. A
Cochrane review however stated that 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.34
GnRH Antagonists
They act reversibly by competitive inhibition of GnRH
receptors resulting in rapid decline in LH and FSH. There is no
stimulatory phase unlike the GnRH agonists. It reduces the dose
and duration of gonadotropin treatment as it does not nullify
FSH or LH secretion but interrupts the premature LH surge.
There are two protocols used in ovulation induction with
antagonists. In both gonadotropins are started as usual. When
follicle reaches 14 mm (usually Day 7), in the Lubeck Protocol
antagonist, Centrorelix, is started at a dose of 0.25 mg/day
(Fig. 3.3) whereas in the French protocol a single dose of 3
mg is given. Cochrane review 2002 has concluded that both
protocols were equally effective in preventing premature LH
surge.35
Surgical Ovulation Induction

Laparoscopic ovarian drilling (LOD) is an alternative
to ovulation induction with gonadotropins for polycystic ovarian
Ch-03.indd 42 18-01-2014 12:03:59

Fig. 3.3: Clomiphene with gonadotropins and GnRH antagonist
syndrome (PCOS) patients unresponsive to clomiphene.36

Since it is as effective as FSH treatment in terms of live births,
and reduces the need for ovulation induction or ART in a
significantly higher proportion of women. It also increases the
sensitivity to clomiphene. Laparoscopic ovarian drilling using
electrocautery or laser photocoagulation can be done (Fig.
3.4). The advantage is that it is a single time treatment free
of intensive monitoring with no risk of OHSS and multiple
pregnancy.37 Ovulation occurs in 70–80% of patients and
there is a conception rate of 60%. Complications include
adhesion formation (80%) and ovarian atrophy.38 Unilateral
ovarian diathermy was as effective and long lasting as bilateral
ovarian diathermy in the resumption of menstruation and
pregnancy rates.39 However, there are ongoing concerns about
long-term effects of LOD on ovarian function.40
Patients with clomiphene resistance require further
evaluation and form a challenging diagnostic problem to the
infertility specialist. A step-by-step approach to rule out and
treat other subclinical endocrinopathies is required.
Ch-03.indd 43 18-01-2014 12:03:59

Fig. 3.4: Management of clomiphene resistance
Ch-03.indd 44 18-01-2014 12:04:00

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14. Agarwal SK, Buyalos RP. Corpus luteum function and
pregnancy rates with clomiphene citrate therapy: comparison
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ovulation. Hum Reprod. 1995;10:328-31.
15. Branigan EF, Estes MA. A randomised clinical trial of treatment
of clomiphene citrate-resistant anovulation with the use of oral
contraceptive pill suppression and repeat clomiphene citrate
treatment. Am J Obstet Gynecol. 2003;188(6):1424-9.
16. Damario MA. Ovarian hyperstimulation syndrome prevention
strategies: oral contraceptive pills-dual gonadotropin-releasing
hormone agonist suppression with step-down gonadotropin
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17. Genazzani AD, Petraglia F, Battaglia C, Gamba O, Volpe A,
Gennazani AR. A long-term treatment with gonadotropins
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with polycystic ovary syndrome. Fertil Steril. 1997;67:463-8.
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18. Hughes E, Collins J, Vandekerckhove P. Gonadotrophin-
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19. Padilla SL, Person GK, McDonough PG, Reindollar RH.
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20. Parsanezhad ME, Alborzi S, Namavar Jahromi B. A prospective,
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bromocriptin in clomiphene-resistant patients with polycystic
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21. Lord JM, Flight IH, Norman RJ. Insulin-sensitising drugs
(metformin, troglitazone, rosiglitazone, pioglitazone, D-chiro-
inositol) for polycystic ovary syndrome. Cochrane Database
Syst Rev. 2003;3:CD003053. Comment in: ACP J Club.
2004;140(3):75.
22. Creanga AA, Bradley HM, McCormick C, Takacs Witkop C. Use
of metformin in polycystic ovary syndrome: A meta-analysis.
23. Legro RS, Barnhart HX, Schlaff WD, Carr BR, Diamond MP,
Carson SA, et al. Clomiphene, metformin or both for infertility in
the polycystic ovary syndrome. N Engl J Med. 2007;356:551-66.
24. Tang T, Lord JM, Norman RJ, Yasmin E, Balen AH. Insulin-
sensitising drugs (metformin, rosiglitazone, pioglitazone,
D-chiro-inositol) for women with polycystic ovary syndrome,
oligo amenorrhoea and subfertility. Cochrane Database Syst
Rev. 2010;(1):CD003053.
25. Moll E, Korevaaur JC, Bossuyt PMM, van der Veen F. Does
adding metformin to clomifene citrate lead to higher pregnancy
rates in a subset of women with polycystic ovary syndrome?
Human Reprod. 2008;23:1830-4.
26. Hwu YM, Lin SY, Huang WY, Lin MH, Lee RK. Ultra-
short metformin pretreatment for clomiphene citrate-
resistant polycystic ovary syndrome. Int J Gynaecol Obstet.
2005;90(1):39-43.
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27. Sinawat S, Buppasiri P, Lumbiganon P, Pattanittum P. Long

versus short course treatment with metformin and clomiphene
citrate for ovulation induction in women with PCOS. Cochrane
Database Syst Rev. 2008;(1):CD006226.
28. Stout DL, Fugate SE. Thiazolidinediones for treatment of
polycystic ovary syndrome. Pharmacotherapy. 2005;25(2):244-
52.
29. Ortega-Gonzalez C, Luna S, Hernandez L, Crespo G, Aguayo
P, Arteaga-Troncoso G. Responses of Serum Androgen and
Insulin Resistance to Metformin and Pioglitazone in Obese,
Insulin-Resistant Women With Polycystic Ovary Syndrome. J
Clin Endocrin Metab. 2005;90(3):1360-5.
30. Abu Hashim H, Anwar K, El-Fatah RA. N-acetyl cysteine plus
clomiphene citrate versus metformin and clomiphene citrate in
treatment of clomiphene-resistant polycystic ovary syndrome:
a randomized controlled trial. J Women’s Health (Larchmt).
2010;19(11):2043-8.
31. Sönmez AS, Yasar L, Savan K, KoçS, Ozcan J, Toklar A, et al.
Comparison of the effects of acarbose and metformin use on
ovulation rates in clomiphene citrate-resistant polycystic ovary
syndrome. Hum Reprod. 2005;20(1):175-9.
32. Hara S, Takahashi T, Amita M, Igarashi H, Kurachi H. Usefulness
of bezafibrate for ovulation induction in clomiphene citrate-
resistant polycystic ovary syndrome patients with dyslipidemia:
a prospective pilot study of seven cases. Gynecol Obstet Invest.
2010;70(3):166-72.
33. Ahmed MI, Duleba AJ, El Shahat O, Ibrahim ME, Salem A.
Naltrexone treatment in clomiphene resistant women with
polycystic ovary syndrome. Hum Reprod. 2008 ;23(11):2564-9.
34. Hughes E, Collins J, Vandekerckhove P. Ovulation
induction with urinary follicle stimulating hormone versus
human menopausal gonadotropin for clomiphene-resistant
polycystic ovary syndrome. Cochrane Database Syst Rev.
2000;(2):CD000087.
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reproduction: a Cochrane review. Hum Reprod Update.
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36. Flyckt RL, Goldberg JM. Laparoscopic ovarian drilling for
clomiphene-resistant polycystic ovary syndrome. Semin
Reprod Med. 2011;29(2):138-46.
37. Nahuis MJ, Kose N, Bayram N, van Dessel HJ, Braat DD,
Hamilton CJ, et al. Long-term outcomes in women with
polycystic ovary syndrome initially randomized to receive
laparoscopic electrocautery of the ovaries or ovulation induction
with gonadotrophins. Hum Reprod. 2011;26(7):1899-904.
38. Campo S. Ovulatory cycles pregnancy outcome and
complications after treatment of polycystic ovarian syndrome.
Obstet Gynecol Survey. 1998;53:297.
39. Al-Mizyen E, Grudzinskas JG. Unilateral laparoscopic ovarian
diathermy in infertile women with clomiphene citrate-resistant
polycystic ovary syndrome. Fertil Steril. 2007;88(6):1678-80.
40. Farquhar C, Lilford RJ, Marjoribanks J, Vandekerckhove P.
Laparoscopic ‘drilling’ by diathermy or laser for ovulation
induction in anovulatory polycystic ovary syndrome. Cochrane
Ch-03.indd 49 18-01-2014 12:04:00

cHAPTER
4
Gonadotropins
Surveen Ghumman
The first birth after gonadotropin stimulation was reported

by Alan Trounson in 1981. Since then it has become the
cornerstone of ART stimulation protocols. FSH with LH
separated by polyvalent antibodies was commercially
available by 1987, but these still contained urinary proteins.
A highly purified FSH was obtained on removing LH by
monoclonal antibodies.1 Finally, the recombinant technology
was used for a FSH preparation with absolutely no LH activity.
Gonadotropin Preparations
1. Human pituitary gonadotropin.
2. Human menopausal gonadotropins (75 IU of FSH, 75 IU
LH).
3. Highly purified hMG (75 IU of FSH and 75 IU of LH with
<5% of urinary protein).
4. Purified urinary FSH (75 IU of FSH and < 0.7 IU of LH).
5. Highly purified urinary FSH (75 IU of FSH and <0.1 IU of
LH and < 5% urinary protein).
6. Recombinant FSH (75 IU of FSH and no LH).
7. Recombinant LH.
Ch-04.indd 50 18-01-2014 12:04:52

Gonadotropins 51
8. Human chorionic gonadotropin (hCG).
9. Recombinant hCG.
Follicle Stimulating Hormone
Effective daily dose: It is the dose of gonadotropins which can

elicit an ovarian response.
There are two phases of stimulation:
1. The latent phase: An initial period of 3 to 7 days where
there is no measurable ovarian response in spite of folli
cular growth.
2. Active phase: After latent phase, a 4 to 7 days period
where there is an exponential rise of estrogen with
follicular growth.
Choice and Dosage of Gonadotropin

The dose and duration of gonadotropin required may vary
with the patient and also from cycle to cycle in the same
patient. There is a relationship with body weight and dose
requirement but the response threshold with all individuals
is unpredictable. Implantation, pregnancy, and live birthrates
were poorer in obese women and were reduced progressively
with each unit of BMI.2
The choice of gonadotropin also depends on indication
of controlled ovarian stimulation. In women with
hypogonadotropic hypogonadism, the drug of choice is
menotropin because it contains both FSH and LH. LH is
essential for ovulation and luteinization and in these cases
LH levels are low. These patients respond to low doses of
gonadotropin stimulation. Luteal phase support may be vital
where endogenous LH levels are low (less than 3 IU/L). These
patients are prone to hyperstimulation and must be monitored
carefully if hCG is given as luteal support (Table 4.1).
Ch-04.indd 51 18-01-2014 12:04:52

Table 4.1: Choice and dose of gonadotropin

Type of gonadotropin Dose of gonadotropin
Hypogonadotropic FSH and LH Adequate dose
hypogonadism (LH (Menotropin)
low)
Clomiphene Recombinant FSH Low dose
resistance/PCOS (LH
high)
Unexplained Any preparation High dose
infertility
In patients with PCOS, LH levels are high. Recombinant FSH

is given after down regulation (E2 < 30 pg/ml, LH < 4IU/L).
There is a very narrow margin between doses which induce
successful ovulation and those which cause hyperstimulation
(Table 4.1). Patients with unexplained infertility are older
subfertile women and the aim is multifollicular ovulation.
Hence, higher doses of gonadotropins are used. In these,
normally ovulating women where endocrinopathies have
been ruled out, any available gonadotropin preparation can
be used. Patients who are obese, above 35 years of age, poor
responders, those with a baseline FSH of more than 10 IU/L or
those downregulated with GnRH agonists, should be started on
a higher dose of 225 IU of FSH. A day 8 LH assay of more
than 10 IU/L predicts failure or increased risk of miscarriage if
pregnancy occurs (Table 4.2). The CONSORT dosing algorithm
individualizes recombinant human FSH (rhFSH) doses for
assisted reproduction technologies, assigning 37.5 IU increments
according to patient characteristics: basal FSH, body mass index,
age and antral follicle count. Use of the CONSORT algorithm
achieved an adequate oocyte yield and good pregnancy rates in
a preliminary study. Adjustment of the algorithm could reduce
cancelation rates.3
Ch-04.indd 52 18-01-2014 12:04:52

Gonadotropins 53
Table 4.2: Factors influencing the dose of gonadotropin

1. Weight
2. Baseline FSH If > 10 IU/l—give higher dose
3. Age beyond 35 years—a higher dose is required
4. Higher effective daily dose in previous cycle
5. Poor responders
6. PCOS patients are usually started on a lower dose to avoid
hyperstimulation
7. Prior down regulation with GnRH agonists—a higher dose is required
8. Hypogonadotropic hypogonadism
Anti-Müllerian Hormone Tailored Protocols

AMH-guided, controlled ovarian hyperstimulation protocols
can significantly improve positive clinical outcomes, reduce
the incidence of complications and reduce the financial
burden associated with assisted reproduction. In a recent
study, when stimulation protocols were tailored according
to the AMH level embryo transfer rates, pregnancy rate
per cycle started and live birthrate increased significantly
compared with conventionally treated women. Moreover, the
incidence of the ovarian hyperstimulation syndrome (OHSS)
fell significantly (6.9 to 2.3%,) and failed fertilization fell
from 7.8% to 4.5%. The cost of fertility drug treatment fell by
29% per patient and the overall cost of clinical management
of OHSS fell by 43% in the AMH group. Within the AMH-
tailored group, the live birthrate was not significantly different
between agonist and antagonist-treated groups.4
Human Menopausal Gonadotropin vs Highly Purified Human

Menopausal Gonadotropin
Patients undergoing controlled ovarian hyperstimulation
for IVF that includes HP-hMG preparations produce
Ch-04.indd 53 18-01-2014 12:04:52

significantly higher implantation (20% vs 8.1%) and pregnancy

rates (47.2% vs 19.4%), as compared to the traditional hMG.5
Alpha Follitropin vs Beta Follitropin

In a study, it was seen that although both Follitropin beta and
alpha achieved a comparable number of retrieved oocytes,
the use of follitropin-beta was associated with a tendency
toward a lower clinical pregnancy rate (PR), and with
significantly higher E2 levels despite the use of significantly
lower total gonadotropin dose.6
Protocols
The treatment is started within the first 2 days of the menstrual
cycle.
Step-up Conventional Protocol

This conventional protocol is started with 150 IU of FSH per
day. Serum estradiol is measured on day 8 and transvaginal
ultrasonography is done. The dose of gonadotropin is
maintained or increased accordingly as indicated. Once the
serum estradiol begins to rise, the size and number of the
developing follicles is determined every 1 to 2 days along
with serum estradiol. If estradiol levels are not increasing
then the dose of gonadotropins needs to be increased. A
maximum of 300 to 375 IU of FSH can be used. There are
studies where doses have gone up to 600 IU. Injection hCG
is given once follicle is more than 16 to 17 mm. Patients will
ovulate 36 hours after the hCG. This regime is useful for poor
responders but has a high rate of multiple pregnancy and
ovarian hyperstimulation syndrome. The effective daily dose
of gonadotropins must be noted for each cycle. In subsequent
stimulation cycles while determining the effective dose
of gonadotropins, the response threshold and pattern of
Ch-04.indd 54 18-01-2014 12:04:52

Gonadotropins 55
follicular development observed in previous cycles should be
considered (Fig. 4.1).
Fig. 4.1: Step-up conventional protocol
Ch-04.indd 55 18-01-2014 12:04:53

Step-up Low Dose Protocol

It is started with an initial dose of 37.5 to 75 IU/day. If no response
is seen in terms of estradiol level or follicle, it is increased in
increments of 37.5 IU every week. This protocol though safe
has an extended duration. Lesser ampules of gonadotropin are
used and preovulatory estradiol levels are lower. Age, obesity
and raised serum LH levels can adversely affect the outcome
of treatment.7 It is useful in patients of PCOS who are prone to
hyperstimulation as they have a large number of antral follicles
ready to respond to FSH stimulation. Administration of FSH
converts already present androgens to estrogens producing
very high levels of estrogens and overstimulation of ovary. This
is avoided by this protocol as small doses of FSH provide the
right amount of stimulation needed to make the process occur
in a controlled manner. Homberg et al found in their study
comparing conventional vs low dose regimen that patients
treated with low dose regimen had a greater pregnancy rate
and no hyperstimulation or multiple pregnancy. Patients on
conventional treatment had an 11% incidence of OHSS and
33% incidence of multiple pregnancy (Fig. 4.2).8
Step-Down Protocol
Since many anovulatory women are very sensitive to low
doses of exogenous gonadotropin stimulus the initiating
dose of this protocol is determined in one or more pervious
stimulation cycles before starting the regime. Total amount
of gonadotropins are reduced in this regimen. The treatment
is usually started with 225 IU hMG/FSH (or 300 IU in
some cases) until follicles of 10 mm is seen. The dose is
then reduced to 112.5 IU and 3 days later decreased to 75
IU and this is continued till administration of hCG. This is
an effort to promote continued development of the more
sensitive dominant follicle while withdrawing support from
Ch-04.indd 56 18-01-2014 12:04:53

Gonadotropins 57
Fig. 4.2: Step-up low dose protocol
less sensitive smaller follicles in the cohort. It is indicated in

oligo-amenorrheic women with PCOS or in high responders
in IVF. FSH promotes follicular growth because of 2 events,
the ‘FSH threshold’ and the ‘FSH window’. FSH threshold
is the level of FSH below which no follicular growth can be
Ch-04.indd 57 18-01-2014 12:04:53

initiated.9 Usually this level in normal women is 7.8 IU/l. The

FSH window is the number of days that serum FSH levels are
above the threshold and determines the number of follicles
which are activated. Since sensitivity of the follicle increases
with development, the required FSH for a follicle will
decrease. The balance between the decreasing FSH levels
and increasing FSH sensitivity is responsible for the growth
of the follicle. Using this concept FSH levels are raised by
exogenous FSH to reach the threshold and prolong the
window in order to obtain specific number of follicles to be
growing. The decreased dose would switch off the recruiting
phase and limit the number of dominant follicles. A multiple
pregnancy rate of 8% and OHSS rate of 2% is seen. This
regimen mimics the physiological normal menstrual cycle.10
It is a second-line protocol in PCOS patients where other
regimens do not achieve success (Fig. 4.3).
Sequential Step-Up, Step-Down Regimen

It is started similar to the step-up protocol but the dose is
reduced by half when leading follicle is 14 mm. This approach
reduces the number of lead follicles.11
Mild Stimulation Protocol

In the recent years, mild protocols have been introduced
aiming at a low stimulation which gives acceptable results
with minimal risks and lower cost (See chapter on mild
stimulation protocols). Here, the endogenous FSH is also
taken advantage of while stimulating. It could be a stimulation
regimen in which gonadotropins are administered at a lower
than usual dose and/or for a shorter duration throughout a
cycle in which GnRH antagonist may or may not be given as
co-treatment, or a stimulation in which oral compounds (e.g.
antiestrogens) are used either alone or in combination with
gonadotropins and GnRH antagonists.12
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Gonadotropins 59
Fig. 4.3: Step-down protocol
Low dose of gonadotropin: A starting dose of 37.5 IU/

day FSH may be used in selected cases to prevent ovarian
hyperstimulation, without loss of efficacy. In a recent study,
follitropin-alpha at 37.5 IU/day was sufficient to achieve
ovarian stimulation in 72.8% cycles. A single follicle ≥16 mm
in diameter developed in 61.1%. Pregnancy rate was 24.7%
with 94.9% singleton and 5.1% twin pregnancies. 4.4%
cycles were canceled, mainly due to poor response.13
Role of GnRH antagonist in mild stimulation: The IVF cycle
can start with an undisturbed early follicular phase recruitment
of follicles by an endogenous FSH rise which occurs in a
natural menstrual cycle. The endogenous inter-cycle FSH rise
Ch-04.indd 59 18-01-2014 12:04:53

is taken advantage of rather than suppressed. FSH is added on

day 5 to continue FSH elevation and extend the FSH window,
for many follicles to develop. This limits the duration and
dose of FSH administration. A premature LH surge may
occur with rising estradiol levels which act through positive
feedback loop. GnRH, antagonist has an immediate action
blocking the pituitary when estradiol levels start rising and
approach threshold levels at which an LH surge can occur.
Clomiphene in mild stimulation protocol: The second mild
regime includes using clomiphene 100 mg, delayed low dose
gonadotropin and a flexible GnRH antagonist administration
for ovarian stimulation protocol. Pregnancy rates comparable
to the standard stimulation regimens were obtained, with a
significant reduction in the total dose of gonadotropin needed
and of the economical costs.14
Clomiphene with single dose FSH: Addition of single
dose of uFSH on day 3 along with clomiphene recruits
the co-dominant follicles earlier at follicular phase
and therefore enhances the chances of pregnancy.15
It is not only cost-effective but also prevents multiple
pregnancy. In order to determine the ideal dose, a study
showed the clinical pregnancy rate was 14.8% when
150 IU of rFSH and 20.4% when only 100 IU of rFSH was
given in IUI patients along with clomiphene. The incidence
of multiple pregnancy was 41.7% in the first group compared
with 12.5% in the second group.16
Monitoring
Careful monitoring with serum estradiol levels and
ultrasonography is needed to achieve the goal of ovulation
without hyperstimulation and multiple pregnancy.
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Gonadotropins 61
Serum Estradiol Levels
Follicles with a diameter of less than 10 mm produce relatively
little estradiol but its level starts rising exponentially doubling
every 2 to 3 days before ovulation. A change in the rate of
rise of estradiol suggests a need for increasing or decreasing
the dose of gonadotropin. For each mature follicle the level
of estradiol is 200 to 300 pg/ml. When the gonadotropin
injection is given between 5 and 8 pm, the estradiol estimation
should be done early morning.
Ultrasonography
A baseline ultrasonography is a must. In case there are residual
ovarian cysts (more than 10 mm) treatment should be deferred
as stimulation in the presence of a cyst is often unsuccessful.
In a gonadotropin stimulated cycle follicle exhibits a linear
growth but reaches maturity at a much smaller mean diameter.
40% patients ovulate when follicle is of 15 to 16 mm diameter.
The rate of growth is 1 to 3 mm/day. Endometrial thickness
measurements are also important. Cycle fecundity increases
with endometrial thickness. Results are poor if endometrial
thickness is less than 7 mm.
There is no evidence to support cycle monitoring by ultrasound

along with serum estradiol as more efficacious than cycle
monitoring by ultrasound only on outcomes of live birth and
pregnancy rates.17
Problems
1. Multiple pregnancy (10–40%): Twin births have increased
by 50% and higher order births have quadrupled. Risk is
reduced if ovulation is not triggered when the estradiol
level or number of maturing follicles is excessive.
Ch-04.indd 61 18-01-2014 12:04:53

2. Hyperstimulation syndrome: It is seen more in young age, low

body weight, PCOS and usage of high doses of gonadotropins.
Rapidly rising serum estradiol level, concentration over
2,500 pg/ml and observations of a large number of small
and intermediate size follicles indicate a high risk for OHSS.
Mild forms of OHSS are seen in 8 to 23%, moderate in
6 to 7% and severe in 1 to 2% of cases stimulated with
gonadotropins.
3. Breast and ovarian cancer: There have been no consistent
reports of any causal relationship between gonadotropins
and breast or ovarian cancer.
4. Miscarriage (25%): Miscarriage rates are low in hypo
gonadotropic hypogonadism and much higher in
clomiphene resistant anovulatory women.
Recombinant FSH
Recombinant FSH was prepared by transfecting Chinese
hamster ovary cell lines with both FSH subunit genes. Starting
dose is 50 IU.18 The rFSH is quantified as protein content
(mass in µg) rather than biological activity. However, its
biological activity is confirmed too. The conversion factor
is 75 IU corresponds to between 5 and 5.5 µg fill by mass
product.19 The delivery system is a pen-shaped device that
is either prefilled or can be adjusted to fill variable doses
from the vial. They are either lyophilized powder or liquid
formulations found in cartridges or pens.
Recombinant vs Urinary FSH

It was seen that although dose and duration of treatment
with FSH was less and significantly more number of oocytes
were retrieved with rFSH compared with uFSH, there was no
difference in pregnancy rate in the two groups.20 However,
the pregnancy rates improved significantly when using rFSH
Ch-04.indd 62 18-01-2014 12:04:53

Gonadotropins 63
instead of uFSH in poor responders (33% vs 7%).21 There
was no difference in oocytes recovered, dose and duration of
treatment and pregnancy rates between alpha folliculotropin
(Gonal F) and beta folliculotropin (Puregon).22 Clinical choice
of gonadotrophin should depend on availability, convenience
and costs as no substantive differences in effectiveness or
safety was seen on comparing recombinant FSH with other
gonadotropins.23
Advantages of Recombinant FSH

1. It has identical amino acids to natural FSH.
2. Consistent.
3. No LH activity.
4. No contamination with urinary proteins.
5. Highly specific and pure.
6. No restriction in supply.
7. Can be administered subcutaneously.
Disadvantages
1. Cost
2. Increased incidence of OHSS has been reported in some
studies.
Recombinant FSH-CTP in IVF

The b subunit of hCG is different from gonadotropic hormones
as it has a C-terminal peptide extension which is responsible
for reduced clearance resulting in major enhancement of in
vivo bioavailabilty. Daily injections of FSH have to be given
as it has a short half-life. Genes containing the sequence
coding the C-terminal peptide (CTP) of hCG is fused with b
subunit of FSH creating an FSH which is long acting with
a half-life of 95 hours eliminating need for daily injections.
Ch-04.indd 63 18-01-2014 12:04:53

Early follicular phase administration of FSH-CTP avoids

the need for daily injections as a single injection enables
follicular growth over a period of 7 days. Maximum serum
levels are obtained after 36 to 48 hours. A second injection
7 days later may cause hyperstimulation. Hence, daily doses
of recombinant FSH are given thereafter. It is given as a single
subcutaneous injection of 180 µg recombinant FSH-CTP on
day 3 followed by daily injections of recombinant FSH 150 IU
from day 10 onward combined with GnRH antagonist 0.25
mg subcutaneously to prevent premature surge of LH.24 The
pharmacokinetics of corifollitropin alfa and rFSH are quite
different but their induced pharmacodynamic effects at the
dosages used are similar.25 The safety and efficacy of such
regimens is currently being evaluated in large comparative
phase III clinical trials. It is recommended that patients should
be treated with the appropriate dose of corifollitropin alfa
according to their body weight as a lower dose does not result
in milder stimulation and a higher dose does not result in an
improved ovarian response. Two strengths of corifollitropin
are available (for patients ≤ 60 kg and > 60 kg). Compared
with a daily dose of 200 IU of rFSH, 150 µg of corifollitropin
is equivalent in safety and pregnancy outcomes in women
using an antagonist protocol.
In normal responder patients undergoing ovarian
stimulation with GnRH antagonist co-treatment for IVF
ongoing pregnancy rates of 38.9% for the corifollitropin alfa
group and 38.1% for rFSH were achieved showing similar
results for number of embryos transferred. Median duration
of stimulation was equal (9 days) and incidence of (moderate/
severe) ovarian hyperstimulation syndrome was the same
(4.1% and 2.7%, respectively).26 Fertilization rates were
high, ranging from 66% to 68%. Corifollitropin alfa was
generally well tolerated, with a tolerability profile similar to
Ch-04.indd 64 18-01-2014 12:04:53

Gonadotropins 65
that of rFSH. There were no clinically relevant differences in
pregnancy complications and the incidence of infant adverse
events between the two drugs.27
Hence, compared with seven once-daily injections
of rFSH, a single injection of corifollitropin alfa achieves
equivalent efficacy, and provides a well tolerated and more
convenient treatment option to induce multiple follicular
growth prior to assisted reproduction.
Recombinant LH
It is known that the follicular selection and final stages of
follicular maturation are equally if not more dependent on low
28
circulating levels of LH. In addition to stimulating production
of thecal androgens as substrate for estrogen synthesis, LH
stimulates granulosa cells via LH receptors induced by FSH
and estrogen in larger but not smaller follicles. LH then
becomes the principal stimulus for final stages of follicular
maturation while at the same time declining concentration
of FSH starve the smaller more FSH-dependent follicles into
atresia. Low dose hCG or recombinant LH can promote larger
follicles to grow while hastening the regression of smaller
follicles.
Exogenous LH supplementation was consistently associated
with higher peak estradiol concentrations. The use of hMG in
long GnRH agonist cycles was associated with a 3–4% increase
in live birthrate. There was insufficient evidence to make
definitive conclusions on the need for exogenous LH activity in
GnRH antagonist cycles or the benefit of recombinant LH and
hCG protocols. Poor responders and patients 35 years of age
and older benefit from exogenous LH.29
Recombinant LH can be used for inducing rupture in
a single dose of 15,000 or 30,000 IU which is equivalent
to reference treatment of 5000 IU hCG. It is superior with
Ch-04.indd 65 18-01-2014 12:04:53

regard to incidence of OHSS and has a shorter half-life than

hCG. Recombinant LH is also needed in hypogonadotropic
hypogonadism in a dose of 75 IU daily for ovulation induction
with rFSH for better results.30
Human Chorionic Gonadotropin

Human chorionic gonadotropin (hCG) promotes the final stages
of follicular maturation helping the oocyte reach metaphase II.
Approximately 36 hours are required for completion of meiotic
process and oocyte retrieval should be done within this time.
It can be derived from human urine or can be recombinant.
Recombinant hCG is available in syringes of 250 µg which is
equivalent to 5000–6000 IU of hCG. There is no evidence of
difference between rhCG or rhLH and uhCG in achieving final
follicular maturation in IVF, with equivalent pregnancy rates
and OHSS incidence.31 BMI affects hCG levels. The highest
levels of hCG were measured in women with the lowest BMI.
Patients’ body size, rather than route of hCG delivery, appears
to determine circulating levels of hCG.32
Exogenous gonadotropins have been used since last 4
decades. They are highly effective in ovulation induction but
are accompanied with the disadvantage of high cost, extensive
monitoring and risks of ovarian hyperstimulation and multiple
pregnancy.
References
1. ASRM Practice Committee. Gonadotropins. Fertil Steril.
2008;90:S13-20.
2. Bellver J, Ayllón Y, Ferrando M, Melo M, Goyri E, Pellicer A, et
al. Female obesity impairs in vitro fertilization outcome without
affecting embryo quality. Fertil Steril. 2010;93(2):447-54.
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Gonadotropins 67
3. Olivennes F, Howies CM, Borini A, Germond M, Trew
G, Wikland M, et al. Individualizing FSH dose for assisted
reproduction using a novel algorithm: the CONSORT study.
Reprod Biomed Online. 2011;22 Suppl 1:S73-82.
4. Yates AP, Rustamov O, Roberts SA, Lim HY, Pemberton PW,
Smith A, et al. Anti-Mullerian hormone-tailored stimulation
protocols improve outcomes whilst reducing adverse effects
and costs of IVF. Hum Reprod. 2011;26(9):2353-62.
5. Orvieto R, Meltcer S, Liberty G, Rabinson J, Anteby EY,
Nahum R. Human menopausal gonadotropin versus highly
purified-hMG in controlled ovarian hyperstimulation for in-
vitro fertilisation: does purity improve outcome? Gynecol
Endocrinol. 2010;26(10):733-5.
6. Orvieto R, Nahum R, Rabinson J, Ashkenazi J, Anteby EY,
Meltcer S. Follitropin-alpha (Gonal-F) versus follitropin-beta
(Puregon) in controlled ovarian hyperstimulation for in vitro
fertilization: is there any difference? Fertil Steril. 2009;91(4
Suppl):1522-5.
7. White DM, Polson DW, Kiddy D. Induction of ovulation with
low dose gonadotropins in polycystic ovary syndrome: An
analysis of 109 pregnancies in 225 women. J Clin Endocrinol
Metab.1996;81:3821-24.
8. Homberg R, Levy T, Ben-Rafeal Z. A comparative prospective
study of conventional regimen with chronic low dose adminis
tration of follicle stimulating hormone for anovulation
associated with polycystic ovary syndrome. Fertil Steril.
1995;63:729-33.
9. Baird DT. A model for follicular selection and ovulation: Lessons
from superovulation. Steroid Biochem. 1987;27:15-23.
10. van Santbrink EJP, Donderwinkel PFJ, van Dassel TJHM.
Gonadotropin induction of ovulation using step-down dose
regimen: Single centre clinical experience in 82 patients. Hum
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11. Hugues JN, Cedrin-Dumerin I, Avril C, Bulwa S, Herve-
Fand-Uzan M. Sequential step up and step down regimen:
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polycystic ovarian syndrome. Hum Reprod. 1996;11:2581-4.
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12. Nargund J, Fauser BCJM, Macklon NS, Ombelet W, Nygren K,

Frydman R. The ISMAAR proposal on terminology for ovarian
stimulation for IVF. Hum Reprod. 2007;11(14):2801-504.
13. Bruna-Catalán I, Menabrito M; Spanish Collaborative Group
Ovulation induction with minimal dose of follitropin alfa: a
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14. Karimzadeh MA, Ahmadi S, Oskouian H, Rahmani E.
Comparison of mild stimulation and conventional stimulation
in ART outcome. Arch Gynecol Obstet. 2010;281(4):741-6.
15. Mukherjee S, Sharma S, Chakravarty BN. Comparative
evaluation of pregnancy outcome in gonadotrophin-
clomiphene combination vs clomiphene alone in polycystic
ovarian syndrome and unexplained infertility—A prospective
clinical trial. J Hum Reprod Sci. 2010;3(2):80-4.
16. Chung MT, Chan TF, Loo TC, Tang HH, Lin LY, Tsai YC.
Comparison of the effect of two different doses of recombinant
gonadotropin for ovarian stimulation on the outcome of intrauterine
insemination. Taiwan J Obstet Gynecol. 2011;50(1):58-61.
17. Kwan I, Bhattacharya S, McNeil A, van Rumste MM. Monitoring
of stimulated cycles in assisted reproduction (IVF and ICSI).
Cochrane Database Syst Rev. 2008 Apr 16;(2):CD005289.
18. Calaf Alsina J, Ruiz Balda JA, Romeo Sarrió A, Caballero
Fernández V, Cano Trigo I, Gómez Parga JL, et al. Ovulation
induction with a starting dose of 50 IU of recombinant follicle
stimulating hormone in WHO group II anovulatory women:
the 10–50 study, a prospective, observational, multicentric
open trial. BJOG. 2003;110-12.
19. Hugues JN, Durnerin IC. Gonadotropins-filled-by-mass versus
filled-by- bioassay. Reprod Biomed Online. 2005;10(Suppl
3):11-8, 32.
20. Schats R, De Sutter P, Bassil S, Kremer JAM, Tournaye H,
Donnez J. Ovarian stimulation during assisted reproduction
treatment: A comparison of recombinant and highly purified
urinary human FSH. Hum Reprod. 2000;15:1691-7.
21. De placido G, Alviggi C, Mollo A, Strina I, Varricchio MT,
Molis M. Recombinant follicle stimulating hormone is effective
in poor responders to highly purified follicle stimulating
hormone. Hum Reprod. 2000;15:17-20.
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Gonadotropins 69
22. Brinson P, Adagios F, Gibbons L, et al. A comparison of efficacy
and tolerability of two recombinant human follicle stimulating
preparations in patients undergoing in vitro fertilization-
embryo transfer. Fertil Steril. 2000;73:114-6.
23. van Wely M, Kwan I, Burt AL, Thomas J, Vail A, Van der
Veen F, et al. Recombinant versus urinary gonadotrophin for
ovarian stimulation in assisted reproductive technology cycles.
Cochrane Database Syst Rev. 2011 Feb 16;(2):CD005354.
24. Balen AH, Mulders AG, Fauser BC, Schoot BC, Renier MA,
Devroey P, et al. Pharmacodynamics of a single low dose of
long-acting recombinant follicle-stimulating hormone (FSH-
Carboxy Terminal Peptide, Corifollitropin Alfa) in women with
World Health Organization Group II Anovulatory Infertility. J
Clin Endocrinol Metab. 2004;89(12):6297-304.
25. Fauser BJC, Alper MM, Ledger W, Schoolcraft WB, Zandvliet A,
Mannaerts BMJM. Engage Investigators. Pharmacokinetics and
follicular dynamics of corifollitropin alfa versus recombinant
FSH during ovarian stimulation for IVF. Reprod Biomed
Online. 2010;21(5):593-601.
26. Croxtall JD, McKeage K. Corifollitropin alfa: a review of its use
in controlled ovarian stimulation for assisted reproduction.
BioDrugs. 2011;25(4):243-54.
27. Rombauts L, Talmor A. Corifollitropin alfa for female infertility.
Expert Opin Biol Ther. 2012;12(1):107-12s.
28. Levy DP, Navarro JM, Schattman GL, Davis OK, Rosenwaks
Z. The role of LH in ovarian stimulation: Exogenous LH: Lets
design the future. Hum Reprod. 2000;15:2258-65.
29. Hill MJ, Levy G, Levens ED. Does exogenous LH in ovarian
stimulation improve assisted reproduction success? An appraisal
of the literature. Reprod Biomed Online. 2012;24(3):261-71.
30. Schoot DC, Harlin J, Shaham Z, Mannerts BM, Lahlou N,
Bouchard P, et al. Recombinant human follicle stimulating
hormone and ovarian response in gonadotropin deficient
women. Hum Reprod. 1994;9(7):1237-42.
31. Youssef MA, Al-Inany HG, Aboulghar M, Mansour R, Abou-
Setta AM. Recombinant versus urinary human chorionic
gonadotropin for final oocyte maturation triggering in IVF
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and ICSI cycles. Cochrane Database Syst Rev. 2011 Apr

13;(4):CD003719.
32. Elkind-Hirsch KE, Bello S, Esparcia L, Phillips K, Sheiko A,
McNichol M. Serum human chorionic gonadotropin levels
are correlated with body mass index rather than route of
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embryo transfer using human menopausal gonadotropin and
intracytoplasmic sperm injection. Fertil Steril. 2001;75(4):700-4.
Ch-04.indd 70 18-01-2014 12:04:53

cHAPTER
5
Role of GnRH Agonists and
Antagonists in Assisted
Reproductive Technology
Surveen Ghumman
The GnRH agonists and antagonists have occupied an

increasingly important position in the ovulation induction
protocols. GnRH analogs are able to suppress gonadotropin
release and subsequently, the gonadal function. This is the
basis for their clinical applications as it controls the premature
endogenous luteinizing hormone (LH) surge and therefore,
decreases the cycle cancelation rate.
GnRH Agonist (GnRHa)

Substitutions in the GnRH molecule cause enhanced
affinity for the GnRH receptors and protects against enzyme
degradation increasing half-life from 8 minutes to 5 hours.
Decapeptide Agonists
• Triptorelin
• Naferelin
• Goserelin.
Ch-05.indd 71 18-01-2014 12:05:10

Nonapeptide Agonists
• Buserelin
• Leuprolide
• Histerelin.
Mechanism of Action
The mechanism of action is a “flare effect”, followed by
downregulation. Within 12 hours of administration it induces
liberation of high amount of FSH and LH and also increases the
number of receptors (5-fold increase in FSH, 10-fold increase
in LH and 4-fold increase in estradiol receptors). This is the so-
called ‘upregulation.’ A continuous administration of GnRH
agonist produces the opposite effect. There is a decrease in
level of FSH and LH by internalization of the receptor-agonist
complex and a reduction in the number of receptors. This
is called ‘downregulation’ or desensitization of the pituitary.
This eliminates any premature LH surge and decreases LH
stimulation of ovarian androgen production. The advantage
is reduced cycle cancelation, convenient timing of treatment
and higher live birthrates. Stimulation is then begun with
gonadotropins. Also it can be used as an ovulation trigger to
prevent ovarian hyperstimulation syndrome.
Commonly used GnRH agonists are:
Leuprolide sc 500–1000 µg or im depot 3.75, 7.5 mg/month
Buserelin sc 200–500 µg/day or 300–400 µg intranasally
3–4 times/day
Goserelin sc implant 3.6 mg/month
Triptorelin sc 100–500 µg/day or im depot 3.75 mg/month.
Route of Administration
1. Subcutaneous injections.
2. Sustained release implants.
Ch-05.indd 72 18-01-2014 12:05:10

Role of GnRH Agonists and Antagonists 73
3. Intramuscular depot injections.
4. Nasal spray.
Subcutaneous: This route is most commonly used because
of high bioavailability and low interindividual variation. It
results in prolonged and delayed absorption compared to
intravenous route.
Intranasal route: Disadvantages of this route include a marked
interindividual variation in absorption and considerable
losses of peptides by proteolysis and swallowing. Initially
preparation like buserelin needed frequent administration (5
times a day); however, nasal preparations like naferelin only
require twice a day administration.1 There is an advantage of
persistence of drug in the nasal mucosa for up to 24 hours
consistent with depot like effects. The drug absorption varies
with rhinitis and allergy. It is a more convenient route for the
patient as compared to daily injections.
Depot formulation: Since there is more profound suppression
of the pituitary gonadal axis with continuous administration
of the drug, sustained or continuous release formulations
have been developed. Currently available preparations
include a suspension of 3.75 mg triptorelin or leuprolide
in microcapsules injected intramuscularly once a month or
3.6 mg of goserelin dispersed in a biodegradable polymeric
matrix of polylactide-co-glycolide as a cylindrical rod implant
injected subcutaneously every month. The pharmacokinetics
of the two differ. In both, the drug is released over 30 to 55
days. The number of follicles developed, E2 levels, oocyte
quality, fertilization and pregnancy rates were same as with
daily administration.2 Because of prolonged desensitization
the dose of gonadotropins needed is more and stimulation is
longer.2
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Use of GnRH Agonist in COH Protocols

The use of GnRH agonists decreased cancelation rates in
IVF cycle from 20 to 2% and improved fertilization and
implantation rates.3 Three protocols have been described:
a. Long protocol.
b. Short protocol.
c. Ultrashort protocol.
Protocols for Administration

Long Protocol
Ch-05.indd 74 18-01-2014 12:05:10

Advantages of long Protocol
1. It prevents unwanted LH surge and hence, cancellation of

cycles.
2. It helps plan the time of ovum pick-up.
3. Improves overall pregnancy rates especially in patients
with raised LH levels.
4. Allows synchronization ingrowth of follicles.
5. Reduces intensive monitoring of cycles to detect premature
LH surge.
6. Most studies show a better result with the long protocol
than with short or ultrashort protocol.
Disadvantages of Long Protocol

1. Extends or prolongs treatment cycle.
2. Higher doses of gonadotropins are needed.
3. More expensive.
4. It is associated with symptoms of depression in
hypogonadal phase.4
How Long Can we Continue with GnRH Agonist if Sup-

pression is not Achieved?
In a recent study suppression was obtained after 14 GnRHa
days in 75.70% and 24.30% required a mean ± SD (range)
of 10 ± 4 (7–28) additional days to achieve complete
suppression. In a standardized long GnRHa protocol,
prolonging desensitization to achieve complete ovarian
suppression does not affect the outcome in terms of pregnancy
rate, oocytes retrieved, cycle cancelation, implantation rate,
quality of embryos and live birthrates.5
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Oral Contraceptive Pretreatment before Suppression by

GnRH Agonist
Administration of a gonadotropin-releasing hormone
analog (GnRHa) causes a flare effect leading to formation
of ovarian cysts that can be functional and can impair
downregulation and stimulation. Hence, they must be treated
before commencement of stimulation. Oral contraceptives
(OC) prevent the formation of ovarian cysts during GnRHa
administration through a dual effect of pituitary suppression
and ovarian protection. OC may be given for 14 days prior to
downregulation. Pretreatment with an OC abolishes ovarian
cyst formation, shortens the time required to achieve pituitary
suppression, and decreases gonadotropin requirements
without having a negative effect on pregnancy rates.6
Short Protocol
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Advantages of Short Protocol
1. Better for older patients and poor responders as it causes
greater follicular recruitment.
2. The flare effect offers an advantage in hypogonadotropin
hypogonadism.
3. Shorter protocol
4. Less expensive.
5. Less chances of ovarian hyperstimulation because of
lower E2 levels.
Disadvantages of Short Protocol

In PCOS it causes irregular growth of follicle and is not helpful
where LH levels are raised.
Ultrashort Protocol
This differs from the short protocol in discontinuing the agonist

once it has stimulated the flare. This reduced the doses of
both drugs. However, this protocol had poor pregnancy rates
as compared to long protocol because of premature LH surge.
Which Protocol to Use?

The pregnancy rate was found to be higher when GnRHa was
used in a long protocol as compared to a short or ultrashort
Ch-05.indd 77 18-01-2014 12:05:11

protocol but there was no difference in live birthrate. There

was no evidence of a difference in the outcomes amongst
various long protocols, nor that stopping or reducing GnRHa
at the start of stimulation was associated with a reduced
pregnancy rate.7
Disadvantages of GnRH Agonists

1. Increased time for stimulation in the long protocol.
2. Short protocol may add to increase in premature LH surge.
3. Luteal phase support is needed.
4. Increased cost due to increased requirement of gona
dotropin.
5. It may cause hyperstimulation due to flare response in
luteal phase in the long protocol leading to high estradiol
levels and ovarian cyst.8
Advantages of GnRH Agonists

1. Decreases the need for close monitoring to detect
spontaneous LH surge.
2. Less cycle cancelation.
3. Better response.
4. More flexible schedule.
5. Higher oocyte recovery and pregnancy rate.
Side Effects and Risks of gnrh Agonists

1. Ovarian cyst: It is seen in 14 to 29%, more with the short
protocol.
2. Ovarian hyperstimulation syndrome: The increased inci
dence of OHSS is due to increased pregnancy rate and
higher doses of gonadotropins being used.
3. Luteal phase defect.
4. Transient neurological disturbances like parasthesia or
headaches occur in 5%.
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Gnrh Agonist for Ovulation Trigger
In patients at risk to develop OHSS, the only option available
earlier was to withhold the ovulatory dose of human chorionic
gonadotropin leading to canceled cycles. GnRH agonist,
when administered in a single dose, bring about the LH surge
and triggers ovulation like hCG, because of its flare effect.
Dose: Leuprolide acetate: 1 mg given either subcutaneously
as a single, or two doses 12 hours apart can act as an ovulation
trigger.
Advantages
a. Its short duration of action is more physiological unlike
extended surge with the use of hCG.
b. Decrease in multiple pregnancy.
c. Prevents OHSS as it has shorter duration of action
compared to hCG. Luteotropic action is prolonged in
hCG administration leading to development of multiple
corpora lutea and supraphysiological levels of E2.
d. Can be used along with antagonist.
Disadvantages
a. Cannot be used in cases of hypogonadotropic hypo
gonadism.
b. Not used for cases downregulated with GnRH agonist as
the flare effect of LH release by a single dose of the agonist
will not occur because of pituitary downregulation,
making ovulation trigger ineffective.
c. It causes pituitary desensitization lead lowered pregnancy
and live birthrates. Hence, luteal support is necessary
in these women. Triggering final oocyte maturation with
GnRH agonist instead of hCG in IVF cycles dramatically
decreases luteal levels of inhibins, reflecting significant
Ch-05.indd 79 18-01-2014 12:05:11

inhibition of the corpus luteum function. This effect

may explain, at least in part, the mechanism of ovarian
hyperstimulation syndrome prevention by the use of
GnRH agonist.9 A recent Cochrane review 2011 has not
recommended that GnRH agonists be routinely used
as a final oocyte maturation trigger in fresh autologous
cycles because of lowered live birthrates and ongoing
pregnancy rates. An exception could be made for women
with high risk of OHSS, after appropriate counseling.10
A defective corpus luteum function resulting from the
relatively short endogenous luteinizing hormone surge
may be detrimental to endometrial receptivity. Adequate
estradiol and progesterone supplementation in the
luteal phase and the first trimester is recommended. An
alternative approach is the use of adjuvant low-dose
human chorionic gonadotropin, although caution should
be exercised in view of the associated risk of OHSS
development.11 After modified luteal support there is now
a non-significant difference of 6% in delivery rate in favor
of hCG triggering.12
GnRH Antagonists
Antagonists act by competitive inhibition of GnRH receptors
preventing the native GnRH from exerting its stimulatory
effect on the pituitary cells, resulting in rapid decline in LH
and FSH lasting for 10 to 100 hours. There is no stimulatory
phase unlike the GnRH agonists. Due to competitive nature
of action this effect is dose-dependant and depends on the
equilibrium between endogenous GnRH and the antagonists.
Their action is easily reversible. Antagonists neither deplete
the LH and FSH stores nor inhibit their synthesis.
Ch-05.indd 80 18-01-2014 12:05:11

Contraindications
1. Hepatic dysfunction.
2. Renal dysfunction.
3. Hypersensitivity to GnRH analogs.
Protocols
Antagonist can be given in two ways:
a. Lubeck protocol (Multidose protocol): Gonadotropins
are started as usual. When follicle reaches 14 mm or on
a fixed day of protocol, antagonist is added at a dose of
0.25 mg/day until the day before ovulation (Fig. 5.1). This
protocol can be either fixed or flexible.
a. Fixed Protocol – Daily injections of small doses initiated
on a fixed day of stimulation till hCG administration
b. Flexible Protocol – Daily injections of small doses
initiated depending on the size of the dominant follicle
(14 mm) or on estradiol levels till hCG administration.
b. French protocol (Single dose protocol): Gonadotropins
are started as usual. Antagonist is given in a single dose of
3 mg when E2 is about 150 to 200 pg/ml and follicular
size is 14 mm (Fig. 5.2).
Fig. 5.1: Lubeck protocol
Ch-05.indd 81 18-01-2014 12:05:11

Fig. 5.2: French protocol
Single Versus Multiple Dose GnRH Antagonist Protocol

Advantage of single dose protocol was lesser injections but
if hCG needs to be delayed additional daily doses are given.
About 10% women require additional doses. Cochrane
review 2002 has concluded that both protocols were equally
effective in preventing premature LH surge.13 It was seen that
the single dose protocol may lead to extreme suppression of
LH but pregnancy rates were similar with both protocols.14
Fixed Versus Flexible Antagonist Administration

In an analysis of three studies, a flexible GnRH antagonist
protocol was compared to the fixed protocol. In stimulated
cycles it was seen that intense ovarian response with more
number of follicles led to an early rise in estradiol. Thus,
threshold levels of estradiol, which initiates a LH surge, are
reached earlier before follicles reach an optimum size. In
these cases the flexible protocol which is dependent on the
size of the follicle on ultrasound to start antagonist in order to
suppress surge, may no longer be accurate to determine time
of initiation of GnRH antagonist.15 This observation might
explain the observed lower efficacy of the flexible protocol
Ch-05.indd 82 18-01-2014 12:05:11

compared with a fixed protocol in a meta-analysis of four
studies.16
Hence, for patients with a profound ovarian response,
early initiation of the GnRH antagonist may be needed.
Which GnRH Antagonist is to be used?

Cetrorelix and ganirelix both effectively prevented LH surge.
However, cetrorelix required significantly fewer injections,
increasing patient convenience.14
Should FSH dose be Increased in Antagonist Cycle ?

Although with antagonist cycles, gonadotropin dose needed
is lower as there is no pituitary suppression; however, a
reduced oocyte recovery was notice. An initial higher dose
of FSH gave a higher oocyte recovery but there was no
difference in pregnancy rates.17 It was seen that increasing
dose of FSH or hMG after starting antagonist did not increase
pregnancy rates.18,19
Role of Oral Contraceptive Pill Pretreatment in Ovarian

Stimulation with GnRH Antagonists for Cycle Scheduling
Pretreatment with an oral contraceptive (OC) in antagonist
cycle has been suggested to allow greater control over
patient response rate and to avoid follicular asynchrony.
Scheduling of cycle is no longer based on menstruation but
on discontinuation of OCP. A meta-analysis proved that no
increase in pregnancy rate was seen with OC.20 However, it
has been associated with increased duration of treatment and
higher doses of gonadotropin.21 In a recent study OCP (0.030
ethinyl E(2)/0.15 desogestrel) for 12–16 days, and controlled
ovarian hyperstimulation with GnRH antagonist was started
on day 5 after OCP treatment. On comparison with long
Ch-05.indd 83 18-01-2014 12:05:11

protocol no differences were observed in the fertilization

rates (68.1% vs 64.8%), total number of embryos obtained
(5.9 vs 6.2), mean number of embryos transferred (1.8 vs
1.8), implantation rate (36% vs 39%), miscarriage rate (8.9%
vs 17%), ongoing pregnancy rate (47.8% vs 53.9%), or live
birthrate (44.3% vs 47%).22
LH Supplementation with GnRH Antagonist

An abrupt suppression of endogenous LH by GnRH antagonist
occurs in the mid-follicular phase, at a critical stage for
follicular development. However, studies have shown no
increase in pregnancy rate with LH supplementation or
increase of hMG dose on initiation of antagonist.19,23 The
decision to add LH must be individualized. It has been seen
that the direction and rate of change in LH concentrations
are the important factors governing the follicular unit
development, not the LH concentration itself.24 It was found
in a study that in 12–14% of downregulated patients the
initial response to FSH is suboptimal (in terms of follicular
growth and estradiol rise) and their day 8 LH concentration
decreased from 1.2 to 0.7. It was suggested that these
patients are the candidates for LH supplementation. Normal
responders increased their mean LH concentrations from
1.5 to 4.3 after 8 days of stimulation. It was suggested that
the follicular unit is sensitive not necessarily to the current
concentration of LH, but rather to the dynamics of the change
in these concentrations and hence, LH supplementation must
be individualized.25 In women on antagonist-based cycles for
the first time, it is preferable to add recombinant LH or partly
switch to hMG on the day of antagonist administration.26
Ch-05.indd 84 18-01-2014 12:05:11

Luteal Support
It is seen that pituitary suppression may continue into luteal
phase with poor development of endometrium. Hence, luteal
support is a must and has shown to improve pregnancy rates.
Advantages of GnRH Antagonists over GnRH-agonist in

ART
1. Short, simple and convenient method of stimulation,
which is well tolerated by the patient.
2. There is immediate suppression with no stimulatory
phase. So no ovarian cyst formation takes place as in
agonist cycle.
3. There are no symptoms of estrogen deprivation.
4. Minimal local reactions.
5. Decreased risk of OHSS: A recent Cochrane (2011)
showed a decreased risk of OHSS but similar live
birthrates compared to GnRH agonists.27
6. Clinical results of IVF cycles are comparable in both
(Cochrane 2011)27
7. Decrease in the overall cost of treatment.
8. Immediate reversibility.
9. Reduced dose of gonadotropins.
10. Effect on endometrium: Simón et al (2005) observed that
the endometrial development after GnRH antagonist
mimics the natural endometrium more closely than after
GnRH agonist.28
11. LH levels and embryo quality: GnRH antagonists
administration during the late follicular phase resulted
in lower serum LH levels and better embryo quality in
comparison to GnRH agonists.29
Ch-05.indd 85 18-01-2014 12:05:11

Studies have concluded that antagonists should be the

first choice in IVF treatment, with less of the complications
and risks of controlled ovarian hyperstimulation and an
acceptable success rate.29
Recommendation: For GnRH antagonist use in IVF cycle:30

1. Increase in the starting dose of gonadotropins or to increase
gonadotropin dose at antagonist initiation is not necessary.
2. OCP pretreatment can be used for scheduling IVF cycles.
3. Addition of LH with initiation of antagonist not necessary.
4. Fixed protocol appears to be superior to flexible initiation by
a follicle of 14–16 mm.
5. Results with single dose and multiple dose protocols were
similar but single dose led to more profound LH suppression
although convenience of a single injection administration was
there.
Disadvantages of Antagonists
1. Easy patient scheduling is lacking, because of the reliance
on spontaneous menstrual cycles.
2. Lack of stimulatory effects on folliculogenesis typical of
GnRH agonist regimens.
3. Need to replace LH if recombinant FSH is used.
Gonadotropin-Releasing Hormone
It is mainly used in WHO group I anovulatory women but can
be used in PCOS patients. The advantages are that significant
follicular monitoring is not needed and it has less risk for OHSS
and multiple pregnancy. It can be given either subcutaneously
in a dose of 20 µg or intravenously 5 µg at 90 min interval
through a portable programmable mini pump worn by the
patient throughout. If there is no response in weekly estradiol
level the dose is increased by increments of 5 µg. Luteal phase
Ch-05.indd 86 18-01-2014 12:05:11

support can be given by continuation of the pump. Problems
encountered are malfunction of the pump and local effects like
thrombophlebitis, cellulitis, urticaria or anaphylaxis. Ovulation
rates of 90%, conception rates of 20 to 30% per cycle and
cumulative pregnancy rate of 80 to 90% after 12 months
are seen in WHO group 1 women.31 In PCOS cumulative
pregnancy rate is 30 to 40%. Abortion occurs in 20% cases
and multiple pregnancies in 5%.
Thus, to conclude the GnRH antagonist reduces the dose
and duration of gonadotropin treatment as it does not nullify
FSH or LH secretion but interrupts the premature LH surge.
It has the disadvantage of loss of easy patient rescheduling
because of reliance on natural recruitment of follicles, lack of
stimulatory effect on folliculogenesis unlike GnRH agonists
and need for replacement of LH if recombinant FSH is used.
References
1. Anik ST, McRae G, Narenberg C, Worden A, Foreman J,
Hwang JY, et al. Nasal absorption of naferelin acetate, the
decapeptide (D-Nal{2}6) LHRH, in rhesus monkeys. J Pharm
Sci. 1984;73:684-5.
2. Albuquerque LE, Saconato H, Maciel MC. Depot versus daily
administration of gonadotrophin releasing hormone agonist
protocols for pituitary desensitization in assisted reproduction
cycles. Cochrane Database Syst Rev. 2005 Jan 25;(1):CD002808.
3. Akagbosu FT. The use of GnRH agonists in infertility. In:
Brinsden R (Ed). A Textbook of In Vitro Fertilization and
Assisted Reproduction (2nd ed): London: Parthenon Publishing;
1999:83-9.
4. Bloch M, Azem F, Aharonov I, Ben Avi I, Yagil Y, Schreiber S,
et al. GnRH-agonist induced depressive and anxiety symptoms
during in vitro fertilization-embryo transfer cycles. Fertil Steril.
2011;95(1):307-9.
5. Dessolle L, Ferrier D, Colombel A, Fréour T, Jean M, Barrière
P. Prolonging GnRH-agonist to achieve ovarian suppression
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does not compromise the results of a long protocol. Eur J

Obstet Gynecol Reprod Biol. 2011;159(1):111-4.
6. Biljan MM, Mahutte NG, Dean N, Hemmings R, Bissonnette
F, Tan SL. Effects of pretreatment with an oral contraceptive
on the time required to achieve pituitary suppression
with gonadotropin-releasing hormone analogues and on
subsequent implantation and pregnancy rates. Fertil Steril.
1998;70(6):1063-9.
7. Maheshwari A, Gibreel A, Siristatidis CS, Bhattacharya S.
Gonadotrophin-releasing hormone agonist protocols for
pituitary suppression in assisted reproduction. Cochrane
Database Syst Rev. 2011 Aug 10;(8):CD006919.
8. Depenbusch M, Diedrich K, Griesinger G. Ovarian
hyperresponse to luteal phase GnRH-agonist administration.
Arch Gynecol Obstet. 2010;281(6):1071-2.
9. Nevo O, Eldar-Geva T, Kol S, Itskovitz-Eldor J. Lower levels
of inhibin A and pro-alpha C during the luteal phase after
triggering oocyte maturation with a gonadotropin-releasing
hormone agonist versus human chorionic gonadotropin. Fertil
Steril. 2003 ;79(5):1123-8.
10. Youssef MA, Van der Veen F, Al-Inany HG, Griesinger G,
Mochtar MH, Aboulfoutouh I, et al. Gonadotropin-releasing
hormone agonist versus HCG for oocyte triggering in antagonist
assisted reproductive technology cycles. Cochrane Database
Syst Rev. 2011 Jan 19;(1):CD008046.
11. Engmann L, Benadiva C. Ovarian hyperstimulation syndrome
prevention strategies: Luteal support strategies to optimize
pregnancy success in cycles with gonadotropin-releasing
hormone agonist ovulatory trigger. Semin Reprod Med.
2010;28(6):506-12.
12. Humaidan P, Kol S, Papanikolaou EG. Copenhagen GnRH
Agonist Triggering Workshop Group. GnRH agonist for
triggering of final oocyte maturation: time for a change of
practice? Hum Reprod Update. 2011;17(4):510-24.
13. Al-Inay H, Aboulghar M. GnRH antagonist in assisted
reproduction: a Cochrane review. Hum Reprod Update.
2002;17(4):874-85.
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14. Wilcox J, Potter D, Moore M, Ferrande L, Kelly E. CAP IV
Investigator Group. Prospective, randomized trial comparing
cetrorelix acetate and ganirelix acetate in a programmed,
flexible protocol for premature luteinizing hormone surge
prevention in assisted reproductive technologies. Fertil Steril.
2005;84(1):108-17.
15. Al-Inany HG, Aboulghar M, Mansour R, Serour GI. Optimizing
GnRH antagonist administration: meta-analysis of fixed vs
flexible protocol. Reprod Biomed Online. 2005;10:567-70.
16. Tarlatzis BC, Fauser BC, Kolibianakis EM, Diedrich K, Rombauts
L, Devroey P. GnRH antagonists in ovarian stimulation for IVF.
Hum Reprod Update. 2006;12:333-40.
17. Out HJ, Rutherford A, Fleming R, Tay CCK, Trew G, Ledger
W, et al. A randomized, double-blind, multicentre clinical trial
comparing starting doses of 150 and 200 IU of recombinant
FSH in women treated with the GnRH antagonist ganirelix for
assisted reproduction. Hum Reprod. 2004;19:90-5.
18. Propst AM, Bates GW, Robinson RD, Arthur NJ, Martin JE, Neal
GS. A randomized controlled trial of increasing recombinant
follicle-stimulating hormone after initiating a gonadotropin-
releasing hormone antagonist for in vitro fertilization-embryo
transfer. Fertil Steril. 2006;86(1):58-63.
19. Aboulghar MA, Mansour RT, Serour GI, Al-Inany HG,
Amin YM, Aboulghar MM. Increasing the dose of human
menopausal gonadotropins on day of GnRH antagonist
administration: randomized controlled trial. Reprod Biomed
Online. 2004;8:524-7.
20. Griesinger G, Venetis CA, Marx T, Diedrich K, Tarlatzis BC,
Kolibianakis EM. Oral contraceptive pill pretreatment in ovarian
stimulation with GnRH antagonists for IVF: a systematic review
and meta-analysis. Fertil Steril. 2008;90(4):1055-63.
21. Bendikson K, Milki A, Speck-Zulak A, Westphal L.
Comparison of GnRH antagonist cycles with and without oral
contraceptive pill pretreatment in poor responders. Fertil Steril.
2003;80(Suppl. 3):s188.
22. Garcia-Velasco JA, Bermejo A, Ruiz F, Martinez-Salazar J,
Requena A, Pellicer A. Cycle scheduling with oral contraceptive
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pills in the GnRH antagonist protocol vs the long protocol: a

randomized, controlled trial. Fertil Steril. 2011;96(3):590-3.
23. Griesinger G, Schultze-Mosgau A, Dafopoulos K, Schroeder
A, Schroer A, von Otte S, Hornung D, et al. Recombinant
luteinizing hormone supplementation to recombinant follicle
stimulating hormone induced ovarian hyperstimulation in
the GnRH antagonist multiple-dose protocol. Hum Reprod.
2005a;20:1200-06.
24. Huirne JA, van Loenen ACD, Schats R, McDonnell J, Hompes
PGA, Schoemaker Joop, et al. Dose-ﬁnding study of daily
GnRH antagonist for the prevention of premature LH surges in
IVF/ICSI patients: optimal changes in LH and progesterone for
clinical pregnancy. Hum Reprod. 2005;20:359-67.
25. De Placido G, Alviggi C, Perino A, et al. Recombinant human
LH supplementation versus recombinant human FSH (rFSH)
step-up protocol during controlled ovarian stimulation in
normogonadotrophic women with initial inadequate ovarian
response to rFSH. A multicentre, prospective, randomized
controlled trial. Hum Reprod. 2005;20:390-6.
26. Kol S. To add or not to add LH: consideration of LH
concentration changes in individual patients. Reprod BioMed
Online. 2005;11:664-6.
27. Al-Inany HG, Youssef MAFM, Aboulghar M, Broekmans FJ,
Sterrenburg MD, Smit JG, et al. Gonadotrophin-releasing
hormone antagonists for assisted reproductive technology.
Cochrane Database of Systematic Reviews. 2011, Issue 5. Art.
No.: CD001750. DOI: 10.1002/14651858.CD001750.pub3
28. Simon C, Oberye J, Bellver J, Vidal C, Bosch E, Horcajadas
JA, et al. Similar endometrial development in oocyte donors
treated with either high- or standard-dose GnRH antagonist
compared to treatment with a GnRH agonist or in natural
cycles. Hum Reprod. 2005;20(12):3318-27.
29. Xavier P, Gamboa C, Calejo L, Silva J, Stevenson D, Nunes
A, et al. A randomised study of GnRH antagonist (cetrorelix)
versus agonist (buserelin) for controlled ovarian stimulation:
effect on safety and efficacy. Eur J Obstet Gynecol Reprod Biol.
2005;120:185-9.
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30. Tarlatzis BC, Kolibianakis EM, Griesinger G, et al. GnRH
antagonists in ovarian stimulation for IVF. Hum Reprod
Update. 2006;12:333-40.
31. Ghosh C, Buck G, Priore R, Wende JW, Severino M. Follicular
response and pregnancy among infertile women undergoing
ovulation induction and intrauterine insemination. Fertil Steril.
2003;80:328-35.
Ch-05.indd 91 18-01-2014 12:05:11

cHAPTER
6
Mild Ovarian
Stimulation
Surveen Ghumman
The basis of successful assisted reproduction is appropriate

ovarian stimulation. Since IVF procedures have not
produced a 100% result, ovarian stimulation has become the
compensatory mechanism to improve results by increasing
the number of oocytes retrieved; thus, providing the choice
of the best quality embryos for transfer.
In the conventional protocol downregulation is started
in the luteal phase and continued into next cycle, involving
high doses and prolonged administration of FSH. It has high
chances of complications like ovarian hyperstimulation
syndrome (OHSS). The prolonged treatment with high cost
results in larger dropout rates.
In the recent years, mild protocols have been introduced
that aim at a low stimulation that gives acceptable results with
minimal risks. International Society of Mild Approaches in
Assisted Reproduction (ISMAAR) defines a “mild” IVF cycle
either as (a) a stimulation regimen in which gonadotropins are
administered at a lower-than-usual dose and/or for a shorter
duration throughout a cycle in which GnRH antagonist
Ch-06.indd 92 18-01-2014 12:05:44

Mild Ovarian Stimulation 93
is given as co-treatment, or (b) a stimulation in which oral
compounds (e.g. antiestrogens) are used either alone or in
combination with gonadotropins and GnRH - antagonists.1
Role of GnRH Antagonist in Mild Stimulation

With use of antagonists downregulation is not needed. The
IVF cycle can start with an undisturbed early follicular phase
recruitment of follicles by an endogenous FSH rise that occurs
in a natural menstrual cycle. The endogenous inter-cycle
FSH rise is taken advantage of rather than suppressed. FSH
is added on day 5 to continue FSH elevation and extend the
FSH window, for many follicles to develop. This limits the
duration and dose of FSH administration. A premature LH
surge may occur with rising estradiol levels that act through
positive feedback loop. GnRH, antagonist has an immediate
action blocking the pituitary when estradiol levels start
rising and approach threshold levels at which an LH surge
can occur. The action of GnRH antagonists is immediate
suppression of the pituitary release of gonadotropins and a
rapid reversibility of normal gonadotropin secretion when the
drug is withdrawn.
Protocols
Antagonist can be given in three ways:
a. Single large dose on, usually sixth day of stimulation with
gonadotropins
b. Fixed Protocol: Daily injections of small doses initiated on
a fixed day of stimulation till hCG administration.
c. Flexible Protocol: Daily injections of small doses initiated
depending on the size of the dominant follicle or on
estradiol levels till hCG administration.
In an analysis of three studies, a flexible GnRH antagonist
protocol was compared to the fixed protocol. In stimulated
Ch-06.indd 93 18-01-2014 12:05:44

cycles it was seen that intense ovarian response with more

number of follicles led to an early rise in estradiol. Thus,
threshold levels of estradiol that initiates a LH surge are
reached earlier before follicles reach an optimum size. In these
cases the flexible protocol, which is dependent on the size of
the follicle on ultrasound to start antagonist to suppress surge,
may no longer be accurate to determine time of initiation
of GnRH antagonist.2 This observation might explain the
observed lower efficacy of the flexible protocol compared
with a fixed protocol in a meta-analysis of four studies.3
Hence, for patients with a profound ovarian response, early
initiation of the GnRH antagonist may be needed.
Clomiphene, Gonadotropins and

GnRH Antagonist
The second mild regime includes using clomiphene 100
mg, delayed low dose gonadotropin and a flexible GnRH
antagonist administration for ovarian stimulation protocol.
Pregnancy rates comparable to the standard stimulation
regimens were obtained, with a significant reduction in the
total dose of gonadotropin and hence, the cost. The number
of recovered oocytes, obtained embryos, transferred embryos,
peak of estradiol on the day hCG administration and OHSS
were significantly higher in conventional group but there
were no significant difference in clinical pregnancy rate and
ongoing pregnancy rate between two groups.4,5
Mild vs Conventional Protocols

Dose of FSH
The mild form used lower dose FSH for a shorter period.
Mean dose of FSH used was 1183 IU in the mild group versus
1836 IU for the conventional group (Table 6.1).6
Ch-06.indd 94 18-01-2014 12:05:44

Table 6.1: Comparison of mild and conventional protocols

Mild Conventional
Low oocyte Pregnancy rate per Pregnancy rate per embryo
recovery embryo transfer – transfer – Poor
Good
Optimal 5 oocyte recovery 10 oocyte recovery
outcomes
Poor outcome > 8 oocytes recovered > 18 and < 4 oocytes
recovered
Proportion of 73% 55%
abnormal and
mosaic embryos
Dose of FSH used 1836 1183
Correlation of Number of Oocytes Recovered with

Pregnancy Rate
A higher pregnancy rate is achieved when there is a moderate
ovarian response. The highest ongoing pregnancy rate per
embryo transfer of 30.7% in mild stimulation is observed
where five oocytes were obtained but a 28.5% ongoing
pregnancy rate with a median of 10 oocytes is seen in the
conventional protocol. A sharp decline in implantation
rates was seen with retrieval of more than 8 oocytes in the
mild stimulation protocol. These differences between the
two stimulation regimens were statistically significant (P =
0.045).6
Excessive follicles do not lead to a higher pregnancy rate.
In both protocols, the number of pregnancies following the
retrieval of 18 oocytes or more was very low (Table 6.1).
Hence, when a few oocytes are recruited they are better
quality oocytes from a homogenous group that lead to a
higher pregnancy rate. Mild stimulation protocol simulates
Ch-06.indd 95 18-01-2014 12:05:44

a natural cycle where the natural selection of good quality

oocytes remains. It decreases detrimental effect of ovarian
stimulation on the growing follicle. By delaying the initiation
of ovarian stimulation to the mid-follicular phase, exogenous
FSH may only stimulate the naturally selected most mature
follicles giving rise to the best quality oocytes.
A second study reinforced this, showing that those patients
where stimulation was started on day 5, fewer cycles were
characterized by a total fertilization failure or by abnormal
embryo development. After stronger ovarian stimulation,
only 7% of the patients who retrieved less than 5 oocytes
conceived, whereas after “mild” stimulation 67% of these
patients conceived. 7 The retrieval of a less number of oocytes
gives higher chance of ongoing pregnancy per embryo
transferred in mild stimulation but poor results in conventional
protocols. The implication of a poor ovarian response in the
conventional protocol usually means a low ovarian reserve
resulting in poor IVF outcomes whereas a poor response in
mild ovarian stimulation is probably a normal response with
natural selection of follicle with best receptor endowment.
Overall, no differences were found among the two
stimulation protocols as far as the pregnancy rate per started
cycle was concerned because of the higher number of
oocytes retrieved in the conventional group, more number
of embryos were available to select the best. No significant
difference in the quality of the best transferred embryo was
observed among the two groups.7 The higher pregnancy rate
per oocyte retrieved seen with mild protocol may be due
to better development of embryo that has been naturally
selected with higher chance of being chromosomally normal.
Secondly, detrimental effects seen with very high levels of
hormones on endometrium are absent, as ostradiol levels are
lower than the conventional protocol.
Ch-06.indd 96 18-01-2014 12:05:44

Endometrial Factor
The conventional regime has supra-physiological circulating
estradiol levels that have a well-documented negative impact
on the developmental and implantation potential of human
embryos.8 A higher endometrial receptivity is seen in the
natural cycle and since the “mild” stimulation regimen,
like the natural cycle has a lower peak estradiol levels,
implantation is thought to be better.9,10
Chromosomal Abnormality with Mild Ovarian Stimulation

In a recent study, embryos were biopsied on day 3 when at
least six blastomeres were present after stimulation with both
regimes. One or two cells were removed for a fluorescence in
situ hybridization procedure. Both regimens finally generated
the same number (1.8/cycle) of chromosomally normal
embryos. As the conventional protocol had higher number
of oocytes per cycle, overall abnormality rates (abnormal
and mosaic embryos) were 55% following mild and 73%
following conventional ovarian stimulation (Table 6.1).
However, the proportion of mosaic embryos per patient was
more significantly increased following conventional ovarian
stimulation (65% vs 37%; P = 0.004). This observation
indicates that the increase in abnormal embryos is mainly
due to an increase in mitotic segregation errors in early
embryonic cleavage divisions.11 Ovarian stimulation might
disrupt mechanisms involved in maintaining accurate
chromosome segregation leading to differences in rates of
mosaic embryos.12 Hence, a lower embryo aneuploidy rate
was present following mild stimulation. Several animal studies
have supported this. Increased incidences of morphological
and chromosomal abnormalities have been observed in
mouse oocytes after exposure to high doses of gonadotropins
during in vitro maturation of oocytes.13
Ch-06.indd 97 18-01-2014 12:05:44

Ovarian stimulation strategies should avoid maximizing

oocyte yield, but aim at generating a sufficient number of
chromosomally normal better quality embryos by reduced
interference with ovarian physiology.
Cumulative Pregnancy Rate

In another study of the “mild” treatment group the pregnancy
rate per cycle was significantly lower in the “mild”
stimulation group vs the conventional group (17.6% vs
28.6%, p < 0.0001). However less dose of FSH was used
since it was cheaper, patient discomfort was less resulting in
higher acceptance of patient for a second IVF. The one year
cumulative live birthrate was 43.4% with the mild protocol,
44.7% with the standard regimen.14 Hence, there was not
much difference in the cumulative pregnancy rate.
Multiple Pregnancy
The second advantage was that twin pregnancy was 0.5%
in comparison to conventional protocol which had a rate of
13.1%.14 This also contributed to the cost effectivity of the
regime as multiple pregnancy requires a more intensive
monitoring and subsequent neonatal care.
Cryopreservation
The pooled data from a meta-analysis shows that the ongoing
pregnancy rate per started cycle sorts out to be 15% in
the “mild” group and 29% in the classical group clearly
showing conventional protocol to be more effective. Also, the
conventional protocol will give excess embryos for a subsequent
frozen embryo transfer that will get down both the cost and
patient discomfort and increase the overall IVF pregnancy
chance per oocyte pick-up by approximately 10–15%.15
Ch-06.indd 98 18-01-2014 12:05:44

Cancelation
The other factor that decreases the effectiveness of “mild”
strategy is the relatively high rate of cycle cancelation due
to mono- or bifollicular response (around 15–20%). It is
recommended that next cycle stimulation should be started
earlier on day 2. Ovarian aging and high BMI have been
identified as relevant variables to predict the risk of insufficient
response to “mild” stimulation, and a predictive model has
been developed in order to minimize the need of canceling
the cycle.16
Poor Ovarian Reserve and Mild Ovarian Stimulation

The standard approach to women who are poor responders
is based on starting with high doses of stimulation of 300
FSH IU and going up to 600 FSH IU. However, IVF outcomes
in terms of pregnancy rates with 225 FSH UI/day and those
receiving 450 UI/day was shown to be similar, despite the
latter obtained more oocytes.17,18
High gonadotropin doses lower the cycle cancelation rate,
but the likelihood of clinical pregnancy and live birthrate
have been observed to reduce and to increase the risk of
spontaneous miscarriage because of its adverse effects on
endometrium and oocyte and embryo quality generated from
follicles that were rescued from atresia if a natural cycle had
taken place.19
In patients with poor ovarian reserve, the choice of a mild
stimulation protocol instead of a classical, high dose regimen
could be particularly indicated. Although these patients have
a very low risk of OHSS, the quality of both their oocytes
and their endometrium may be better when a smoother
stimulation approach is used.
A combination of clomiphene citrate (CC) plus
gonadotropins and GnRH antagonists has been proposed
Ch-06.indd 99 18-01-2014 12:05:44

as a “mild” stimulation alternative for poor responders. The

treatment protocol consisted of a daily dose of clomiphene
citrate 100 mg for 5 days and gonadotropin injections daily
from cycle day 4 onward. Cetrorelix, 0.25 mg/day, was
started when the leading follicle reached 14 mm. Induction of
ovulation was triggered with human chorionic gonadotropin.
The combination of clomiphene with gonadotropins may
counterbalance its undesired antiestrogenic effect on the
endometrium and clomiphene; at the same time their effects
may reduce the amount of gonadotropins required, because
of the combined synergistic effect on the ovary. A significantly
higher blastocyst development rate and a very good (41.2%)
ongoing pregnancy rate was found with this regimen.20
In CC/Gn/GnRH antagonist cycles, it was seen that in some
cases LH was profoundly suppressed by GnRH antagonist and
the circulating level of LH were less than one third at the time
of hCG than it was at the beginning of stimulation. In these
cases, both the pregnancy (18% vs 39%) and implantation
rates are significantly reduced. This suggests that in these
patients medications containing LH or hCG rather than FSH
alone should be associated with CC in this kind of protocol.21
Risk of Ovarian Hyperstimulation Syndrome (OHSS)

Severe OHSS has an incidence of 1–3% in IVF programs
involving standard ovarian stimulation regimens. The
incidence of severe OHSS is significantly lower when GnRH
antagonists are used instead of agonists probably due to
the smaller cohort of recruited follicles and to the lower
circulating estradiol levels during ovarian stimulation.22
The risk of developing severe OHSS is further significantly
reduced using “mild” stimulation regimens. In one study,
the incidence of OHSS was 1.4% with the mild protocol
and 3.7% with the long protocol.11 While in another study,
Ch-06.indd 100 18-01-2014 12:05:44

there was no case of OHSS in the group treated with “mild”
stimulation versus 6% in the group treated with conventional
stimulation.4 Further, the risk of severe OHSS is reduced
if ovulation trigger is elicited using a single dose of GnRH
agonist instead on hCG; this is possible if a stimulation with
GnRH antagonists has been applied.23
Emotional Stress
Emotional stress represents a well-known negative side effects
associated with IVF treatment, and probably one of the most
important reasons for dropping out of the program.
In the mild stimulation, a lower incidence of side effect
faced with a conventional protocol; maybe the reason for
a lower dropout rate and patients going in for a repeat IVF
sooner as the psychological burden is lower. This leads to a
higher cumulative success rate.24
However, a lower pregnancy chance with mild stimulation
may itself cause psychological problems associated with
failure. Also, the increased number of repeat oocyte retrievals
with this protocol is a stressing event.
Economical Costs
A milder ovarian stimulation is associated with a lower
medication consumption per cycle thus lowering the cost.
The balance between lower costs and lower “per cycle”
results must be kept in mind when taking a decision. Also,
the frequent need to repeat treatment actually increases cost
as amount of FSH required to achieve one pregnancy goes
up. However, in a recent study it was seen that although there
is a significantly increased average number of IVF cycles
(2.3 versus 1.7), lower average total costs over a 12-month
period (8333 euro versus 10,745 euro) were observed using
the mild strategy. Despite an increased mean number of IVF
Ch-06.indd 101 18-01-2014 12:05:44

cycles within 1 year, from an economic perspective, the mild

treatment strategy is more advantageous per term live birth.25
Lower Effectiveness
The lower effectiveness of IVF procedure can also become
a problem for IVF clinics choosing the mild strategy, who
will compete on the market with clinics following classical
stimulation concepts. If the clinic loses patients for the lower
“per cycle” effectiveness of its IVF program, it could be
forced to go back to classical stimulations, or alternatively, to
increase prices, finally weighting on patients’ budget.
In conclusion, lower number of oocytes retrieved during
mild stimulation is associated with favorable pregnancy
outcomes as there may be natural selection. As the mild
stimulation did not show better pregnancy rates compared
with a conventional stimulation protocol with GnRH agonist
co-treatment, the benefits of low cost should be balanced
with the decrease in pregnancy rate per cycle. With current
recommendation of maximum two embryo transfer, there
seems to be no need of aggressive stimulation to obtain large
number of oocytes at the cost of good quality oocyte selection
and adequately primed endometrium.
References
1. Nargund J, Fauser BCJM, Macklon NS, Ombelet W, Nygren K,
Frydman R. The ISMAAR proposal on terminology for ovarian
stimulation for IVF. Hum Reprod. 2007;11(14):2801-04.
3. Tarlatzis BC, Fauser BC, Kolibianakis EM, Diedrich K, Rombauts
L, Devroey P. GnRH antagonists in ovarian stimulation for IVF.
Ch-06.indd 102 18-01-2014 12:05:45

4. Karimzadeh MA, Ahmadi S, Oskouian H, Rahmani E.
Comparison of mild stimulation and conventional stimulation
in ART outcome. Arch Gynecol Obstet. 2010;281(4):741-6.
5. Williams SC, Gibbons WE, Muasher SJ, Oehninger S.
Minimal ovarian hyperstimulation for in vitro fertilization
using sequential clomiphene citrate and gonadotropin with
or without the addition of a gonadotropin-releasing hormone
antagonist. Fertil Steril. 2002;78(5):1068-72.
6. Verberg MFG, Eijkemans MJC, Macklon NS, Heijnen EMEW,
Baart EB, Hohmann FP, et al. The clinical significance of the
retrieval of a low number of oocytes following mild ovarian
stimulation for IVF: a meta-analysis. Hum Reprod Update.
2009;15:5-12.
7. Hohmann FP, Macklon NS, Fauser BC. A randomized comparison
of two ovarian stimulation protocols with gonadotropin-releasing
hormone (GnRH) antagonist co-treatment for in vitro fertilization
commencing recombinant follicle-stimulating hormone on
cycle day 2 or 5 with the standard long GnRH agonist protocol.
J Clin Endocrinol Metab. 2003;88(1):166-73.
8. Valbuena D, Jasper M, Remohi J, Pellicer A, Simon C. Ovarian
stimulation and endometrial receptivity. Hum Reprod.
1999;14(2):107-11.
9. Check JH, Choe JK, Nazari A, Summers-Chase D. Ovarian
hyperstimulation can reduce uterine receptivity. A case report.
Clin Exp Obstet Gynecol. 2000;27(2):89-91.
10. Check JH, Check ML. A case report demonstrating that follicle
maturing drugs may create an adverse uterine environment
even when not used for controlled ovarian hyperstimulation.
Clin Exp Obstet Gynecol. 2001;28(4):217-8.
11. Baart EB, Martini E, Eijkemans MJ, Van Ostal D, Beckers NG,
Verhoeff A, et al. Milder Ovarian stimulation for in vitro fertilization
reduces aneuploidy in the human preimplantation embryo: a
randomised controlled trial. Hum Reprod. 2007;22(4):980-8.
12. Hodges CA, Ilagan A, Jennings D, Keri R, Nilson J, Hunt
PA. Experimental evidence that changes in oocyte growth
influence meiotic chromosome segregation. Hum Reprod.
2002;17:1171-80.
Ch-06.indd 103 18-01-2014 12:05:45

13. Roberts R, Iatropoulou A, Ciantar D, Stark J, Becker DL, Franks

S, Hardy K. Follicle-stimulating hormone affects metaphase I
chromosome alignment and increases aneuploidy in mouse
oocytes matured in vitro. Biol Reprod. 2005;72:107-18.
14. Hejinen EMEW, Eijkemans MJC, De Klerk C, Polinder S,
Beckers NGM, Klinkert ER, et al. A mild treatment strategy for
in vitro fertilization: a randomised non inferiority trial. Lancet.
2007;369(9563):743-9.
15. Revelli A, Casano S, Salvagno F, Piane LD. Milder is better?
advantages and disadvantages of “mild” ovarian stimulation
for human in vitro fertilization. Reprod Biol Endocrinol.
2011;9:25-30.
16. Verberg MF, Eijkemans MJ, Macklon NS, Heijnen EM, Fauser
BC, Broekmans F. Predictors of low response to mild ovarian
stimulation initiated on cycle day 5 for IVF. Hum Reprod.
2007;22(7):1919-24.
17. Land JA, Yarmolinskaya MI, Dumoulin JC, Evers JL. High-
dose human menopausal gonadotropin stimulation in poor
responders does not improve in vitro fertilization outcome.
Fertil Steril. 1996;65(5):961-5.
18. Lekamge DN, Lane M, Gilchrist RB, Tremellen KP. Increased
gonadotrophin stimulation does not improve IVF outcomes in
patients with predicted poor ovarian reserve. J Assist Reprod
Genet. 2008;25(11-12):515-21.
19. Pal L, Jindal S, Witt BR, Santoro N. Less is more: increased
gonadotropin use for ovarian stimulation adversely influences
clinical pregnancy and live birth after in vitro fertilization.
Fertil Steril. 2008;89(6):1694-701.
20. Takahashi K, Mukaida T, Tomiyama T, Goto T, Oka C.
GnRH antagonist improved blastocyst quality and pregnancy
outcome after multiple failures of IVF/ICSI-ET with a GnRH
agonist protocol. J Assist Reprod Genet. 2004;21(9):317-22.
21. Yanaihara A, Yorimitsu T, Motoyama H, Ohara M, Kawamura
T. The decrease of serum luteinizing hormone level by a
gonadotropin-releasing hormone antagonist following the
mild IVF stimulation protocol for IVF and its clinical outcome.
J Assist Reprod Genet. 2008;25(4):115-8.
Ch-06.indd 104 18-01-2014 12:05:45

22. Kolibianakis EM, Collins I, Tarlatzis BC, Devroey P, Griesinger
G. Among patients treated for IVF with gonadotrophins and
GnRH analogues is the probability of live birth dependent
on the type of analogue used? A systematic review and meta-
analysis. Hum Reprod Update. 2006;12a(6):651-71.
23. Humaidan P, Papanikolaou EG, Tarlatzis BC. GnRHa to trigger
final oocyte maturation: a time to reconsider. Hum Reprod.
2009;24(10):2389-94.
24. de Klerk C, Heijnen EM, Macklon NS, Duivenvoorden HJ, Fauser
BC, Passchier J, et al. The psychological impact of mild ovarian
stimulation combined with single embryo transfer compared
with conventional IVF. Hum Reprod. 2006;21(3):721-7.
25. Polinder S, Heijnen EM, Macklon NS, Habbema JD, Fauser
BJ, Eijkemans MJ. Cost-effectiveness of a mild compared with
a standard strategy for IVF: a randomized comparison using
cumulative term live birth as the primary end point. Hum Reprod.
2008;23(2):316-23.
Ch-06.indd 105 18-01-2014 12:05:45

cHAPTER
7
Premature luteinization
Surveen Ghumman, Monika Gupta
Premature luteinization (PL) has been defined as the rise of

progesterone on the day hCG is given. It is an important entity
in women who are undergoing ovulation induction. There is
no strict criterion of diagnosis and no definite etiology has
been identified.
Diagnosis
Serum Progesterone on Day of hCG
Various studies have quoted a cut-off of 0.8 to 2 ng/ml.1 As
more number of follicles produce more progesterone, it may be
important to link ovarian response to estrogen and progesterone
levels rather than absolute progesterone values. Hence, P/E2
ratio may be better in detecting PL. A level of more than 1 is
thought to differentiate between progesterone secretion from
a dysmature follicle as occurs in PCOS from that of a mature
healthy follicle.2 A study showed that PL seems unrelated to
preovulatory luteinizing hormone (LH) elevation and LH/hCG
content of gonadotropins and could be associated with poor
ovarian response and the presence of dysmature follicles.3
Ch-07.indd 106 18-01-2014 12:06:06

Premature luteinization 107
Progesterone/Estradiol Ratio on Day of hCG
Cycles with elevated P/E2 ratios are associated with lower
clinical pregnancy and live birth rates, which decrease further
as the P/E2 ratio rises. P/E2 ratio improves the prediction of
IVF outcome when compared to serum P levels alone.4
Ultrasound Appearance
Collaborative ultrasound appearance of the follicle shows
a thickened follicular wall and appearance of irregular
echogenic structures within the follicle.
Incidence
It varies in various studies from 13 to 71%, using P only
to define PL. It was found that 41% had a P/E2 ratio.2 The
incidence varies with different stimulation protocols. It is
maximum with flare protocol being 85%.5 It is 54.7% in
women undergoing COH with CC hMG and a single 2.5 mg
dose of the GnRH antagonist, cetrorelix.6 With GnRH agonist
protocol incidence varied from 5 to 35% and with antagonist
from 20 to 35%.7,8
Causes
Increased Levels of hCG Accumulated with
hMG Administration
It has been seen that there are higher levels of hCG in women
with PL suggesting that the LH activity in hMG is responsible
for PL. Hence, in these cases recombinant or highly purified
FSH may be given.9
Ch-07.indd 107 18-01-2014 12:06:06

Increased LH Levels
Although GnRH agonists suppress LH, it has been seen that in
some cases suppression may be incomplete. LH levels may be
enough to stimulate granulose cells to produce progesterone
but not enough to cause rupture of follicle.
Increased LH Sensitivity of Granulose Cells to FSH

It is postulated that there is a higher sensitivity of LH receptors
of granulose cells to FSH, which may be due to increased
estradiol levels.
Increased LH Sensitivity in Poor Responders

PL is seen more often in poor responders and raised
progesterone may be because of adversely developing
cumulus oocyte complex and not because of a raised LH.
Effect on Reproductive Outcomes

Adverse Effects on Oocyte Maturation,
Fertilization or Early Cleavage
A study showed that the mean number of retrieved oocytes,
recovered mature oocytes, embryos and top quality embryos
were significantly higher in the non-prematurely luteinized
group than in the prematurely luteinized group. Although
fertilization rates and implantation rates were similar between
the two groups, the clinical pregnancy rate was higher in the
non-prematurely luteinized group than in the prematurely
luteinized group.3 However, many authors have not found a
negative impact of PL.10
Ch-07.indd 108 18-01-2014 12:06:06

Effect on Endometrium
Since many studies did not find an adverse oocyte quality, it
was suggested that PL has an adverse effect on endometrium.
There is an abnormally accelerated endometrial maturation
leading to impaired endometrial receptivity.11
Pregnancy Rate
A systemic review and meta-analysis stated that no statistically
significant association between progesterone elevation and
the probability of clinical pregnancy was detected in women
undergoing ovarian stimulation with GnRH analogs and
gonadotropins for IVF.12
With COH cycles using GnRH antagonists and where
serum P is measured by ELISA there does not seem to be any
disadvantage of higher serum P levels up to 2 ng/ml at the
time of hCG in IVF-ET cycles.13
Prevention
Flexible Antagonist Protocol
In flexible antagonist protocol, antagonist is initiated when
follicle size is more than 14 mm or estradiol is more than 600
pg whereas in the fixed protocol it is administered on day 6.
In stimulated cycles, it was seen that intense ovarian response
with more number of follicles led to an early rise in estradiol.
Thus, threshold levels of estradiol that initiates a LH surge
are reached earlier before follicles reach an optimum size. In
these cases the flexible protocol, which is dependent on the
size of the follicle on ultrasound to start antagonist to suppress
surge, may no longer be accurate to determine time of
initiation of GnRH antagonist.2 This observation might explain
the observed lower efficacy of the flexible protocol compared
Ch-07.indd 109 18-01-2014 12:06:06

with a fixed protocol in a meta-analysis of four studies.3 Hence,

for patients with a profound ovarian response, early initiation
of the GnRH antagonist may be needed.14
Treatment with ganirelix effectively prevents premature
LH rises; luteinization in subjects undergoing stimulated IUI.
Low-dose rFSH regimen combined with a GnRH antagonist
may be an alternative treatment option for subjects with
previous proven luteinization.15
Low-dose hCG Alone in the Late Follicular Stage

Women who were undergoing COS with recombinant FSH/
hMG followed by low-dose hCG (200 IU/day) alone [66].
This regimen did not cause PL.16
Mifepristone
Mifepristone was started in a daily dose of 40 mg along with
stimulation. 50 mg progesterone was given along with hCG
to counteract the antiprogesterone effect of mifepristone. No
PL was seen in any case. However, endometrial receptivity
status requires additional evaluation after decreasing RU-
486 doses.17
hCG Administration Preponed to day of Progesterone Rise

Progesterone was monitored from day 7 and hCG was given
when a rise was detected >1.0 ng/ml. It was seen that the
quality of embryos and implantation rate was better than
when hCG was delayed in cases of PL.18
Aspiration of Single Lead Follicle

Better pregnancy rates were seen if a single lead follicle was
aspirated and other follicles continued to grow and were
aspirated later. No premature LH surge was seen.19
Ch-07.indd 110 18-01-2014 12:06:06

Premature luteinization is a diagnostic and therapeutic
challenge for the infertility specialist. Its impact on ART results
is controversial and more randomized studies are required
before one can be definite about it.
References
1. Hofmann GE, Bentzien F, Bergh PA, Garrisi GJ, Williams MC,
Guzman I, et al. Premature luteinization in controlled ovarian
hyperstimulation has no adverse effect on oocyte and embryo
quality. Fertil Steril. 1993;60:675-9.
2. Younis JS, Simon A, Laufer N. Endometrial preparation: lessons
from oocyte donation. Fertil Steril.1996;66:873-84.
3. Ou YC, Lan KC, Chang SY, Kung FT, Huang FJ. Increased
progesterone/estradiol ratio on the day of hcg administration
adversely affects success of in vitro fertilization–embryo transfer
in patients stimulated with gonadotropin-releasing hormone
agonist and recombinant follicle-stimulating hormone Taiwan.
J Obstet Gynecol. 2008;47:168-74.
4. Keltz MD, Stein DE, Berin I, Skorupski J. Elevated progesterone-
to-estradiol ratio versus serum progesterone alone for predicting
poor cycle outcome with in vitro fertilization. J Reprod Med.
2012;57(1-2):9-12.
5. Sims A, Seltman HJ, Muasher SJ. Early follicular rise of serum
progesterone concentration in response to a flare-up effect of
gonadotrophin-releasing hormone agonist impairs follicular
recruitment for in-vitro fertilization. Hum Reprod. 1994;9:235-40.
6. Seow KM, Lin YH, Huang LW, Hsieh BC, Huang SC, Chen CY,
et al. Subtle progesterone rise in the single-dose gonadotropin-
releasing hormone antagonist (cetrorelix) stimulation protocol
in patients undergoing in vitro fertilization or intracytoplasmic
sperm injection cycles. Gynecol Endocrinol. 2007;23:338-42.
7. Edelstein MC, Seltman HJ, Cox BJ, Robinson SM, Shaw RA,
Muasher SJ. Progesterone levels on the day of human chorionic
gonadotropin administration in cycles with gonadotropin-
releasing hormone agonist suppression are not predictive of
pregnancy outcome. Fertil Steril. 1990;54:853-7.
Ch-07.indd 111 18-01-2014 12:06:06

8. Bosch E, Valencia I, Escudero E, Crespo J, Simon C, Remohi

J, et al. Premature luteinization during gonadotropin-releasing
hormone antagonist cycles and its relationship with in vitro
fertilization outcome. Fertil Steril. 2003;80:1444-9.
9. Copperman AB, Horowitz GM, Kaplan P, Scott RT, Navot
D, Hofmann GE. Relationship between circulating human
chorionic gonadotropin levels and premature luteinization
in cycles of controlled ovarian hyperstimulation. Fertil Steril.
1995;63:1267-71.
10. Martinez F, Coroleu B, Clua E, Tur R, Buxaderas R, Parera, et
al. Serum progesterone concentrations on the day of hCG
administration cannot predict pregnancy in assisted reproduction
cycles. Reprod Biomed Online. 2004;8:183-90.
11. Yovel I, Yaron Y, Amit A, Peyser MR, David MP, Kogosowski
A, et al. High progesterone levels adversely affect embryo
quality and pregnancy rates in vitro fertilization and oocyte
donation programs. Fertil Steril. 1995;64:128-31.
12. Bosch E. Comment on: is progesterone elevation on the day
of human chorionic gonadotrophin administration associated
with the probability of pregnancy in vitro fertilization? A
systematic review and meta-analysis. By Venetis et al (2007).
13. Katsoff B, Check JH, Wilson C, Choe JK. Effect of serum
progesterone level on the day of human chorionic gonadotropin
injection on outcome following in vitro fertilization-embryo
transfer in women using gonadotropin releasing hormone
antagonists. Clin Exp Obstet Gynecol. 2011;38(4):322-3.
15. 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(3):632-9.
Ch-07.indd 112 18-01-2014 12:06:06

16. Filicori M, Cognigni GE, Gamberini E, Parmegiani L, Troilo E,
Roset B. Efficacy of low-dose human chorionic gonadotropin
alone to complete controlled ovarian stimulation. Fertil Steril.
2005;84:394-401.
17. 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.
18. Harada T, Katagiri C, Takao N, Toda T, Mio Y, Terakawa N.
Altering the timing of human chorionic gonadotropin injection
according to serum progesterone concentrations improves
embryo quality in cycles with subtle P rise. Fertil Steril.
1996;65:594-7.
19. Barash A, Shoham Z, Lunenfeld B, Segal I, Insler V, Borenstein
R. Can premature luteinization in superovulation protocols be
prevented by aspiration of an ill-timed leading follicle? Fertil
Steril. 1990;53:865-9.
Ch-07.indd 113 18-01-2014 12:06:06

cHAPTER
8
Polycystic Ovarian
Syndrome and
Insulin Sensitizers
Surveen Ghumman
Polycystic ovarian syndrome (PCOS) is a heterogeneous

collection of signs and symptoms that form a spectrum of mild
to severe disturbance of reproductive, endocrine and metabolic
functions. It was first described by Stein and Leventhal in 1935.1
The disorder is multifactorial in origin. It is thought to have a
genetic etiology but the severity and course is determined by
lifestyle, especially body mass index. 80 to 90% of women
suffering from anovulation have PCOS. Prevalence of PCOS
has been studied in several populations and it appears that it
affects as many as 5–10% of women of reproductive age.
Diagnosis
Presence of two out of the following three criteria are essential
for diagnosis.1
1. Oligo and/or anovulation.
2. Hyperandrogenism (clinical and/or biochemical).
3. Polycystic ovaries with exclusion of other etiologies.
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Polycystic Ovarian Syndrome and Insulin Sensitizers 115
Histopathological Criteria
1. Atretic follicles and/or degenerating granulosa cells.
2. Hypertrophy and luteinization of the inner theca cell
layer.
3. Thickened ovarian tunica.
Transvaginal Sonography
Diagnosis is on the basis of these criteria:2
1. Presence of 12 or more cysts of 2 to 9 mm
2. Ovarian volume equal to or more than 12 cm3
3. Bright echogenic stroma.
Degree of insulin resistance is correlated well with the
ovarian volume and stromal echogenicity whereas serum LH
and testosterone is related well with ovarian volume, stromal
echogenicity and follicle number. Ovarian volume was found
to be the best predictor for hyperandrogenism.3
Insulin Resistance
Insulin resistance is defined as reduced glucose response to
a given amount of insulin. It occurs in 80% of obese women
and 30 to 40% of women with normal weight with PCOS.
Hyperinsulinemia is more common in patients with more
than 10 follicles in the ovary, enlarged ovarian volume or
elevated day 10 LH.
Peripheral target tissue insulin resistance can be due to
decreased number of peripheral insulin receptors, decreased
insulin binding or a post receptor failure. In PCOS it is caused
by the post-receptor defect because of excessive serine phos
phorylation of beta chain of insulin receptor and of adrenal
and ovarian cytochrome P450c17 enzyme. This enzyme
catalyzes 17 hydroxylase and the 17, 20 lyase activities
Ch-08.indd 115 18-01-2014 12:07:02

that is a rate limiting step in androgen biosynthesis thus

leading to hyperandrogenemia. There is evidence of adrenal
hyperandrogenemia in 15% of PCOS women (Fig. 8.1).
Peripheral target tissue resistance leads to hyperinsulinemia
as a compensatory mechanism. When the beta cells of pancreas
fail to meet this challenge there are declining insulin levels and an
impaired GTT finally leading to type 2 NIDDM. Hyperinsulinemia
leads to adverse lipid effects (Increased triglycerides and VLDL
cholesterol and a decreased HDL) (Fig. 8.2).
Insulin when in excess binds to IGF-I receptors and
also decreases insulin-like growth factor binding protein I
(IGFBP-I) production in liver thus, increasing levels of IGF-I.
IGF-I augments theca androgen response to LH. Another
theory states that insulin binds to its own receptors causing
steroidogenesis. Increased IGF-I activity in endometrium may
also be responsible for the endometrial growth and increased
risk of endometrial cancer in these patients. Plasminogen
activator inhibitor-I is increased causing impaired fibrinolysis.
In PCOS the ovary does not secrete increased amount of
estrogen. Levels of estrone are increased because of peripheral
conversion of increased amount of androstenedione to
Fig. 8.1: Mechanism of hyperinsulinemia and hyperandrogenemia4
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Fig. 8.2: Effect of hyperinsulinemia in polycystic ovarian syndrome
estrone. Serum prolactin levels may be high in 30 to 40% of

PCOS women because of increased estrogen levels.
Sex hormone binding globulin are decreased because
raised insulin levels inhibit hepatic synthesis of SHBG (Fig.
8.2). Also the increased testosterone level suppresses SHBG.
This further increases levels of estradiol and testosterone.
High levels of estradiol cause increased LH secretion and
suppress FSH secretion 40% of cases will have an increased
level of LH. As FSH secretion is not totally suppressed
follicular growth is continuously stimulated but not to the
point of full maturation and ovulation. Small follicles 2 to
10 mm in diameter are present that may last for months.
These are surrounded by hyperplastic theca cells that under
the influence of LH get luteinized. The tissue derived from
follicular atresia contributes to stromal compart ment that
secretes androstenedione and testosterone. High androgens
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prevent normal follicular development and premature atresia

of follicles.
All anovulatory women who are androgenic should be
assessed for glucose tolerance and insulin resistance with
measurement of 2 hour glucose and insulin value after 75 g
load.4
Clinical Presentation
1. Hyperandrogenism (acne, hirsutism, alopecia—not
virilization).
2. Menstrual disturbance.
3. Infertility.
4. Obesity.
5. Clinical evidence of insulin resistance – Acanthosis
nigricans.
Late Sequelae
1. Diabetes mellitus.
2. Dyslipidemia.
3. Hypertension and cardiovascular disease.
4. Endometrial carcinoma.
5. Breast cancer.
Serum Endocrinology
1. Fasting insulin levels (Normal < 25 IU/L) in glucose
tolerance test preferred (Tables 8.1 and 8.2).
2. Postprandial insulin >100 ug/ml
3. Fasting blood sugar:insulin ratio (> 4.5)
4. Glucose tolerance test (Table 8.1)
5. Total and free testosterone (Normal total testosterone
20–80 ng/dl)
6. DHEAS (Normal–Less than 350 µg/dl)
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Table 8.1: Blood glucose value after 75 g load4

Normal Impaired Diabetes mellitus
Fasting (mg/dl) < 100 100–126 > 126
2 hour value (mg/dl) < 140 140–199 > 200
Table 8.2: Hour insulin value after 75 g load4

Likely insulin Insulin resistance Severe insulin
resistance resistance
Value (µg/ml) 100–150 150–300 > 300
7. LH raised (2–10 IU/l) Measured on day 2–3 or on any

day if amenorrheic
8. FSH normal (2-8 IU/L)
9. Decreased SHBG (normal 16–119 nmol/L)
10. Free androgen index (FAI) T × 100/SHBG (Normal <5)
11. Estradiol, estrone are increased (not measured routinely)
12. Serum prolactin increased (normal < 20 ng/ml).
Measure if oligo-/amenorrheic.
13. Thyroid stimulating hormone—increased sometimes
14. Lipid profile—Low-density lipoprotein and high-density
lipoprotein cholesterol levels.
Treatment
Goals
1. Reducing insulin.
2. Treating anovulation.
3. Regularizing cycles.
4. Antagonizing androgens.
5. Maintaining a normal endometrium.
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Weight Loss
Weight loss must be initiated as part of treatment plan alone or
along with drug therapy for all patients of PCOS irrespective
of whether they desire pregnancy or not. It improves ovarian
function and hormonal abnormality by decreasing insulin and
androgens and increasing SHBG. Central obesity and BMI are
major determinants of insulin resistance, hyperinsulinemia
and hyperandrogenemia. 5–10% of weight loss is enough
to decrease the visceral fat by 30% and restore reproductive
function. It should be encouraged prior to ovulation as
patients respond better and require less dose of ovulation
inducing drugs.
Diet
Food with low glycemic index such as vegetables, fruits,
and fiber should be consumed. Regular aerobic exercise is
beneficial. Two hours of exercise a week is sufficient.
Drugs
Orlistat: Orlistat reduces up to 30% lipid adsorption
and produced a significant reduction in weight and total
testosterone. The reduction in total testosterone was similar
to that seen after treatment with metformin.5 Orlistat improves
the hormonal and metabolic profile in women with PCOS
after 6 months of treatment, independent of BMI changes.6
Sibutramine: A new drug, sibutramine increases satiety
and energy expenditure caused by thermogenesis in brown
adipose tissue. Sibutramine in combination with lifestyle
intervention results in significant weight reduction in obese
patients with PCOS. Sibutramine 15 mg once daily together
with brief lifestyle modification has lead to a weight loss of
7.8 kg in 6 months compared with a weight loss of 2.8 kg in
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those who followed only lifestyle changes.7 In addition to the
weight loss, sibutramine seems to have beneficial effects on
metabolic and cardiovascular risk factors.
Surgery
Bariatric surgery can be considered in morbidly obese women
who do not respond to any treatment.
Weight loss has the advantage of being effective and cheap with
no side effects and should be the first line of treatment in women
with PCOS and anovulatory infertility.
Insulin Sensitizers
The insulin sensitizers used in ovulation induction are shown
in Table 8.3.
Metformin
Metformin is a water-soluble oral biguanide that lowers
insulin, LH, free testosterone levels, PAI-I and endothelin I
levels in overweight women with polycystic ovaries.
Table 8.3: Insulin sensitizers

Insulin sensitizers Dose
1. Biguanides metformin 1500–2000 mg/day
2. Thiazolidinediones
Rosiglitazone 4–8 mg/day
Pioglitazone 30–50 mg/day
3. D-chiroinositol 1200 mg/day
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Action
1. Blunting of hepatic gluconeogenesis.
2. Decreased intestinal absorption of glucose.
3. Increased peripheral glucose uptake and utilization.
However, it is seen that the ability of metformin to alter
insulin sensitivity in morbidly obese (BMI 40 kg/m2) is
limited.8 Metformin by reducing hyperinsulinemia causes a
decrease in intraovarian androgens. This in turn leads to a
reduction in E2 levels and favors orderly follicular growth in
response to exogenous gonadotropins. There is a decrease in
testosterone, free testosterone, DHEAS, androstenedione and
LH, normalization of LH: FSH ratio and an increase in SHBG.
Indication for Metformin Therapy
1. PCOS patients with increased androgens.
2. Documented ovulation induction failure after clomiphene.
3. Fasting insulin level more than 25 IU/L (some take a value
of 15 IU/L).
4. Altered glucose tolerance test.
Justification of administrating insulin lowering agents in
patients with normal insulin values needs to still be evaluated
although some therapeutic benefit is seen in terms of
reproductive function.
Precautions: Metformin can cause lactic acidosis in 1:33,000
cases. It is a serious condition with a mortality of 50%, mainly
occurring in women with renal impairment. Symptoms are
often nonspecific like fatigue, myalgia, abdominal distension,
vomiting and respiratory depression. Immediate cessation
of the drug is indicated on observing any of the symptoms.
Serum electrolytes, blood glucose, ketones, pH, serum lactate
level and serum metformin levels, if possible, should be done.
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To take precautions against this condition metformin
should be discontinued 48 hours before any planned surgery
or any radiographic study utilizing intravenous contrast dye.
Ethanol potentiates the effect of metformin and patients
should be warned against high alcohol intake. Hemodialysis
may be needed to resolve the situation.9
Minor side effects like nausea, vomiting, diarrhea,
bloating, flatulence and metallic taste occurs in 20% patients.
It resolves if drug is taken with food. Since this effect is dose
dependent, the dose of metformin should be increased in
an incremental fashion. If discomfort is significant, the drug
should be discontinued. There may be weight loss associated
with the nausea and vomiting accompanying the drug.
Megaloblastic anemia may occur in some patients because of
subnormal B12 levels.
Hypoglycemia does not occur with metformin in eugly
cemic patients. It may be seen in special cases where there is:
1. Deficient caloric intake.
2. Concomitant use with sulfonylureas.
3. Strenuous exercise is not compensated with adequate
intake.
4. Excessive alcohol consumption.
Contraindications
1. Renal disease: If serum creatinine is more than 1.5 mg/dl
or creatinine clearance is less than 60% of normal for that
age, metformin is not given.
2. Metabolic acidosis.
3. Myocardial infarction.
Drug interaction: Drug interaction occurs with diuretics, oral
contraceptives and phenytoin.
Dose: The drug is usually started in the follicular phase in
a dose of 500 mg/day for 5 to 7 days. This is increased in
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weekly increments of 500 mg up to 1500 to 2000 mg/day. If

patient is amenorrheic pregnancy needs to be ruled out.
Results: Metformin induces regular cycles in 68 to 95%
patients treated for 4 to 6 months. It improved ovulation,
hirsutism, hyperandro genemia and insulin resistance.
Lowering of fasting insulin levels are seen in 2 to 3 months.
A repeat test is required only after this period. If amenorrhea
persists clomiphene or rosiglitazone is added. Ovulation rates
are higher when combined with clomiphene (76% versus
46% when used alone).10 Patients with elevated pretreatment
levels of testosterone show the best results in resumption of
ovulation with significant reduction in testosterone. Those
with raised fasting insulin responded less and those with
normal testosterone showed no effect.
A Cochrane review 2010 concluded that metformin is of
benefit in improving clinical pregnancy and ovulation rates.
However, there is no evidence that metformin improves live
birthrates whether it is used alone or in combination with
clomiphene, or when compared with clomiphene. Hence,
the use of metformin in improving reproductive outcomes in
women with PCOS appears to be limited.11
Metformin in ART Cycles
A recent Cochrane review found that the risk of OHSS
in women with PCOS and undergoing IVF or ICSI cycles
was reduced with metformin. There was no evidence that
metformin treatment before or during ART cycles improves
live birth or pregnancy rates.12
Role of Metformin After Conception
It has been suggested that metformin be continued after
conception as it decreases rate of miscarriage and gestational
diabetes without any teratogenicity as it is a category B drug.13
The risk of miscarriage is thought to be due to increased
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levels of PAI-I that accompany hyperinsulinemia suggesting
the possibility that placental thrombosis induces miscarriage.
However, there are no randomized controlled trials.
Thiazolidinediones
They markedly improve insulin sensitivity mainly by
improved peripheral glucose utilization in skeletal muscle.
Troglitazone decreases hyperinsulinemia, androgens, PAI-I,
LH and increases SHBG. Cycles become ovulatory. However,
it was withdrawn from the market because of liver toxicity.
Pioglitazone and rosiglitazone have been reported free of
liver toxicity but liver function should be monitored every 2
months. Minor side effects like weight gain and fluid retention
may be present. Pioglitazone in a dose of 30 to 50 mg/day
and rosiglitazone in a dose of 4 to 8 mg/day can also be used
as monotherapy or in combination with metformin.14,15 They
produce an ovulatory response in cases that were resistant to
metformin.16 They are both Category C drugs and need to be
discontinued when patient becomes pregnant.
Acarbose
Acarbose is used orally in the management of type 2 diabetes.
Acarbose reduces the postprandial rise in both serum glucose
and insulin levels by inhibiting a-glucosidase, an enzyme
responsible for the intestinal absorption of carbohydrates. It
was as effective as metformin when given in a dose of 100
mg tid in clomiphene resistant PCOS women. It significantly
reduced LH, LH:FSH ratio, and testosterone and fasting
insulin concentrations, and increased FSH concentrations
versus pretreatment values. There was a significant increase
in ovulation. Acarbose was found to be a safe and effective
agent that could be used in cases with clomiphene-resistant
PCOS.17 Acarbose improved hirsutism, acne, and menstrual
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irregularities through reduction in androgen concentrations

and increased androgen binding. Markers of cardiovascular
risk were also significantly improved following 6 months of
acarbose therapy in obese women with PCOS.18 The rate of
flatulence and diarrhea was significantly lower for acarbose
compared to metformin (38% vs 80%).19
D-chiroinositol
Administration of D-chiroinositol makes up deficiency of
D-chiroinositol containing phosphoglycan that mediates action
of insulin in these patients. It is given in a dose of 1200 mg/
day for 6–8 weeks to correct ovulatory dysfunction.20 86% of
women ovulated compared to 26% in the placebo group.
Endometrial Biopsy
It is indicated in all women who have a clinical history of
long-term unopposed estrogen exposure even when the
endometrial thickness is normal 5 to 12 mm and in those
where endometrial thickness is greater than 12 mm even
though clinical suspicion of the disease is low.
Ovulation Induction
Aim of ovulation should be to correct the underlying distur
bance and achieve unifollicular ovulation.
Problems of Ovulation Induction in PCOS

1. Disturbed folliculogenesis leading to poor response to
induction.
2. Large number of antral follicles sensitive to FSH leading
to multiple follicular development, OHSS and multiple
pregnancy.
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3. Tonically elevated serum LH levels leading to premature
luteinization, low pregnancy rates and high miscarriage
rates.
Several modes of inducing ovulation are used (Fig. 8.3).
Maybe a combination of all will work (Table 8.4).
The approach for ovulation induction in a PCOS should go from

a less aggressive to more aggressive one as these patients are
prone to hyperstimulation.
1. Weight loss: It is important to take into consideration the

patients weight while prescribing any drug. Weight loss
helps in restoring ovulation and improves response to
ovulation inducing drugs.
2. Clomiphene citrate: In PCOS patients the usual dose of
50 mg may need to be lowered to 25 mg as patients
are prone to hyperstimulation. 20% of women do not
Fig. 8.3: Modes of ovulation induction in PCOS
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Table 8.4: Options for ovulation induction in PCOS

1. Weight loss
2. Clomiphene citrate
– Clomiphene alone
– Clomiphene along with adjuvants
i. hCG
ii. Metformin
iii. Glucocorticoids
iv. Bromocriptine
3. Gonadotropin therapy
– Gonadotropin alone
– Gonadotropins with addition of
– GnRH agonist
– GnRH antagonist
4. Insulin sensitizers like metformin
5. Surgical ovulation induction—laparoscopic ovarian drilling
respond to clomiphene. Dose can be increased to 250

mg (see Chapters 2 and 3). In cases which do not respond
clomiphene may be given for a period of 8 days.21 Prior
administration of progesterone intramuscularly in a
dose of 50 mg for 5 days can cause a suppression of LH
secretion. Injection hCG is given in a dose of 5000 to
10,000 IU as ovulation trigger in cases where there is
a delayed or absent LH surge despite presence of well-
developed follicle.
3. Insulin sensitizing drugs: Metformin in a dose of 1500 to
2000 mg may be started along with clomiphene in cases
with hyperinsulinemia as has been discussed in detail
earlier in this chapter.
4. Naltrexone: It is an opiate receptor antagonist that lowers
insulin, LH and androgen levels and induces ovulation
in 86% clomiphene resistant cases with a pregnancy
rate of 55%.22
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5. Glucocorticoids: 50% of patients of PCOS show
involvement of an adrenal component with raised
DHEAS.23 The desired effect should be to normalize
without suppressing the adrenal component, with dexa
methasone (0.25–0.5 mg/day) or prednisolone (5–10
mg/day). Dexamethasone has the advantage of having a
longer half-life compared to prednisolone although this
may cause over suppression at times. Dose of 0.25 mg/
day is seen to suppress 50% of patients. Two regimes
can be followed. Dexamethasone may be started with
clomiphene and stopped when ovulation is documented.
The other regime is continuous administration of
glucocorticoid till pregnancy is achieved. The logic
behind this regime is that the follicle takes 100 days for
development and the effect of the drug is present through
that period. It is usually never given beyond 6 months.
Dexamethasone gives best results when administered at
night as adrenals are most active early morning. DHEAS
and testosterone levels are monitored after one month.
Glucocorticoids with gonadotropins have been tried and
show conflicting results with some quoting an improved
pregnancy rate and others showing no change.24,25 The
side effect most commonly seen is weight gain that can
be upto 4 to 5 kg in 4 months. It is a common cause for
discontinuation of the therapy. There may be adrenal
suppression and inability to cope with stresses of major
surgery if dose is more than 0.5 mg or duration of therapy
is more than one month. There may be osteoporosis,
worsening of glucose tolerance, skin changes, gastritis,
lipid abnormalities and hypertension on prolonged use.
6. Bromocriptine: In cases of a raised serum prolactin or
galactorrhea bromocriptine in a dose of 2.5 to 7.5 mg/
day may be added along with clomiphene to improve
results.
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7. Gonadotropins: These patients are more prone to

hyperstimulation. This is not due to the difference in FSH
threshold level but to the fact that they contain twice
the number of FSH sensitive antral follicles. Due to this
the chronic low dose regime is employed where FSH is
started on day 3 at a low dose of 37.5 to 75 IU for 14 days
in first cycle and 7 days in subsequent cycles. Thereafter
increments of 25 to 37.5 IU are given at weekly intervals
until follicular development is initiated. The dose that
initiates follicular development is continued till criteria
for giving hCG is attained. Monitoring is done as
usual. Compared to the conventional step-up protocol
pregnancy rates improved (40% vs 24%), uniovulation
was induced in more (74% vs 27%) and there was no
OHSS or multiple pregnancy that was prevalent (11%
OHSS and 33% multiple pregnancy) in the conventional
therapy.26 The chances of multiple pregnancy were
reduced if a strict criteria is followed for administration
of hCG. There should be no more than three follicles
greater than 14 mm and estradiol should be less than
1500 pg/ml. In poor responders conventional step-
up protocol may be tried where the gonadotropin is
started at 150 IU and increased by 75 IU according
to response. Recently, some studies showed better
results regarding unifollicular ovulation with step-down
regimes compared with low dose step-up protocol.
These involve starting higher dose of FSH and bring it
down after follicular recruitment (see Chapter 4). It is
thought that pure FSH may be better in cases where LH
levels are high. This theory has been refuted by a few
studies where no difference in ovulation, pregnancy,
or miscarriage rate are seen following administration of
hMG versus purified FSH.27
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8. GnRH agonists: They can be used to downregulate
patients with high LH levels prior to giving ovulation
induction drugs. There was a miscarriage rate of 17.6%
vs 39% and a cumulative live birthrate of 64% vs 26% for
regimen with GnRH agonist vs those without.28 It has the
disadvantage of requiring higher dose of gonadotropin
for longer periods and increased incidence of multiple
follicular development leading to OHSS and multiple
pregnancy. This treatment is reserved for women with
high serum concentration of LH with failure to conceive
on gonadotropins, repeated premature luteinization,
and early miscarriages. They are usually started as a long
protocol on day 21 of previous cycle. Gonadotropins
are added after confirming downregulation on day 2
(Details in Chapter 5).
9. GnRH antagonist: They have the advantage of acting
by competitive binding that allows a modulation of the
degree of hormonal suppression by their dose. They act
within hours, have no flare effect and gonadal function
assumes without a lag effect. Compared with an agonist
treated cycle this would have the advantage of a shorter
cycle treatment, promise more conceptions, and fewer
miscarriages, reduce the amount of gonado tropins
needed and increase the incidence of monofollicular
ovulation with a consequent reduction in prevalence of
OHSS and multiple pregnancy. Centrorelix can be given
as a single dose of 3 mg once follicle reaches 14 mm
(Detail in Chapter 5). However, they cannot bring down
raised basal LH.
10. Surgical ovulation induction: Laparoscopic ovarian
drilling is done by laser or electrocautery where multiple
punctures are made in the ovary. This induces ovulation
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in 70 to 92% patients with a pregnancy rate of 40 to

80%. There is no need for intensive monitoring as there
is no hyperstimulation or multiple pregnancy (Details in
Chapter 9).
GnRH antagonists are more effective, safe and a well-tolerated

alternative to agonists for assisted reproduction cycles in PCOS
women with the advantage of reduction in the incidence of
OHSS.29
11. IVF: If all other treatment is ineffective IVF is the next

option. Although smaller percentage of oocytes are ferti
lized, the large number of oocytes recovered in these
cases balances out the pregnancy rate.
Guidelines for ovulation induction in PCOS:30

1. Lifestyle modification—exercise weight loss and diet should
be the first option before drug treatment is commenced as this
alone can restore ovulation and achieve pregnancy
2. First-line drug treatment should be clomiphene in low doses
3. Metformin combined with clomiphene citrate may be used in
clomiphene resistant cases or those with obesity and insulin
resistance as they increase ovulation rates and pregnancy rates
although live birthrate is not increased.
4. Second-line drug therapy is gonadotropin but higher cost,
intensive monitoring and risk of multiple pregnancy and
ovarian stimulation must be kept in mind.
5. Surgery, i.e. laparoscopic ovarian drilling may be considered
in women who are unable to come for monitoring, those with
clomiphene and gonadotropin resistant PCOS, or where other
indications for laparoscopy are present.
6. In vitro fertilization is the final line of treatment if gonadotropin
therapy fails.
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Treatment in those who do not

Desire Pregnancy
Treatment is given to these patients to improve symptoms and
prevent complications.
Prevention of Endometrial Hyperplasia

1. Monthly medroxyprogesterone: Medroxyprogesterone in
a dose of 5 to 10 mg/day or norethindrone in a dose of
5 to 15 mg for 10 to 14 days each month should be given.
This avoids abnormal endometrial proliferation but does
not suppress the ovarian androgen production.
2. Low dose oral contraceptive pills.
3. GnRH agonists: They are used where there is no response
to hormones or there are severe side effects.
Regularization of Cycles
1. Low dose contraceptive pill: Advantages of contraceptive
pills are contra ception, prevention of endometrial
hyperplasia, regulari zation of cycles and treatment of
hirsutism. Oral contraceptive pills containing estradiol in
low dose and progestogen desogestrel that is lipid friendly
and has no androgenic effect, are used (Fig. 8.4).
2. Metformin: Metformin may be given in cases where
insulin levels are high. Menstrual cyclicity returns in 65 to
95% cases when treated for 4 to 6 months.
Hyperinsulinemia
Hyperinsulinemia should be treated because of the metabolic
effects it has (Fig. 8.2). Metformin, rosiglitazone or pioglitazone
may be given. Details have already been discussed earlier in
the chapter.
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Fig. 8.4: Management of PCOS
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Hyperandrogenism
Hyperandrogenism may be determined clinically by hirsutism,
acne and alopecia and biochemically by raised testosterone,
free testosterone index, dehydroepiandrosterone sulfate
(DHEAS) and androstenedione.
Other tests in patients showing increased androgen levels
are:
1. 17 hydroxyprogesterone: It is a screening test for adult
onset congenital adrenal hyperplasia. This should be done
once PCOS is ruled out. The sample should be drawn at 8
AM. Basal follicular phase serum 17 OHP levels above 5
ng/ml suggest this disorder.
2. Overnight dexamethasone suppression test: It should be
performed in women with physical features of cortisol
excess such as hypertension, central obesity, facial
plethora, easy bruisibility, striae and proximal muscle
weakness.1 mg of dexamethasone is administered orally
at 11 PM and serum cortisol measurement is taken at 8
am, the following morning. Serum cortisol level below 5
µg (140 nmol/L) rules out Cushing’s syndrome but may be
present in PCOS women.
Treatment consists of:
1. Oral contraceptive pills: They suppress ovarian androgen
production and increase sex hormone binding globulin
thereby reducing free testosterone. Oral contraceptive
pills containing 2 mg cyproterone acetate and 35 µg
ethinyl estradiol or those containing desogesterol with
ethynyl estradiol are recommended.
2. Cyproterone acetate: It antagonizes the androgen receptors
in the skin and acts as a weak progestogen that inhibits
gonadotropin secretion thereby decreasing androgen
production. Dose 50 to 100 mg/day for 5 to 15 along with
cyclic estrogen to regularize menstruation. It can also be
Ch-08.indd 135 18-01-2014 12:07:04

given as oral contraceptive pill. It has been shown that

it increases ovulation rate in women on clomiphene or
gonadotropins.
3. Spironolactone: It is an oral aldosterone antagonist
with antiandrogenic properties. It increases metabolic
clearance of testosterone and reduces cutaneous 5 alpha
reductase activity. It reduces the hirsuitism score by 40%
and is effective alone in 50% women. Dose 50 to 200 mg/
day. The most common side effect is irregular menses and
hence, it should be used along with oral contraceptive
pills.
4. Flutamide: It is a nonsteroidal antiandrogen at the receptor
level given in a dose of 250 mg once or twice a day. It
reduces the levels of free and total testosterone reducing
the hirsuitism and regularizing the menstrual cycle.
5. Finasteride: It acts as a type II 5 alpha reductase inhibitor
given in a dose of 5 mg/day.
6. GnRH agonist: They can be given in a depot preparation
with the goal of reducing serum testosterone to 40 ng/dl
for patients resistant to above therapy.
7. Metformin: It is added if there is hyperinsulinemia.
8. Ketoconazole: By suppression of steroidogenesis it brings
down androgen and LH levels. It is a known teratogen and
hence, has limited use in young woman with PCOS trying
to conceive.
Antiandrogens are potentially teratogenic and must be administered

along with oral contraceptives.
Management of PCOS is complex and requires multiple

metabolic and endocrine factors to be taken into account.
Since the spectrum of clinical presentation and metabolic
pathology is vast all ovulation induction protocols have to be
individualized in PCOS (Fig. 8.4).
Ch-08.indd 136 18-01-2014 12:07:04

References
1. Fauser B, Tarlatzis B, Chang J, Azziz R, et al. The Rotterdam
ESHRE/ASRM sponsored PCOS consensus workshop group.
Revised 2003 consensus on diagnostic criteria and long-term
health risks related to polycystic ovarian syndrome (PCOS).
Hum Reprod. 2004;19:41-7.
2. Balen AH, Laven JSE, Tan SL, Dewailly D. Ultrasound assessment
of polycystic ovary: international consensus definitions. Human
Reprod Update. 2003;9:505-14.
3. van Santbrink EJP, Hop WC, Fauser BCJM. Classification of
normogonadotropic infertility: Polycystic ovaries diagnosed by
ultrasound versus endocrine characteristics of polycystic ovary
syndrome. Fertil Steril. 1997;67:452-9.
4. Speroff L, Fritz MA. Anovulation and Polycystic Ovary. In:
Speroff L, Fritz MA (Eds): Clinical Gynecological Endocrinology
and infertility. Williams and Wilkins Philadelphia USA.
2005;465-98.
5. Jayagopal V, Kilpatrick ES, Holding S, Jennings PE, Atkin
SL. Orlistat is as beneficial as metformin in the treatment
of polycystic ovarian syndrome. J Clin Endocrinol Metab.
2005;90(2):729-33.
6. Diamanti-Kandarakis E, Katsikis I, Piperi C, Alexandraki K,
Panidis D. Effect of long-term orlistat treatment on serum levels
of advanced glycation end-products in women with polycystic
ovary syndrome. Clin Endocrinol (Oxf). 2007;66(1):103-9.
7. Lindholm A, Bixo M, Björn I, Wölner-Hanssen P, Eliasson M,
Larsson A, et al. Effect of sibutramine on weight reduction in
women with polycystic ovary syndrome: a randomized, double-
blind, placebo-controlled trial. Fertil Steril. 2008;9(5):1221-8.
8. Kahn SE, Prigeon RL, Mcculloch DK, Bayco EJ, Bergman RN,
Schwartz MW, et al. Quantification of relationship between
insulin sensitivity and b cell function in human subjects.
Diabetes. 1993;42:1663-72.
9. Heaney D, Majid A, Junor B. Bicarbonate hemodialysis as a
treatment of metformin overdose. Nephrol Dial Transplant.
1997;12:1046-7.
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10. Lord JM, Flight IH, Norman RJ. Insulin-sensitising drugs

(metformin, troglitazone, rosiglitazone, pioglitazone,
D-chiroinositol) for polycystic ovary syndrome. Cochrane
Database Syst Rev. 2003;(3):CD003053. Comment in: ACP J
Club. 2004;140(3):75-80.
11. Tang T, Lord JM, Norman RJ, Yasmin E, Balen AH. Insulin-
sensitising drugs (metformin, rosiglitazone, pioglitazone,
D-chiroinositol) for women with polycystic ovary syndrome,
oligo amenorrhoea and subfertility. Cochrane Database Syst
Rev. 2010 Jan 20;(1):CD003053.
12. Tso LO, Costello MF, Albuquerque LE, Andriolo RB, Freitas V.
Metformin treatment before and during IVF or ICSI in women
with polycystic ovary syndrome. Cochrane Database Syst Rev.
2009 Apr 15;(2):CD006105.
13. Glueck CJ, Wang P, Kobayashi S, Philips H, Seive -Smith,
Wang P. Continuing metformin throughout pregnancy in
women with polycystic ovary syndrome appears to safely
prevent first trimester spontaneous abortion: A pilot study.
14. Stout DL, Fugate SE. Thiazolidinediones for treatment of polycystic
ovary syndrome. Pharmacotherapy. 2005;25(2):244-52.
15. Ortega-Gonzalez C, Luna S, Hernandez L, Crespo G, Aquayo
P, Arteaga-Troncoso G, et al. Responses of serum androgen
and insulin resistance to metformin and pioglitazone in obese,
insulin-resistant women with polycystic ovary syndrome. J Clin
Endocrin Metab. 2005;90(3):1360-5.
16. Glueck CJ, Moreira A, Goldeberg N, Sieve L, Wang P.
Pioglitazone and metformin in obese women with polycystic
ovary syndrome not optimally responsive to metformin. Hum
Reprod. 2003;18:1618-22.
17. Sönmez AS, Yasar L, Savan K, KoçS, Ozcan J, Toklar A, et al.
Comparison of the effects of acarbose and metformin use on
ovulation rates in clomiphene citrate-resistant polycystic ovary
syndrome. Hum Reprod. 2005;20(1):175-9.
18. Kircher C, Smith KP. Acarbose for polycystic ovary syndrome.
Ann Pharmacother. 2008;42(6):847-51.
Ch-08.indd 138 18-01-2014 12:07:04

19. Hanjalic-Beck A, Gabriel B, Schaefer W, Zahradnik HP,
Schories M, Tempfer C, et al. Metformin versus acarbose
therapy in patients with polycystic ovary syndrome (PCOS):
a prospective randomised double-blind study. Gynecol
Endocrinol. 2010;26(9):690-7.
20. Nestler JE, Jakubowicz DJ, Reamer P, Gunn RD, Allan G.
Ovulatory and metabolic effects of D-chiro-inositol in the
polycystic ovary syndrome. New Eng J Med. 1999;340:314.
21. Lobo RA, Granger LR, Davajan V, Mishcell DR Jr. An extended
regime of clomiphene citrate in women unresponsive to
standard therapy. Fertil Steril. 1982;37:762-6.
22. Hadžiomerović-Pekić D, Wildt L, Weiss JM, Moeller K, Mattle
V, Seeber BE. Metformin, naltrexone, or the combination of
prednisolone and antiandrogenic oral contraceptives as first-
line therapy in hyperinsulinemic women with polycystic ovary
syndrome. Fertil Steril. 2010;94(6):2385-8.
23. Gonzalez F. Adrenal involvement in polycystic ovarian
disease. Semin in Reprod Endocrinol. 1997;15:137-57.
24. Evron S, Navot D, Laufer N, Diamant YZ. Induction of ovulation
with combined human gonadotropins and dexamethasone
in women with polycystic ovarian disease. Fertil Steril.
1983;40:183-6.
25. Bider D, Blankstein J, Levron J, Tur Kaspa I. Gonadotropins and
glucocorticoid therapy for low responders: A controlled study.
J Assist Reprod Genet. 1997;14:328-31.
26. Homberg R, Levy T, Ben Rafael Z. A comparative prospective
study of conventional regimen with chronic low dose adminis
tration of follicle stimulating hormone for anovulation
associated with polycystic ovary syndrome. Fertil Steril.
1995;63:729-33.
27. Venturoli S, Paradisi R, Fabbri R, Porcu E, Orsini LF, Flamigni C.
Induction of ovulation in polycystic ovary: Human menopausal
gonadotropins or human urinary follicle stimulating hormone?
Int J Fertil. 1987;32:66-70.
28. Homberg R, Levy T, Berkowitz D. GnRH agonist reduces
miscarriage rate for pregnancies conceived in polycystic ovary
syndrome. Fertil Steril. 1993;59:527-31.
Ch-08.indd 139 18-01-2014 12:07:04

29. Hosseini MA, Aleyasin A, Saeedi H, Mahdavi A. Comparison

of gonadotropin-releasing hormone agonists and antagonists
in assisted reproduction cycles of polycystic ovarian syndrome
patients. J Obstet Gynaecol Res. 2010;36(3):605-10.
30. Vause TD, Cheung AP, Sierra S, Claman P, Graham J, Guillemin
JA, et al. Society of Obstetricians and Gynecologists of Canada.
Ovulation induction in polycystic ovary syndrome. J Obstet
Gynaecol Can. 2010;32(5):495-502.
Ch-08.indd 140 18-01-2014 12:07:04

cHAPTER
9
Surgical Ovulation
Induction
Lalita Badhwar, Surveen Ghumman
Polycystic ovarian disease is a heterogeneous group of

disorders that may present with a wide variety of clinical
syndromes. It may present with obesity, hyperandrogenism,
menstrual cycle abnormalities, infertility and ultrasound
finding of increased ovarian volume, multiple small cysts and
bright echogenic stroma.
The aim of therapy of patients with polycystic ovarian
disease is treatment of infertility, hirsutism, endometrial
hyperplasia and irregular cycles. Patients desirous of
pregnancy are treated with clomiphene citrate, gonadotropins
with or without GnRH agonists or antagonists and insulin
sensitizers (Refer to Chapter 8). The medical method of
inducing ovulation fails in 25% of patients due to lack of
adequate response or complications like OHSS. In these
cases surgical option becomes important.
Wedge resection was first reported in 1935. With the
introduction of clomiphene citrate, medical management
replaced surgical management as the primary mode of
treatment. Interest in laparoscopic surgical management was
Ch-09.indd 141 18-01-2014 12:07:19

renewed in 1984 by Gjonnaess.1 Today, surgical management

has definite indications and occupies an important place in
management of PCOS patients.
Mechanism of Action
Proposed theories of how laparoscopic ovarian drilling
improves chances of ovulation in these patients are many.
1. Puncturing of follicles release androgen rich fluid and
decrease androgen producing stroma so as to decrease
circulating androgens.
2. Crowding of cortex is reduced allowing progress of
normal follicles to the surface resulting in resumption of
normal ovulation.
3. There is a fall in LH that results in increased secretion of
FSH.
Indications
1. Failure of medical therapy for ovulation induction.
2. Persistent hypersecretion of LH.
3. Intolerable side effects to drug therapy.
4. Need for laparoscopic evaluation of pelvis.
5. Inability to attend any intensive monitoring protocols
required with drug therapy.
Techniques
Wedge Resection
It is no longer the surgery of choice as it requires that 50%
of ovarian substance be removed. This results in a loss of
ovarian tissue and adhesion formation.
Ch-09.indd 142 18-01-2014 12:07:20

Surgical Ovulation Induction 143
Operative Laparoscopy
It is a minimally invasive technique and has replaced ovarian
wedge resection. The advantages of this procedure are:
1. Multiple ovulatory cycles after a single treatment.
2. No cyclic monitoring of ovulation induction is required.
3. No risks of multiple pregnancy or ovarian hyper
stimulation.
4. Spontaneous abortion rate is less than that of medical
induction.
5. Less expensive and less cumbersome compared to gona
dotropin treatment.
Steps of Surgical Technique

Instruments used are shown in Figures 9.1 and 9.2.
The procedure is done under general anesthesia with the
patient in extended lithotomy position with Trendelenburg
tilt (Fig. 9.3).
The (right handed) surgeon stands to the left of the patient.
Currently used is the three port laparoscopy technique (Fig. 9.4).
• A 10 mm scope is used as the visual axis
• The first port with 5 mm sheath is placed on left side
lateral to the inferior epigastric vessels. The instruments
inserted through this port are the atraumatic grasper used
for grasping and retraction (surgeon’s left hand).
• Suprapubic portal is used for suction, irrigation and
monopolar needle cautery (surgeon’s right hand).
• Optional right lateral portals for alternate grasper.
At the outset the uterus, tubes, ovaries and peritoneal folds
are examined for any pathology (Fig. 9.5; See accompanying
interactive CD-Rom).
Then by grasping the ovarian ligament or simply flipping
over the ovary, the ovary is lifted and rotated to a more
convenient position for puncture (Fig. 9.6).
Ch-09.indd 143 18-01-2014 12:07:20

Fig. 9.1: Imaging system and insufflator
Fig. 9.2: Grasper, suction, etc.
Ch-09.indd 144 18-01-2014 12:07:20

Fig. 9.3: Extended lithotomy position
Fig. 9.4: Patients abdomen showing 3 points of entry
Fig. 9.5: View of bilateral polycystic ovaries
Ch-09.indd 145 18-01-2014 12:07:20

Fig. 9.6: Grasping of ovarian ligament
The needle is held perpendicularly to the ovarian surface

and the follicles are punctured with simultaneous application
of current for approximately one second or less (Fig. 9.7). This
prevents accidental injury that may occur due to tangential
slipping of the needle with energy and minimizes ovarian
surface damage.
Attempt is made to puncture almost all the prominent follicles
that amount to 4 to 10 punctures on each ovary (Fig. 9.8).
Fig. 9.7: Position of needle on ovary before puncture
Ch-09.indd 146 18-01-2014 12:07:21

Fig. 9.8: Appearance of ovary after drilling
The ovary is then irrigated thoroughly with normal saline

to ensure hemostasis as well as cool it down at once (Fig. 9.9).
Please note that the surface damage to the ovary as well as the
thermal damage should be minimized by reducing the number
of punctures, the time for that the current is passed as well as by
entering the ovary perpendicularly (Figs 9.10 and 9.11).
Fig. 9.9: Ovary irrigated with normal saline
Ch-09.indd 147 18-01-2014 12:07:21

Fig. 9.10: Excessive injury to ovarian surface
Fig. 9.11: Correct appearance of ovary after drilling
Caution
Sites to be avoided during drilling are:
1. Area close to the mesovarium.
2. Area close to the attachments of the infundibulopelvic
and ovarian ligaments.
3. Corpus luteum.
These sites tend to have troublesome bleeding while
attempting to control may increase the ovarian damage.
Ch-09.indd 148 18-01-2014 12:07:21

Various Laparoscopic Approaches
Simple Needle Puncture

This is thought to have minimal stromal damage, but was seen
to be associated with bleeding and periovarian adhesions.
Fertility rate is poor compared to other procedures.
Electrocauterization
Here monopolar cautery is used at 20 to 30 watts in cutting
mode. Pure cutting current may be used on the thick
ovarian surface. Cortex is usually penetrated at 4 to 10
sites for a depth of 3 to 5 mm. Attempt is made to puncture
almost all the prominent follicles. The fluid mixed with
the irrigating solution is completely aspirated out through
the suction cannula. The ovaries are lavaged with Ringer’s
solution containing hydrocortisone and heparin to minimize
adhesions. The bleeding is usually self-limiting and is arrested
by diathermy if required.
Laser
KTP and CO2 lasers are used and the technique is similar to
that of electrocautery, namely the ovarian cortex is vaporized
over the follicles. As the energy is more precisely focused,
there is less peripheral thermal damage. Either an ultrapulse
CO2 laser (40–80 watts, 25–200 mj) or the super pulse CO2
(25–40 watts) is used. All visible subcapsular follicles are
vaporized and a 2 to 4 mm crater is made in the ovarian
stroma. It is recommended that the number of punctures be
more, 25 to 40, so that all visible follicles are drained. With
Nd:YAG laser the technique is somewhat different. There is
much more thermal diffusion in the non-contact mode with
this laser. Since it is divergent once it passes the tip of the
delivery system, the coagulation of the tissue is achieved. A
Ch-09.indd 149 18-01-2014 12:07:21

wedge-shaped area of 4 to 10 mm is thus coagulated without

opening the cortex. This laser has also been used in the
contact mode to cut out a wedge-shaped portion of the ovary,
not unlike the bilateral ovarian resection. The laser is now
regarded to produce more excessive ovarian surface trauma
than stromal damage leading to adhesion formation.
As a result, attention is now shifting toward the use of
monopolar needle electrodes, which are insulated where they
contact the ovarian surface. The needle punctures the ovarian
surface to the depth of the insulated hub and the deeper
stroma can be cauterized with minimal surface damage. The
most commonly used instrument is the monopolar needle.
Unilateral vs Bilateral Diathermy

It was seen that unilateral diathermy restored bilateral ovarian
activity with the contralateral ovary often being the first to
ovulate after the treatment. Unilateral ovarian diathermy was
as effective and long lasting as bilateral ovarian diathermy in
the resumption of menstruation and pregnancy rates.2
Complications
Postoperative Adhesion
A rate of adhesion formation of 19.3% was seen that
decreased to 16.6% when the peritoneal lavage was done.3
The greater the damage to the surface of the ovary more the
peritubal adhesion formation. Hence, Armar recommended
only 4 diathermy points per ovary for 4 seconds at 40 W.4
A recent study reported a high rate of adhesion formation
up to 60% and their extent and severity was not influenced
by the number of ovarian punctures; however, the left ovary
appeared more prone to develop severe adhesions than the
contralateral one.5
Ch-09.indd 150 18-01-2014 12:07:21

Wedge resection has been seen to cause adhesions
in nearly 100% cases. To prevent adhesions 200 ml of
Hartmann’s solution is instilled in the Pouch of Douglas that
by cooling the ovary prevents heat injury to adjacent tissues
and reduces adhesion formation. The risk may further be
removed by abdominal lavage. Laser treatment may have a
lower adhesion formation rate than diathermy.
The risks of periovarian adhesions can be reduced by
minimizing the ovarian surface damage. This is achieved by
reducing the total number of punctures, and ensuring that the
needle enters perpendicular to the surface, not tangentially.
Ovarian Failure
Ovarian failure has been reported by some.6 If FSH and LH
levels are not too high, avoid too many punctures as it may
lead to ovarian failure. The incidence is very uncommon.7
However, a recent study stated most of the changes in
the ovarian reserve markers observed after LOD could be
interpreted as normalization of ovarian function rather than
a reduction of ovarian reserve. LOD, if applied properly,
normalizes the exaggerated ovarian morphologic and
endocrinologic properties.8
The risk of premature ovarian failure can be reduced by
minimizing the thermal damage to the ovary. This is achieved
by reducing the number of punctures, using only very short
bursts of cutting current and lavaging the ovary to cool it
down.
Advantages
1. In subsequent ovulation induction ovaries become more
responsive and lower dose of drugs are needed to induce
ovulation.
2. There is decreased pregnancy loss.
Ch-09.indd 151 18-01-2014 12:07:21

3. No risk of hyperstimulation or multiple pregnancies.

4. Effect lasts for 12 to 18 months. Recent studies have
shown a beneficial effect up to 9 years.9
Results of Laparoscopic Treatment
Ovulation
Ovulatory rate that varies between 70 to 92% is influenced
by body weight. Ovulation rate being higher in slim and
moderately obese but lower in obese patients.1
Pregnancy Rate
A pregnancy rate of 40 to 80% is seen.1 In cases with
clomiphene resistance pregnancy rate was similar with
laparoscopic ovarian drilling and gonadotropins.10 However,
a recent study showed a 67% cumulative pregnancy rate with
gonadotropins after 6 months but only a 37% pregnancy rate
with laparoscopic ovarian drilling.11
Abortion
The abortion rate is 6 to 7% with laparoscopic ovarian drilling
compared to 26–28% in treatment with gonadotropins.12
Keeping in view the problems of postoperative periovarian
adhesions and ovarian atrophy a combined approach for
ovulation induction is recommended whereby low-dose
diathermy is followed by low dose ovarian stimulation.13
Ovarian drilling by hydrolaparoscopy is an effective
treatment for CC-resistant.14 A recent Cochrane review (2007)
stated that there was no evidence of a difference in live
birth, clinical pregnancy or miscarriage rate between LOD
and gonadotropins. Multiple pregnancy rates were lower
with ovarian drilling than with gonadotropins (1% versus
16%) making it an attractive option. However, there are
Ch-09.indd 152 18-01-2014 12:07:21

ongoing concerns about long-term effects of LOD on ovarian
function.15
Follow-up
If in 12 ovulatory cycles there is no conception, one should
proceed for assisted reproductive techniques rather than
waiting.
Surgical treatment for PCOS has a definite role in manage
ment of the infertile women with the advantage of no
subsequent cycle monitoring. Caution during the procedure
is needed to avoid ovarian damage that may cause adhesions
and ovarian failure.
References
1. Gjonnaess H. Polycystic ovarian syndrome treated by
ovarian electrocautery through the laparoscope. Fertil Steril.
1984;41:20-5.
2. Al-Mizyen E, Grudzinskas JG. Unilateral laparoscopic ovarian
diathermy in infertile women with clomiphene citrate-resistant
polycystic ovary syndrome. Fertil Steril. 2007;88(6):1678-80.
3. Naether OGJ, Fischer R, Weise HC, Geiger-Kotzler L, Delfs
T, Rudolf K. Laparoscopic electrocoagulation of the ovarian
surface in infertile patients with polycystic ovarian disease
4. Armer NA, Mc Garrigle HH, Honour J, Holownia P, Jacobs HS,
Lachelin GC. Laparoscopic ovarian diathermy in management
of anovulatory infertility in women with polycystic ovaries:
endocrine changes and clinical outcome. Fertil Steril.
1990;53:45-9.
5. Mercorio F, Mercorio A, Di Spiezio Sardo A, Barba
GV, Pellicano M, Nappi C. Evaluation of ovarian adhesion
formation after laparoscopic ovarian drilling by second-look
minilaparoscopy. Fertil Steril. 2008;89(5):1229-33.
Ch-09.indd 153 18-01-2014 12:07:22

6. Dabirashrafi H. Complications of laparoscopic ovarian

cauterization. Fertil Steril. 1989;52:878-83.
7. Cohen BM. Laser laparoscopy for polycystic ovaries. Fertil
Steril. 1989;52:167-8.
8. Api M. Is ovarian reserve diminished after laparoscopic ovarian
drilling? Gynecol Endocrinol. 2009;25(3):159-65.
9. Amer SAKS, Banu Z, Li TC, Cooke ID. Long-term follow-up
of patients with polycystic ovarian syndrome after laproscopic
ovarian diathermy: endocrinal and ultrasonic outcomes. Hum
Reprod. 2002;11:2851-7.
10. Ferquhar CM, Williamson K, Gudex G, Johnson NP. A rando
mized controlled trial of laparoscopic ovarian diathermy versus
gonadotropin therapy for women with clomiphene citrate
resistant polycystic ovary syndrome. Fertil Steril. 2002;78:404-11.
11. Bayram N, van Wely MK, Kajik EM, Bossuyut PMM, van
der Veen. Using an electrocautery strategy or recombinant
follicle stimulating hormone to induce ovulation in polycystic
ovarian syndrome: randomized controlled trial. Br Med J.
2004;328:192-5.
12. Abdel GA, Mowafi RS, Alnaser HM, Alrashid AH, et al. Ovarian
electrocautery versus HMG and pure FSH therapy in treatment
of PCOS. Clin Endocrinol. 1990;33:585-92.
13. Farhi J, Soule S, Jacob H. Effect of laparoscopic ovarian
electrocautry on ovarian response and outcome of treatment
with gonadotropins in clomiphene resistant patients with
PCOS. Fertil Steril. 1995;64:930-5.
14. Poujade O, Gervaise A, Faivre E, Deffieux X, Fernandez H. Surgical
management of infertility due to polycystic ovarian syndrome
after failure of medical management. Eur J Obstet Gynecol
Reprod Biol. 2011;158(2):242-7.
15. Farquhar C, Lilford RJ, Marjoribanks J, Vandekerckhove P.
Laparoscopic ‘drilling’ by diathermy or laser for ovulation
induction in anovulatory polycystic ovary syndrome. Cochrane
Ch-09.indd 154 18-01-2014 12:07:22

cHAPTER
10
Hypogonadotropic
Hypogonadism and
Ovulation Induction
Surveen Ghumman
Hypogonadotropic hypogonadism is a disorder characterized

by low or undetectable LH or FSH levels leading to low
estradiol levels and anovulation. These women respond well
to ovulation induction.
Causes
Causes could be pituitary or hypothalamic. Common functional
disturbance like eating disorders, emotional stress or excessive
exercise are responsible in most cases. Exercise increases
prolactin, GH, testosterone, ACTH, adrenal steroids, and
endorphins and decreases gonadotropins (Figs 10.1 and 10.2).
Hypothalmic disorders are diagnosed by absence of pituitary

lesions – diagnosis of exclusion.
Ch-10.indd 155 18-01-2014 12:08:25

Fig. 10.1: Causes of hypogonadotropic hypogonadism
Fig. 10.2: Mechanism of exercise induced hypogonadotropic

hypogonadism
Ch-10.indd 156 18-01-2014 12:08:25

Hypogonadotropic Hypogonadism and Ovulation Induction 157
Clinical Presentation
Clinical presentation depends on degree of GnRH suppression
(Table 10.1).
1. Mild GnRH suppression—Inadequate luteal phase.
2. Moderate GnRH suppression—Anovulation and menstrual
irregularity.
3. Profound GnRH suppression—Amenorrhea. Failure to
demonstrate withdrawal bleeding with progesterone.
Other symptoms like vaginal dryness, hot flushes,
decreased breast tissue, libido and muscle mass may present.
Decreased bone density is also seen due to low estrogen
levels.
Diagnosis
Laboratory Parameters
Tests done are mainly hormonal and imaging so as to establish
diagnosis and to identify cause:
1. Low gonadotropins (LH and FSH).
2. Low estradiol levels.
Table 10.1: Grades of severity of hypothalamic amenorrhea
Grade I : Positive response with clomiphene
Grade Ia: Normal ovulatory
Grade Ib: Ovulatory with LPD
Grade Ic: Anovulatory
Grade II: Progesterone withdrawal + but clomiphene response negative
Grade III: Response to 100 mg IV bolus
Grade IIIa : Normal adult type
Grade IIIb: Blunted prepubertal type
Grade IIIc: No response
Ch-10.indd 157 18-01-2014 12:08:25

3. Normal prolactin and imaging.

4. Normal testosterone and DHEA
5. Pituitary dynamic testing:
i. Gonadotropin-releasing hormone challenge test: IV
bolus injection of 100 mg of GnRH is given. LH and
FSH measured at regular interval of 0, 30, 60, 90
min, respectively after application of GnRH.
ii. Pituitary capacity test: Differentiates pituitary cause
from hypothalamic origin. An IV bolus of GnRH
100 mg is given followed by subsequent stimulation
by pulsatile GnRH 15 mg/90 min for 4 days to
prime pituitary. One week after discontinuation of
stimulation pituitary challenge test is repeated. If
second response same or lower than first pituitary
gonadotrophs are deficient.
6. Bone mineral density: Bone mineral density shows lower
values as these women are estrogen deficient.
Precautions whereas measuring LH and FSH:

1. Delay of two weeks required if hormones have been given for
withdrawal bleed.
2. Assume high levels are because of ovulatory surge if she
bleeds after 2 weeks of the sample collection.
Differential Diagnosis of Hypogonadotropic

Hypogonadism with Amenorrhea
Conditions like hyperprolactenemia, hypothyroidism, PCOS
and ovarian failure can mimic this condition (Table 10.2).
Treatment
These women have anovulatory infertility. This can be treated
by GnRH therapy or replacement of gonadotropins. The
important thing to be kept in mind with these women is:
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Table 10.2: Differential diagnosis of hypogonadotropic

hypogonadism
Tests Rules out or confirms
LH/FSH/Prolactin/TSH Excludes ovarian failure,
hyperthyroidism,
hypothyroidism, prolactin secreting
adenoma
Androgen –Testosterone, PCOS
androstenedione, insulin
Corticotropin stimulation test, Cushing’s syndrome/Addison’s disease
or perform dexamethasone
suppression test
Pituitary stimulation test Panhypopituitarism
All normal except elevated 24 Functional hypothalamic chronic

hour urinary cortisol anovulation
1. Low values of LH and their impact on ovulation,

fertilization and pregnancy rates.
2. The other aspect is the effect of low estradiol level on the
pregnancy rate. Estradiol does not seem to be important
for the fertilization but it is highly essential for pregnancy
and its maintenance.1,2 It is important for a normal
endometrial receptivity.
Gonadotropin Therapy
Role of LH Supplementation
LH supplementation is essential in follicular phase as low
endogenous levels of LH acts on corpus luteum to produce
progesterone which prepares the endometrium. One key
aspect of the effect of LH activity on the developing follicle is
the follicle-stimulating hormone (FSH) mediated acquisition
of LH receptors in granulosa cells that occurs in the mid-
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follicular phase of the normal menstrual cycle, once ovarian

follicles reach a diameter of 10 mm. At this stage LH can
stimulate granulosa cell function and folliculogenesis
independently of FSH activity.
Stimulation without LH induces normal follicular growth
with accompanying low estradiol level leading to absence of
normal oocyte maturation and fertilization competence.3 The
poor oocyte quality is because, proper maturation of oocyte
requires both gonadotropins.4 Optimal follicular development
is obtained if exposure to endogenous and/or exogenous LH
is sufficient. This is the ‘threshold’ concept. However, it is
seen that excessive levels of LH inhibit follicular growth.
This is the “ceiling” concept, i.e. level beyond that normal
follicular growth and oocyte quality will be compromised
by LH. Follicular development was achieved in 65.4%
of patients receiving lutropin alfa and 15.4% of patients
receiving placebo.5
Which Gonadotropin Should be Used?

Gonadotropins that can supplement LH are used:
a. hMG: hMG, with a fixed LH:FSH ratio, represents a non-
physiological stimulation where the ratio of LH and FSH
is fixed. However, in the natural cycle early part of the
follicular phase is FSH dominated and latter part has
increasing levels of LH that are important (Fig. 10.3).
b. Stimulation with recombinant FSH and LH
c. hCG supplementation: Activity of LH can also be obtained
by the addition of hCG (50 IU/day) as has been shown in
a woman with secondary amenorrhea.6
What Dose of Gonadotropins is Needed?

Higher doses of gonadotropin and longer duration of
stimulation are required as there is no endogenous production.
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In IVF higher doses given for a longer time yielded lower
peak E2 levels and lesser number of oocytes compared to
women with unexplained infertility (Fig. 10.3).7
At What level should LH Supplementation be Started?

A study showed that rhLH is indicated in LH deficient women
(defined by an endogenous LH level < 1.2 IU/l).8 A transition
from LH dependence to independence was observed between
basal LH values of ≥1.2IU/L and ≤1.6IU/L.9
Fig. 10.3: hMG protocol for hypogonadotropic hypogonadism
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What Dose of LH should be Given?

• A study carried out in women with hypogonadotropic
hypogonadism showed that when there was no LH
supplementation E2 levels on last day of FSH were
only 65 pmol/l. This level increased marginally to
195 pmol/l on supplementing with 25 IU of LH but
increased to 1392 pmol/l when a supplementation of
75 IU was given. Difference in serum E2 levels resulted
in different endometrial growth. The follicular growth
increased from 27% to 79% with supplementation between
75 IU and 225 IU and endometrium became excellent.
They also responded better to hCG permitting successful
luteinization of follicles.
• Daily dose of 75 IU rLH is sufficient for promoting
optimal follicular development in the majority of HH
patients. High doses of exogenous LH greater than 225 IU
lead to atresia of secondary follicles LH ceiling concept.
Androstenedione levels were higher among patients
treated with the higher doses of LH.10
How Do We Monitor LH Dose?

Such low doses do not lead to a measurable change in serum
LH trough levels and hence, are difficult to monitor.10
Adverse Effects
Most adverse events are mild to moderate in severity.11 Adverse
events were seen in same incidence as women taking only
FSH and consisted of pelvic and abdominal pain, headache,
breast pain, nausea, ovarian enlargement and somnolence.10
Results of Gonadotropin Therapy

Cumulative PR after 6 treatment cycles was 89%. Severe
OHSS occurred in 1% and multiple pregnancy rate in 30%.12
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Poor Response with Gonadotropins and Role of Growth Hormone
Growth hormone (GH) replacement may be beneficial in
hypopituitarism when response to conventional treatment
is absent. A study showed that GH (1 IU/day) alone for 3
months followed by GH and hMG gave good results. Other
have tried higher doses up to 12 IU/day.13,14
GnRH Therapy
GnRH therapy needs an intact pituitary gland. It can be
administered by an autosyringe or a peristaltic pump.
Dose and Frequency of Administration

Depends on:
1. Characteristics of amenorrhea.
2. Pulse frequency and dose.
3. Route of administration.
Characteristic of Amenorrhea
The classification shown in Table 10.1 determines the dose
needed. Grade II to IIIb requires 2.5–5 µg per pulse but for
grade IIIc 15–20 µg per pulse is required.
Higher the grade of amenorrhea higher the pulse dose necessary

to induce ovulation.
Pulse, Frequency and Dose

With 60 µg/day dose of GnRH a 60 minutes interval gave a 94%
ovulation and a 120 minute interval gave a 70% ovulation. A
low frequency of pulsatile GnRH in women decreases mean
LH levels, blunts the midcycle gonadotropin surge, does not
increase follicle-stimulating hormone concentrations, and is
associated with a reduced rate of ovulation (Fig. 10.4).15
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Fig. 10.4: GnRH pulsatile therapy: Suitable for women with intact pituitary
gland
Higher dose leads to increased ovulation rates and multiple

pregnancy.
Route of Administration—IV or SC Administration

Earlier and higher LH peaks with IV than SC administration are
seen. Daily resorption from subcutaneous sites may lead to a
continuous pattern resulting in desensitization. Irreversible
loss of 30% may be seen in SC infused GnRH because of
local catabolism of the hormone by GnRH proteases. Site of
SC administration—upper arm vs abdomen—has twice the
concentration. GnRH antibodies may form with SC therapy
because of binding of GnRH to large protein molecules
around tip of the needle. SC therapy requires higher pulse
doses and prolonged duration of treatment and results in
lower ovulation and pregnancy rates.
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Failure of Response to GnRH Therapy
Combined use of Pulsatile GnRh and gonadotropins: If there
is no response to GnRH therapy a combination of pulsatile
GnRH with gonadotropins can be given. An early rise in
estradiol keeps the FSH levels suppressed below threshold
level for ongoing follicular growth. Addition of hMG may
bring these above threshold resulting in ovulation.
Advantages of GnRH Pulsatile Therapy

It induces a menstrual cycle like the natural one with
monofollicular development, physiological estradiol levels
and subsequent luteal phase characteristics similar to a
normal cycle. The cumulative pregnancy rate was higher with
this than hMG stimulated cycle.16
1. High ovulation rate – 90%
2. High pregnancy rate – 23% per cycle. Cumulative
conception rate – 6 cycles – 78%, 12 cycles – 93%
3. Multiple pregnancy rate – lower
4. Low abortion rate
5. No OHSS
6. No monitoring
7. No frequent office visits
8. Avoidance of gonadotropin therapy.
Disadvantages of GnRH Pulsatile Therapy

1. Carrying an infusion pump requires adaptation.
Unfortunately, many patients displayed psychological
problems and were irritated by the carrying of an electronic
pump on their body for several days or weeks.
2. Slight risk of infection bacteremia or sepsis.
3. Reaction at skin site.
4. Hematoma.
5. Development of GnRH antibodies.
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Monitoring of Thyroid Activity

Constant monitoring of thyroid to maintain free thyroxine at
upper limit of normal is done.
Long-term Therapy
• Hormone replacement therapy for bone health is needed.
Bone loss is greater in the initial period, hence, early
treatment is required.
• Exercise, adequate diet, calcium supplementation and
counseling and support are also essential.
Pregnancy in Cases with

Hypogonadotropic Hypogonadism
Pregnancy Monitoring
• Luteal and early pregnancy progesterone support is a
must in these cases. Luteal support with progestogen is
continued till 12 weeks
• Thyroxine intake is raised to 150 µg/day in first and 200
µg/day in second trimester to maintain free thyroxine at a
higher limit of normal 1.5 ng/ml.
Pregnancy Complications
A study showed that pregnancies in hypopituitary women
had the following complications
• Postpartum hemorrhage – 8.7%,
• Transverse lie in 16%,
• Small for gestational age – 42.4%
• Uterine dysfunction caused by hormone deficiency:
In women with severe hypopituitarism oxytocin
supplementation was given in third trimester with the
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aim to establish physiologic conditions and to prevent
postpartum uterine inertia.17
Women with hypogonadotropic hypogonadism may
present with a spectrum of presentations according to the
severity. They respond well to ovulation induction therapies.
LH supplementation must be done in these women.
Pregnancies in these women require special care and must
receive luteal support.
References
1. Sonntag B, Loebbecke KC, Nofer JR, Kiesel L, Greb RR. Serum
estradiol and progesterone in the mid-luteal phase predict
clinical pregnancy outcome in IVF/ICSI cycles. Gynecol
Endocrinol. 2013;29(7):700-3.
2. Murray AA, Swales AKE, Smith RE, Molinek MD, Hillier SG,
Spears N. Follicular growth and oocyte competence in the
in vitro cultured mouse follicle: Effects of gonadotropins and
steroids. Mol Hum Reprod. 2008;14(2):75-83.
3. Balasch J, Miró F, Burzaco I, et al. The role of luteinizing
hormone in human follicle development and oocyte fertility:
Evidence from in-vitro fertilization in a woman with long-standing
hypogonadotrophic hypogonadism and using recombinant human
follicle stimulating hormone. Hum Reprod.1995;10(7):1678-83.
4. Huirne JA, van Loenen AC, Schats R, McDonnell J, Hompes
PG, Schoemaker J, et al. Dose-finding study of daily GnRH
antagonist for the prevention of premature LH surges in IVF/
ICSI patients: optimal changes in LH and progesterone for
clinical pregnancy. Hum Reprod. 2005;20(2):359-67.
5. Shoham Z, Smith H, Yeko T, O’Brien F, Hemsey G, O’Dea
L. Recombinant LH (lutropin alfa) for the treatment of
hypogonadotrophic women with profound LH deficiency:
A randomized, double-blind, placebo-controlled, proof-of-
efficacy study. Clin Endocrinol. 2008;69(3):471-8.
6. Filicori M, Cognigni GE, Taraborrelli S, Spettoli D, Ciampaglia
W, de Fatis CT. Low-dose human chorionic gonadotropin
Ch-10.indd 167 18-01-2014 12:08:26

therapy can improve sensitivity to exogenous follicle-stimulating

hormone in patients with secondary amenorrhea. Fertil Steril.
1999;72L:118-1120.
7. Kumbak B, Kahraman S Women with hypogonadotropic
hypogonadism: cycle characteristics and results of
assisted reproductive techniques. Acta Obst Gyne Scand.
2006;85:1453-7.
8. Loumaye E. Ovarian stimulation: is exogenous LH necessary in
all patients?.Gynecol Obstet Fertil. 2002;30(11):890-5.
9. O’Dea L, O’Brien F, Currie K, Hemsey G. Follicular
development induced by recombinant luteinizing hormone
(LH) and follicle-stimulating hormone (FSH) in anovulatory
women with LH and FSH deficiency: evidence of a threshold
effect. Cur Med Res Opin. 2008;24:2785-93.
10. The European Recombinant Human LH Study Group.
Recombinant human luteinizing hormone (LH) to support
recombinant human follicle-stimulating hormone (FSH)-
induced follicular development in LH- and FSH-deficient
anovulatory women: a dose-finding study. J Clin Endocrinol
Metabol. 1998;83:1507-14.
11. Dhillon S, Keating GM Lutropin alfa. Drugs. 2008;68(11):1529-
40.
12. Messinis IE. Ovulation induction: a mini review. Hum Reprod.
2005;20:2688-97.
13. Salle A, Klein M, Pascal-Vigneron V, Dousset B, Leclere
J, Weryha G. Successful pregnancy and birth after sequential
cotreatment with growth hormone and gonadotropins in a
woman with panhypopituitarism: a new treatment protocol.
Fertil Steril. 2000;74(6):1248-50.
14. Park JK, Murphy AA, Bordeaux BL, Dominguez CE, Session
DR. Ovulation induction in a poor responder with
panhypopituitarism: a case report and review of the literature.
Gynecol Endocrinol. 2007;23(2):82-6.
15. Filicori M, Flamigni C, Campaniello E, Ferrari P, Meriggiola
MC, Michelacci L, et al. Evidence for a specific role
of GnRH pulse frequency in the control of the human menstrual
cycle. Am J Physiol. 1989;257(6 Pt 1):E930-6.
Ch-10.indd 168 18-01-2014 12:08:26

16. Martin KA, Hall JE, Adams JM, Cowley WF Jr. Comparison of
exogenous gonadotropins and pulsatile gonadotropin-releasing
hormone for induction of ovulation in hypogonadotropic
amenorrhea. J Clin Endocrinol Metab. 1993;77(1):125-9.
17. Kübler K, Klingmüller D, Gembruch U, Merz WM. High-
risk pregnancy management in women with hypopituitarism.
2009;29:89-95.
Ch-10.indd 169 18-01-2014 12:08:26

cHAPTER
11
Hyperprolactinemia
Hyperprolactinemia is the condition when there is increased

prolactin secretion from pituitary lactotrophs that may lead to
galactorrhea, amenorrhea or infertility. Prolactin is a single
chain polypeptide containing 199 amino acids similar to
growth hormone and placental lactogen in structure. It is
secreted by lactotroph cells from the anterior pituitary. This
secretion is controlled by the hypothalamus via prolactin
inhibiting neurotransmitter, dopamine that acts on the D2
receptors. Gamma-aminobutyric acid is also inhibitory.
The stimulatory effect on prolactin secretion is through
thyrotropin releasing hormone, vasoactive intestinal peptide,
and angiotensin II. Prolactin circulates in various forms with
structural modification that are the result of glycosylation,
phosphorylation, deletion and addition. They differ in their
bioactivity (assessed by clinical symptoms like galactorrhea
and amenorrhea) and immunoreactivity (recognized by
immunoassay). Prolactin is found in serum in different
molecular forms differing in molecular size, i.e. monomeric
prolactin (molecular mass 23 kDa), “big prolactin” (50–60
kDa, possibly a dimer or a complex with receptor) and “big-
big prolactin” or “macroprolactin” (150–170 kDa), usually
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Hyperprolactinemia 171
a complex with immunoglobulin G. The little prolactin
constitutes 80% of the prolactin and is biologically most
active. The big prolactin account for 10 to 25% of the
hyperprolactinomas reported.
Prolactin and Ovarian Function

High levels of prolactin in proliferative phase may interfere
with follicle and oocyte development, cause atresia of
dominant follicle and inhibit ovulation. In the secretory phase,
high levels of prolactin interfere with corpus luteal function,
downregulate LH receptors, and cause premature destruction
of corpus luteum leading to corpus luteum deficiency.
Incidence
Hyperprolactinemia occurs in 0.4% of normal population
and 9 to 17% of patients with reproductive disorders. It is
seen in 40% of PCOS patients.
Etiology
1. Physiological
a. Pregnancy and lactation
b. Chest wall stimulation, i.e. by sucking
c. Sleep
d. Stress.
2. Pathological
a. Hypothalamic pituitary stalk damage
i. Tumors: They disrupt the inhibitory influence of
dopamine on prolactin secretion—craniopharyn
gioma, supraseller pituitary mass extension,
meningioma, dysgerminoma, and metastasis.
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ii. Empty sella syndrome

iii. Lymphocytic hypophysitis
iv. Adenoma with stalk compression
v. Granulomas
vi. Irradiation
viii. Trauma.
b. Pituitary hypersecretion
i. Prolactinoma
a. Micro-adenoma: These tumors are less than 1
cm in diameter, do not invade parasellar area
and resolve spontaneously.
b. Macro-adenoma: These are tumors more than 1
cm in diameter, locally invasive and compress
adjacent structures.
ii. Acromegaly
iii. Hyperplasia of lactotrophs.
c. Systemic disorders
i. Chronic renal failure
ii. Hypothyroidism
iii. Cirrhosis
iv. Epileptic seizures.
3. latrogenic causes: Drug-induced hypersecretion:
i. Dopamine receptor blockers: Phenothiazines, butyro
phenones, thioxanthenes, metoclopromide
ii. Dopamine synthesis inhibitors
iii. Catecholamine depletors
iv. Opiates
v. H2 antagonist: Cimetidine, ranitidine
vi. Imipramines: Amitryptilene, amoxapine
vii. Serotonin re-uptake inhibitors: Fluoxetine
viii. Calcium channel blockers: Verapamil
ix. Hormones: Estrogens, oral contraceptive pills.
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Idiopathic Hyperprolactinemia
Hyperprolactinemia in patients where no cause can be
found is termed as idiopathic. Usually prolactin level never
exceeds 100 ng/ml. It could be because of fluctuating levels
of prolactin or macroprolactinemia where the large prolactin
molecule is immunoreactive but not biologically active.
Transient Hyperprolactinemia
Transient preovulatory rise is seen in prolactin levels with
some patients of unexplained infertility. This lasted 2 to 3 days
and coincided with estradiol peak. 40% of patients conceived
with bromocriptine as compared to 1% in controls.1
Clinical Features of Hyperprolactinemia

1. Menstrual irregularities like amenorrhea and oligome
norrhea.
2. Galactorrhea: 33% women with hyperprolactinemia have
galactorrhea.
3. Infertility.
4. Estrogen deficiency—Vaginal dryness, dysparenia,
osteoporosis (if hyperprolactinemia persists for a long
duration).
5. Reduced libido.
6. Delayed puberty.
7. Visual defects: They occur in 5% women due to CNS
compression.
Hyperprolactinemia and Infertility

Hyperprolactinemia inhibits ovulation leading to menstrual
irregularities as well as amenorrhea. High prolactin levels
directly inhibit the amount of GnRH secretion. This results
Ch-11.indd 173 18-01-2014 12:09:07

in inhibition of LH and FSH release leading to anovulation

and hypogonadism. The high prolactin levels interfere with
the positive effect of estrogen on midcycle surge and may
directly inhibit ovarian steroidogenesis. It hinders normal
corpus luteum formation by directly acting on the ovary
leading to luteal phase defect and recurrent pregnancy loss.2
Mild transient hyperprolactinemia is seen in 30% of PCOS
patients. As prolactin concentration increases women pro
gressively show increasingly severe reproductive abnormality
(Fig. 11.1).
Ovulatory cycles and regular menses are achieved within
6 months of therapy with 80% of patients. Infertile women
with galactorrhea and normal prolactin have responded to
treatment.3 The choice of treatment for infertility is medical.
About 60–80% patients with hyperprolactinemia become
ovulatory with bromocriptine. There is a good response to
clomiphene induction in previously resistant cases. It is a safe
drug in pregnancy. In some studies, bromocriptine has been
given only in follicular phase.
Fig. 11.1: Progressive reproductive abnormality seen in hyperprolactinemia
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Diagnostic Evaluation
Serum Prolactin Estimation
Normal level is 1 to 20 ng/ml. It has a circadian rhythm
with maximum levels between 3 AM to 9 AM; thus, sample
should be collected between 9 AM and noon. It is to be done
in fasting state with no prior breast or pelvic examination,
exercise or sexual activity.
Fallacy
1. Occasionally in presence of a large pituitary tumor
falsely low levels of serum prolactin are caused by an
effect known as ‘high dose hook effect’ where extremely
large doses of prolactin prevent accurate assessment by
antibody assay. Serial dilutions may reveal a high level.
2. Sometimes, high levels of relatively inactive prolactin
in absence of tumor can be due to the creation of
macromolecules of prolactin by antiprolactin auto
antibodies.4
What is Macroprolactin?
Hyperprolactinemia can occur in physiological and pathological
conditions. Prolactin has 3 different isoforms—little prolactin,
big prolactin and big-big prolactin. Macroprolactin is a
complex of little prolactin and an immunoglobulin G antibody
and the weight of the complex is more than 150 kDa. In
physiological condition, macroprolactin comprises up to 1%
of all circulating prolactin in the serum blood. In pathological
condition, percentage of macroprolactin can increase in the
serum blood. The prevalence of macroprolactinemia is found
in around 10–26% of all patients with hyperprolactinemia.
Women with high serum prolactin concentration should be
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screened for macroprolactinemia. Presence of macroprolactin

should always be suspected when a patient’s clinical history
and/or radiological data are incompatible with his/her prolactin
value. Thus, it may be useful to screen all patients with high
sera prolactin levels by tests, such as the polyethyleneglycol
precipitation method although gel filtration chromatography
remains the gold standard. Macroprolactinemia doesn’t
require any pharmacological treatment or other medical
procedures. Confirmation prevents unnecessary procedures
such as laboratory controls, MRI of the pituitary, treatment
with dopamine agonists or even pituitary surgery.5,6
T3, T4 and TSH

It is done to rule out compensated or primary hypothyroidism.
Both of them may be found in cases of hyperprolactinemia.
Goldmann’s Perimetry
Visual field defects may be detected.
Radioimaging of the Sella Turcica
Cone Down view X-ray of Sella Turcica

With newer accurate imaging techniques this is no longer the
investigation of choice. If the view is normal, then it is unlikely
there is an extrasellar extension of the tumor. Macroadenoma
may show imaging findings of an asymmetrically enlarged
pituitary fossa with a double contour to its floor and erosion
of the clinoid process.7,8
MRI/CT Scan of the Sella Turcica

MRI with gadolinium is the best imaging modality.9 CT scan
can detect microadenomas of 2 mm diameter and presence
Ch-11.indd 176 18-01-2014 12:09:07

of any suprasellar extension. MRI has a resolution of 1 mm
and is more sensitive than CT. It also avoids radiation. The
indications for this test are:
i. Serum prolactin level > 100 ng/ml.10
ii. Presence of headaches and visual field defects.
iii. Abnormal X-ray cone down view of the sella turcica.
With increasing use of these modalities, incidental
discovery of pituitary microadenomas is seen in 10% of
individuals having normal prolactin levels. These tumors are
called pituitary incidentalomas.7
Macroadenoma by definition is more than 1 cm and imaging
techniques now identify suprasellar extensions, compression
of optic chiasma and invasion of cavernous sinus.
Treatment of Hyperprolactinemia (Fig. 11.2)

Aim
• Elimination of symptoms like galactorrhea and amenorrhea
• Induction of ovulation
• Treatment of prolactin secreting macroadenomas.
The management options for hyperprolactinemia are:
• Expectant
• Medical
• Surgical
• Radiation.
Management of Hyperprolactinemia due to Antipsychotic Drugs

The pituitary is imaged to rule out prolactinoma. The drug is
changed to an alternative drug such as an atypical neuroleptic
or be discontinued. Serum prolactin levels are monitored to
ensure they are not rising further. Low dose contraceptive
pill may be given if estrogen deficiency is present. The use
of dopamine agonist along with an antipsychotic drug may
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Fig. 11.2: Management of hyperprolactinemia
Ch-11.indd 178 18-01-2014 12:09:07

lower the prolactin levels but would antagonize the effect of
the anti-psycotic drug. Dopaminergic agents can occasionally
induce or worsen psychotic symptoms.
Expectant Management
Where no tumor is seen on imaging and there is absence of
symptoms like galactorrhea, infertility, menstrual disturbance
or hypoestrogenism one can use the expectant line of
management with serial monitoring of prolactin levels and a
CT scan every 2 years.
Medical Management
Bromocriptine
It is a derivative of lysergic acid substituted with bromine at
position 2. It is a dopamine agonist that binds to dopamine
receptors and therefore, induces inhibition of pituitary
prolactin secretion.
Dosage
1. Orally
a. Tablet of 2.5 mg given in a twice daily dose as half-life
is 8 to 12 hours. It can be increased to 10 mg/day.
b. Slow release oral preparation is also available to be
given once a day in a dose of 5 to 15 mg/day and is
equally effective.
2. Long-acting depot intramuscular injection: They are made
by embedding glucose initiated polygycolide micro
spherules and have a maximum degradation time of 3
months. They are given in a dose of 50 to 75 mg/month.
Since response to these injections is rapid, they are useful
in large tumors with visual field impairment.10 It has the
same severity of side effects as the oral preparation.
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3. Intravaginal: It is given in a similar dose of 5 to 10 mg/day.

Since it avoids direct contact with the intestinal mucosa, it
has lesser side effects than oral administration. The levels
are sustained for a longer time as it escapes the liver first
pass effect when given vaginally and therapeutic results
are achieved at a lower dose.
Side effects
10% patients show intolerable side effects (Table 11.1).
Measures to reduce side effects are:
• Building tolerance by slowly increasing the dose at weekly
intervals.
• Taking the drug at bedtime as peak levels are achieved
after 2 hours.
• Individualizing the dosage schedule
• Using intravaginal route.
Table 11.1: Side effect of bromocriptine

Immediate effects
• Nausea
• Headache
• Fatigue
• Dizziness
• Orthostatic hypotension
• Nasal congestion
• Vomiting
• Abdominal cramps
• Hallucinations
Long-term effects11
• Raynaud’s phenomenon
• Constipation
• Psychiatric changes specially aggression
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Efficacy
1. Amenorrhea and galactorrhea: 80% of patients with
amenorrhea and galactorrhea improved.12 There was 75%
reduction in breast secretion by 6 weeks and galactorrhea
was suppressed in 60% of patients by 12 weeks.
2. Infertility: Ovulation was restored within 5 to 6 weeks.
Studies have shown successful ovulation induction and
pregnancy with bromocriptine in the absence of galactorrhea
or hyperprolactinemia in previous nonresponders to
clomiphine.13
3. Pituitary tumor: Bromocriptine causes regression of
macroadenomas. In some shrinkage is seen even with low
dose (5–7.5 mg/day) whereas in others larger doses and
prolonged duration may be required. Usually a dose of
more than 10 mg is ineffective. Visual improvement occurs
within days and tumor shrinkage occurs rapidly in first 3
months of therapy. Locally invasive tumors with levels
of bromocriptine more than 1000 ng/ml show a good
response to medical treatment. Problem with treatment of
the tumor with this drug is that it has to be taken indefinitely.
No adverse effect of bromocriptine has yet been seen
as in early pregnancy.14 After 2 years therapy, 75% of
microadenomas and 80 to 90% of macroadenomas regress.
On discontinuation of drug after 5 years only 25% patients
remained normoprolactinemic.15
Problems
1. Recurrence: Recurrence of symptoms occurred in 75%
of patients with prolactinomas within 4 to 6 weeks on
stopping of the drug. Hence, these drugs are used only
for short-term purpose of achieving pregnancy, curing
galactorrhea or reducing tumor mass.16
2. Resistance: 5 to 18% of patients do not tolerate bromo
criptine or are resistant to it because of decreased
Ch-11.indd 181 18-01-2014 12:09:08

dopamine receptor on lactotroph cell membrane. In these

cases other drugs can be tried.
3. Perivascular fibrosis: It may cause perivascular fibrosis in
tumors if given for a long time making surgery difficult.
Other Dopamine Agonists

a. Pergolide: It is more potent, longer-acting, better tolerated
and useful in bromocriptine resistant patients. It is given
in a dose of 50 to 150 mg/day and is increased slowly to
avoid side effects.
b. Quinagolide: It is a long-acting non-ergot derivative, with
higher affinity for dopamine receptors and lesser side
effects. It is useful in bromocriptine resistant tumors. It
also has antidepressant properties and is given in a dose
of 75 to 300 mg/day at bedtime.
c. Cabergoline: It is useful in bromocriptine resistant cases. It
has less side effects compared to bromocriptine, the most
common being headache. It is more effective in reducing
tumor size and prolactin levels than bromocriptine or
quinagolide.17 It is given in a dose of 0.5 to 3 mg once
a week orally or vaginally, usually starting with a lower
dose. Fetal safety is not yet completely established as
there is limited experience. A recent study showed
that cabergoline achieved a high pregnancy rate with
uneventful outcomes in infertile women with prolactinoma,
independent of tumor size and bromocriptine resistance
or intolerance. Cabergoline monotherapy could
substitute for the conventional combination therapy of
pregestational surgery or irradiation plus bromocriptine in
macroprolactinomas.18
d. Hydergine: It is a mixed ergot alkaloid effective only if
serum prolactin levels are less than 100 ng/ml. It is well
tolerated by patients and should be used in cases where
bromocriptine fails.
Ch-11.indd 182 18-01-2014 12:09:08

Cabergoline vs Bromocriptine in ART
A recent study showed that the cost of treatment was significantly
higher with cabergoline than with bromocriptine. However,
side effect rate was significantly higher with bromocriptine
than with cabergoline (15.3% vs 2.5%). Cabergoline and
bromocriptine showed no differences in IVF outcomes and
pregnancy results.19
Patients who show resistance to one dopamine agonist may

respond to another.
Estrogen Replacement Therapy

Where tumor is small but is producing a significant hypo
estrogenism estrogen replacement therapy should be given
for protection of the bones and vascular system. When
contraception is needed, they can be put on low dose
contraceptive pills. There is no risk of tumor expansion due to
estrogens since the level given is only enough to raise levels
up to those in a natural cycle.20
Surgical Removal
Indications
1. Patient unwilling for long-term drug therapy.
2. Drug resistance.
3. Intolerable side effects of drugs.
4. Nonfunctioning tumors where prolactin levels are not
very high. These tumors may expand with invasion into
cavernous sinus, compression of optic chiasma and
hemorrhage causing pituitary apoplexy.
5. Suprasellar extension not regressing with drug therapy.
Ch-11.indd 183 18-01-2014 12:09:08

Surgical techniques have advanced to microsurgery

using the trans-sphenoidal approach to expose the sella
turcica. Normal yellow tissue of the pituitary gland can be
distinguished from tumor tissue in small tumors. However,
this tumor does not have a capsule and it may be difficult to
distinguish from normal tissue in large tumors. Once it grows
beyond the sella turcica it cannot be removed totally.
Preoperative medical therapy: This decreases the tumor size
in 50 to 70% of cases making tumor more amenable for sur
gery. However, prolonged administration of drug may cause
fibrosis and difficulty in dissecting.
Results: Serum prolactin comes to normal with resumption
of normal menstrual cycles in 30% of cases with macro
adenoma and 70% with microadenoma. The best results
are obtai ned in patients with serum prolactin less than
500 ng/ml. Cure rate decreases if levels of prolactin are
high. Results are better in intrasellar tumors.21 Pregnancy
was achieved in 88% of those desiring conception following
surgery.22
Recurrence: It may occur for 10% of cases with macroade
noma and 70% of those with microadenoma.23 Reason for
recurrence being:
1. Partial resection of tumor, since it may be difficult to
differentiate from normal tissue.
2. Multifocal origin of prolactinoma.
3. Persistant abnormal stimulus to lactotrophs.
Follow-up in cases where symptoms persist includes
monitoring of serum prolactin every 6 months and imaging
of pituitary every year for 2 years. Imaging is thereafter done
every year. Dopamine agonists are used for tumor recurrence
or when ovulation induction is required.
Repeat surgery has a success rate of 33% only. Irradiation
after surgery may cause stroke and other brain tumors.
Ch-11.indd 184 18-01-2014 12:09:08

Complications
1. Panhypopituitarism: It is seen in up to 10 to 30% of patients.
2. Cerebrospinal fluid leak.
3. Meningitis.
4. Diabetes insipidus: It manifests in 10 to 40% of patients
and lasts for about 6 months.
5. Mortality: Mortality occurs in less than 1% of the total
surgeries.
Radiation
It is not the primary choice of treatment and may be tried if
medical management or surgery fail. It is given using linear
cobalt or proton mode.
Disadvantage
1. Results are less satisfactory than with surgery.
2. Slow response with radiotherapy prolactin levels years to
come to normal.
3. Panhypopituitarism can occur even after many years and
may need hormone replacement.
4. Multiple endocrinopathies.24
5. Damage to optic nerve.
6. Diabetes insipidus.
Hyperprolactinemia is a frequent cause of anovulatory
infertility and luteal phase defect. Dopaminergic treatment
is the first line of treatment and is very effective in both
idiopathic hyperprolactinemia and prolactinoma, with a 60
to 80% pregnancy rate.
References
1. Ben-David M, Schenker JG. Transient hyperprolactinemia.
A correctable cause of female idiopathic infertility. J Clin
Endocrinol Metab. 1983;57:442-4.
Ch-11.indd 185 18-01-2014 12:09:08

2. Cunha-Filho JS, Gross JL, Lemos NA, Brandelli A, Castillos

M, Passos EP. Hyperprolactinemia and luteal insufficiency in
infertile patients with mild and minimal endometriosis. Horm
Metab Res. 2001;33(4):216-20.
3. Padilla SL, Person GK, McDonough PG, Reindollar RH. The
efficacy of bromocriptine patients with ovulatory dysfunction
and normoprolactinemic galactorrhea. 1985;44:695-8.
4. Strachan MW, Teoh WL, Don-Wauchope AC, Seth J, Stoddart
M, Beckett GJ. Clinical and radiological features of patients with
macroprolactinaemia. Clin Endocrinol. 2003;59(3):339-46.
5. Sadideen H, Swaminathan R. Macroprolactin: what is it and
what is its importance? Int J Clin Pract. 2006;60(4):457-61.
6. Cattaneo F, Kappeler D, Müller B. Macroprolactinaemia, the major
unknown in the differential diagnosis of hyperprolactinaemia.
Swiss Med Wkly. 2001;131(9-10):122-6.
7. Elster AD. Modern imaging of the pituitary. Radiology.
1993;187:1-14.
8. Bayrak A, Saadat P, Mor E, Chong L, Paulson RJ, Sokol
RZ. Pituitary imaging is indicated for the evaluation of
hyperprolactinemia. Fertil Steril. 2005;84(1):181-5.
9. Hall WA, Luciano MG, Doppman JL, Patronas NJ, Oldfield EH.
Pituitary MRI in normal human volunteers: Occult adenomas
in general populations. Ann Intern Med. 1994;120:817-20.
10. Beckers A, Petrossians P, Abs R, Flandroy P, Stadnik T, de
Longueville M, et al. Treatment of macroprolactinomas with
long acting and repeatable form of bromocriptine: a report of
29 cases. J Clin Endocrinol Metab. 1992;75:275-80.
11. Soule SG, Jacob HS. Prolactinoma: Present day management.
Br J Obstet Gynecol. 1995;102:178-81.
12. Cuellar FG. Bromocriptine mesylate (Parlodel) in the
management of amenorrhea/galactorrhea associated with
hyperprolactinemia. Obstet Gynecol. 1980;55:278-84.
13. Porcile A, Gallardo E, Venegas E. Normoprolactinemic
anovulation nonresponsive to clomiphene citrate: Ovulation
induction with bromocriptine. Fertil Steril. 1990;53:50-5.
14. Turkalj I, Braun P, Krupp P. Surveillance of bromocriptine in
pregnancy. JAMA. 1982;247:1589-91.
Ch-11.indd 186 18-01-2014 12:09:08

15. Webster J. Carbogoline and qunagolidine therapy for prolacti
nomas. Clin Endocrinol. 2000;53:549-50.
16. Passos VQ, Souza JJ, Musolino NR, Bronstein MD. Long-term
follow-up of prolactinomas: normoprolactinemia after bromo
criptine withdrawal. Clin Endocrinol Metab. 2002;87:3578-82.
17. Di Sarno A, Landi ML, Cappabianca P, Di Salle F, Rossi FW,
Pivonello R, et al. Resistance to cabergoline as compared to
bromocriptine in hyperprolactinemia: prevalence clinical
definition and therapeutic strategy. J Clin Endocrinol Metab.
2001;86:5256-61.
18. Ono M, Miki N, Amano K, Kawamata T, Seki T, Makino
R, et al. Individualized high-dose cabergoline therapy for
hyperprolactinemic infertility in women with micro- and
macroprolactinomas. J Clin Endocrinol Metab. 2010;95(6):2672-
9.
19. Bahceci M, Sismanoglu A, Ulug U. Comparison of
cabergoline and bromocriptine in patients with asymptomatic
incidental hyperprolactinemia undergoing ICSI-ET. Gynecol
Endocrinol. 2010;26(7):505-8.
20. Correnblum B, Donovan L. The safety of physiological estrogen
plus progestin replacement therapy and oral contraceptive
therapy in women with pathological hyperprolactinemia. Fertil
Steril. 1993;59:671.
21. Losa M, Mortini P, Barzaghi R, Gioia L, Giovanelli M. Surgical
treatment in prolactin secreting adenoma: Early results and
long-term outcome. J Clinical Metab. 2002;87:3180-6.
22. Feigenbaum SL, Downey DE, Wilson CB, Jaffe RB. Transs
phenoidal pituitary resection for preoperative diagnosis of
prolactin secreting adenoma in women: Long-term follow-up. J
23. Schlechte JA, Sherman BM, Chapler FK, Van Gilder J. Long-
term follow-up of women with surgically treated prolactin
secreting tumors. J Clin Endocrinol Metab. 1986;62:1296-301.
24. Hoybye C, Grenback E, Rahn T, Degerblad M, Thorén M,
Hulting AL. Adrenocorticotropic hormone producing pituitary
tumor: 12 to 22 year follow up after treatment with sterotactic
radiosurgery. Neurosurg. 2001;49:284-91.
Ch-11.indd 187 18-01-2014 12:09:08

cHAPTER
12
Role of Androgens in
Ovulation Induction
Shashi Prateek, Surveen Ghumman
Androgens are intermediates in estrogen biosynthesis and

local regulators of ovarian function. The atherogenic nature of
androgens has been questioned. It is believed that androgens
may amplify the FSH effects on the ovary improving ovarian
response and that granulosa cell stimulation by FSH is actually
an androgen-modulated process. Androgens contribute to
the paracrine regulation of follicular maturation and atresia.
Ovarian stroma and granulosa cells of primordial follicles
and follicles at more advanced stages of folliculogenesis have
androgen receptors. During intermediate stages of follicular
development, locally produced androgen acts via granulosa
cell androgen receptors (AR) to promote follicle-stimulating
hormone (FSH)-induced granulosa cell differentiation through
amplifying cAMP-mediated post-receptor signaling.1 Granulosa
cell-specific androgen receptors, promote preantral follicle
growth and prevent follicle atresia, thus enhancing ovarian
function.2
In a recent study, the physiological significance of androgens
in female reproduction became clear when female mice with
Ch-12.indd 188 18-01-2014 12:09:26

Role of Androgens in Ovulation Induction 189
global knockout of androgen receptor (AR) expression were
found to have reduced fertility with abnormal ovarian function.3
It was concluded that androgen receptors and androgens
are essential for follicular recruitment, and normal follicle
development and play a critical role in regulating ovarian
function and fertility. This theory is supported by the fact that
very low levels of testosterone on day 3 decrease success rate
of IVF.4
Decreased ovarian reserve is becoming a common entity
as more women are postponing childbearing. Many protocols
are followed for these poor responders. Therapeutic benefits
from supplementation with dehydroepiandrosterone (DHEA)
and testosterone in women with diminished ovarian reserve
(DOR) have been noted in the form of improved response
to ovarian stimulation. Supplemental treatment with these
drugs during ovarian stimulation may represent a novel way
to maximize ovarian response.5
Impact of Androgens on Reproductive

Outcome
Improvement in Number of Oocytes and Embryo
It was suggested that DHEA supplementation appears to
augment ovarian stimulation with gonadotropins in poor
responders, resulting in improved oocyte yields. Cumulative
DHEA effects may have possible effects on follicle recruitment.
In a study after DHEA, a significant decrease in cycle day-3
estradiol levels was found. There was an increased number of
>17 mm follicles (3 versus 1.9) and MII oocytes (4 versus 2.1).6
In a recent study, it was observed that transdermal
testosterone increased the number of recruited follicles in
previously poor responders by over fivefold. The total amount
of gonadotropin needed to achieve such improved response
Ch-12.indd 189 18-01-2014 12:09:26

with testosterone was significantly lower. The antral follicle

count increased during testosterone treatment, and the
number of follicles available for recruitment and development
at the time of starting FSH therapy was higher.7 Androgen
treatment promoted FSH action in those recruitable follicles as
suggested by increased serum levels of androstenedione and
IGF-I (both considered as markers of ovarian responsiveness
to gonadotropin stimulation), thus yielding higher numbers
of oocytes.8 80% of patients underwent oocyte retrieval and
embryo transfer in the testosterone supplemented IVF cycle.7
Improvements in Oocytes and Embryo Quality

It has been observed that with DHEA and testosterone, not
only significant increase in oocytes and embryo numbers are
seen, but also improved embryo quality is available.9
After DHEA supplementation, a significant increase
in number of top quality day 2 (2.2 versus 1.3) and day 3
embryos (1.9 versus 0.7) were achieved. Cycle cancelation
rates were reduced (5.3% versus 42.1%), and pregnancy
rates per patients (47.4% vs 10.5%, P < 0.001) and per
embryo transfer (44.4% vs 0.0%, P < 0.01) were improved.6
A randomized, prospective, controlled study showed higher
live birthrate compared with controls (23.1% versus 4.0%).5
Pretreatment with transdermal testosterone gel (TTG) was
also shown to improve number of mature oocytes, fertilized
oocytes, good-quality embryos, embryo implantation rate
and clinical pregnancy rate per cycle initiated.8
Premature Versus Physiologic Diminished Ovarian Reserve (DOR)

DHEA supplementation was effective in both age dependent
DOR and premature ovarian aging (POA), though POA
patients did mildly better.10 The beneficial effects of DHEA
increased with length of DHEA supplementation.11
Ch-12.indd 190 18-01-2014 12:09:26


Premature ovarian failure (POF)/primary ovarian insufficiency
(POI) patients have conceived spontaneously whereas 50–75
mg of dehydroepiandrosterone supplementation for at least 4
months. It also considerably improved intrauterine insemination
and IVF outcome and pregnancy rates in these women. FSH
levels in these patients decrease with DHEAS administration.
Positive effect has been reported with oocyte and embryo
quality, with number of euploid embryos increasing and
miscarriage rate decreasing.12
Effects on Embryoploidy, Miscarriage Risk and

live Birthrates
It is assumed that ovarian aging is related to aneuploidy
and a higher incidence is seen in older women and those
with DOR. Hence, miscarriage rate, which is dependent
on aneuploidy, is much more in these women. Pregnancy
loss rates in women with DOR were 57.1% in women <35
years old, 63.5% in women 35–40 years old, and 90.0% in
women >40 years old. These rates of pregnancy loss were
significantly higher compared to age-matched patients with
normal ovarian reserve.13 Anti-Mullerian hormone (AMH)
levels are a direct reflection of ovarian aging. Significantly
improved live birthrates at AMH ≥1.06 ng/mL were seen.
The chance of live birth per treatment cycle is only 5% if
AMH was less than 1.05 ng/mL. Above that, chances are
significantly improved. Thus, AMH 1.05 ng/mL represents a
distinct point of separation between poorer and better live
birth chances.14
In a recent study on carrying out preimplantation genetic
screening (PGS), short term DHEAS supplementation of
4–12 weeks resulted in reduction in aneuploidy. Beneficial
DHEA effects on DOR patients, at least partially, are the
likely consequence of lower embryo aneuploidy.15 Increasing
Ch-12.indd 191 18-01-2014 12:09:26

aneuploidy with advancing female age occurs and it is difficult

to have adequate numbers of PGS to check for embryoploidy.
Alternatively, miscarriage rates may be taken as a surrogate for
aneuploidy risk. Since at least 60% of spontaneous pregnancy
loss is attributable to chromosomal abnormalities, it can
be hypothesized that significant reductions in aneuploidy
after DHEA supplementation should be reflected in lower
miscarriage rates. After DHEA supplementation the miscarriage
rate was found to be 15.1%, being significantly lower at all
ages but most pronounced above age of 35 years. Miscarriage
rates after DHEA not only were lower than in an average IVF
population but were also comparable to rates reported in
normally fertile populations. This supports the assumption
of a DHEA effect on embryoploidy. It was suggested that
preconception DHEA supplementation in normal fertile
populations above age 35 years may have a positive role.16
How Does DHEA Affect Ovarian Reserve?

Many mechanisms have been suggested explaining the
beneficial effects of DHEAS and testosterone on ovarian
reserve. DHEA may be able to decrease aneuploidy rate
by reversing damage to oocytes. Second mechanism
may be that oocytes in unrecruited stage do not age but
changes start taking place once follicle starts maturing after
recruitment. The ovarian environment then varies with age
and may provide substandard conditions for the oocyte.
As proposed by Hodges et al, the environment affects
segregation processes during meiosis, giving rise to increased
aneuploidy at older ages. He suggested major disturbances
in chromosome alignments on the meiotic spindle of oocytes
(congression failure), responsible for aneuploidy, result from
the complex interplay of signals regulating folliculogenesis.
These changes subtly alter the late stages of oocyte growth,
Ch-12.indd 192 18-01-2014 12:09:26

increasing the risk of a nondisjunction error. These findings
have important implications for human aneuploidy, since
they suggest that it may be possible to develop prophylactic
treatments for reducing the risk of age-related aneuploidy.
This pharmacological maneuvering to reduce aneuploidy and
miscarriage rate has been tried with DHEAS.17
DHEA levels peak in humans between ages 20 and 30
years, and then decline by approximately 2% per year, to
reach nadirs of 10 to 20% around age 80 years.18
Age-related aneuploidy may actually be a reversible DHEA
deficiency. Since follicles are still present in menopausal
ovaries if ovarian environment can be reconstituted to that
present at young age fertility could be preserved for much
longer. DHEA may, therefore, represent a first compound in
a new category of pharamacological agents with potential to
rejuvenate ovarian environments. Following a similar concept,
Bentov et al based on the known loss of mitochondrial
functions with advancing age, recently suggested the use of
mitochondrial nutrients, like coenzyme Q10 (CoQ10), after
demonstrating that CoQ10 increases oocyte numbers in
older mice.19 Androgens also positively affect mitochondrial
function.20
DHEA was seen to increase IGF-1 and since growth
hormone had been suggested to improve oocytes yields via
IGF-1, it is hypothesized that DHEA may be able to achieve
similar effects.21
Predicting the Effectiveness of DHEA

It was seen in a study that AMH concentrations significantly
improved after DHEA supplementation longitudinally by
60% over time (P=0.002). Younger women (under age 38
years) demonstrated improved AMH concentrations more
than older females.22
Ch-12.indd 193 18-01-2014 12:09:26

DHEA supplementation significantly improved ovarian reserve

in parallel with longer DHEA use and was more pronounced in
younger women.
AMH levels are predictable of treatment outcomes after

DHEA utilization. Spontaneous pregnancies were, of course,
conceived after shorter exposure to DHEA as they conceived
spontaneously on DHEA during waiting period for IVF. So,
it was concluded that shorter exposure sometimes may be
enough to raise fecundity but may not suffice to positively
affect ploidy and miscarriage rates.23
Improvements in AMH are statistically highly predictive of

pregnancy success.22
Treatment Protocols, Side Effects and Complications

Pretreatment with 12.5 mg transdermal testosterone
gel (TTG) has been applied daily for 21 days in the cycle
preceding COS with GnRH antagonist protocol for IVF in
poor responders. It may be given as transdermal 20 µg/kg
per day during the 5 days preceding gonadotropin treatment.
It takes about three months for a given primordial follicle to
reach the preovulatory stage. However, the time of exposure
to testosterone in the above studies that showed a positive
result was relatively reduced. It can be hypothesized that it
affects late events involved in follicular maturation rather than
earlier stages. At present, since it has not been determined
whether androgens are rescuing follicles or simply increasing
the number of recruited ones, further research is needed in
this respect. Therefore, the daily dose, timing and duration
of androgen supplementation may be critical to adequately
stimulate folliculogenesis mainly considering a recent study
in rhesus monkeys showing that chronic administration
Ch-12.indd 194 18-01-2014 12:09:26

(for five days before and continuing throughout FSH and
LH treatment) of high dose of androgens is antagonistic to
gonadotropin-stimulated ovarian function in primates. It has
been postulated that there is a threshold effect of androgens on
follicular function such that antagonistic actions of androgens
may be manifested at elevated concentrations.24
Dose
DHEAS is given as 25 mg of micronized tablet tid, for at least
four weeks prior to IVF cycle.11 Short-term supplementation is
up to 4 to 12 weeks of DHEA prior to IVF and PGS.11
Preparation and Route

Distinct advantages from micronized and orally delivered
DHEA was demonstrated in a single-dose study comparing
three dehydroepiandrosterone delivery methods (oral
crystalline steroid, micronized steroid, and vaginal
administration) to ascertain whether physiologic levels of
circulating dehydroepiandrosterone can be obtained while
increases in testosterone are minimized. Micronization of
oral dehydroepiandrosterone diminishes bioconversion
to testosterone. Vaginal dehydroepiandrosterone delivers
equivalent dehydroepiandrosterone but substantially
diminishes dehydroepiandrosterone bioconversion.25
Side Effects
Side effects at these dosages are small and rare, and primarily
relate to androgen effects.
They include oily skin, acne vulgaris and hair loss. More
frequently, patients comment on improved energy levels and
better sex drive.
Ch-12.indd 195 18-01-2014 12:09:26

A recent systemic review and meta-analysis in 2012

on the use of androgens or androgen-modulating agents in
poor responders undergoing IVF concluded that transdermal
testosterone pretreatment seems to increase clinical
pregnancy and live birthrates in poor responders undergoing
ovarian stimulation for IVF. However, there is insufficient
data to support a beneficial role of rLH, hCG, DHEA or
letrozole administration in the probability of pregnancy in
poor responders undergoing ovarian stimulation for IVF.26
In conclusion, ovarian environments, but not resting
oocytes, age as women grow older. Hence, pretreatment
with transdermal testosterone may be a useful approach for
women known to be low responders on the basis of a poor
response to controlled ovarian stimulation but having normal
basal FSH concentrations. DHEA supplementation apparently
significantly reduces these age-related increases in aneuploidy,
and, therefore, also reduces age-associated increases in
miscarriages. A definite beneficial effect of androgens is seen
in poor responders but needs further research to determine
the best dose and period of administration.
References
1. Hillier SG, Tetsuka M. Role of androgens in follicle maturation
and atresia. Baillieres Clin Obstet Gynaecol. 1997;11(2):249-60.
2. Ware VC. The role of androgens in follicular development in
the ovary. I. A quantitative analysis oocytes ovulation. J Exp
Zoology. 1982;222:155-67.
3. Sen A, Hammes SR. Granulosa cell-specific androgen receptors
are critical regulators of ovarian development and function. Mol
Endocrinol. 2010;24(7):1393-403.
4. Frattarelli JL, Peterson EH. Effect of androgen levels on in vitro
fertilization cycles. Fertil Steril. 2004;81(6):1713-4.
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5. Casson PR, Lindsay MS, Pisarska MD, Carson SA, Buster
JE. Dehydroepiandrosterone supplementation augments
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6. Sönmezer M, Ozmen B, Cil AP, Ozkavukçu S, Taşçi T, Olmuş
H, et al. Dehydroepiandrosterone supplementation improves
ovarian response and cycle outcome in poor responders.
7. Balasch J, Fábregues F, Peñarrubia J, Carmona F, Casamitjana
R, Creus M, et al. Pretreatment with transdermal testosterone
may improve ovarian response to gonadotrophins in poor-
responder IVF patients with normal basal concentrations of
FSH. Hum Reprod. 2006;21(7):1884-93.
8. Kim CH, Howles CM, Lee HA. The effect of transdermal
testosterone gel pretreatment on controlled ovarian
stimulation and IVF outcome in low responders. Fertil
Steril. 2011;95(2):679-83.
9. Barad D, Gleicher N. Effect of dehydroepiandrosterone on
oocyte and embryo yields, embryo grade and cell number in
IVF. Hum Reprod. 2006;21(11):2845-9.
10. Wiser A, Gonen O, Ghetler Y, Shavit T, Berkovitz A, Shulman
A. Addition of dehydroepiandrosterone (DHEA) for poor-
responder patients before and during IVF treatment improves
the pregnancy rate: a randomized prospective study. Hum
Reprod. 2010;25(10):2496-500.
11. Barad D, Brill H, Gleicher N. Update on the use of
dehydroepiandrosterone supplementation among
women with diminished ovarian function. J Assist Reprod
Genet. 2007;24(12):629-34.
12. Mamas L, Mamas E. Dehydroepiandrosterone supplementation
in assisted reproduction: rationale and results. Curr Opin
Obstet Gynecol. 2009;21(4):306-8.
13. Levi AJ, Raynault MF, Bergh PA, Drews MR, Miller BT, Scott RT
Jr. Reproductive outcome in patients with diminished ovarian
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14. Gleicher N, Weghofer A, Barad DH. Anti-Müllerian hormone
(AMH) defines, independent of age, low versus good live-birth
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chances in women with severely diminished ovarian reserve.

Fertil Steril. 2010;94(7):2824-7.
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16. Gleicher N, Ryan E, Weghofer A, Blanco-Mejia S, Barad
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case control study. Reprod Biol Endocrinol. 2009;7:108.
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Experimental evidence that changes in oocyte growth influence
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18. Walker ML, Anderson DC, Herndon JG, Walker LC.
Ovarian aging in squirrel monkeys (Saimiri sciureus).
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19. Bentov Y, Esfandiari N, Burstein E, Casper RF. The use of
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20. Pitteloud N, Mootha VK, Dwyer AA, Hardin M, Lee H, Eriksson
KF, et al. Relationship between testosterone levels, insulin
sensitivity, and mitochondrial function in men. Diabetes
Care. 2005;28(7):1636-42.
21. Casson PR, Santoro N, Elkind-Hirsch K, Carson SA, Hornsby
PJ, Abraham G, et al. Postmenopausal dehydroepiandrosterone
administration increases free insulin-like growth factor-I and
decreases high-density lipoprotein: a six-month trial. Fertil
Steril. 1998;70(1):107-10.
22. Gleicher N, Weghofer A, Barad DH. Improvement in
diminished ovarian reserve after dehydroepiandrosterone
supplementation. Reprod Biomed Online. 2010;21(3):360-5.
23. Gleicher N, Barad DH. Dehydroepiandrosterone (DHEA)
supplementation in diminished ovarian reserve (DOR). Reprod
Biol Endocrinol. 2011;9:67.
24. Zeleznik AJ, Littler-Ihrig L, Ramasawamy S. Administration of
dihydrotestosterone to rhesus monkeys inhibits gonadotropin-
Ch-12.indd 198 18-01-2014 12:09:26

stimulated ovarian steroidogenesis. J Clin Endocrinol
Metab. 2004;89:860-6.
25. Casson PR, Straughn AB, Umstot ES, Abraham GE, Carson
SA, Buster JE. Delivery of dehydroepiandrosterone to
premenopausal women: effects of micronization and nonoral
administration. Am J Obstet Gynecol. 1996;174(2):649-53.
26. Bosdou JK, Venetis CA, Kolibianakis EM, Toulis KA, Goulis
DG, Zepiridis L, et al. The use of androgens or androgen-
modulating agents in poor responders undergoing in vitro
fertilization: a systematic review and meta-analysis. Hum
Reprod Update. 2012;18(2):127-45.
Ch-12.indd 199 18-01-2014 12:09:26

cHAPTER
13
Ovarian Reserve and
Fertility in Older Women
Neerja Goel, Surveen Ghumman
In the modern era, women are increasingly delaying

childbirth till their thirties and forties when fertility declines
and risk of congenital anomalies and miscarriage increases.
This is the section of population that is becoming a challenge
for the infertility expert. A woman’s advancing age is directly
related to poor ovarian response to simulation. This situation
arises from the natural process of aging and the depletion
of the primordial follicular pool and consequent failure in
recruitment of follicles. When superovulated these women
produce few eggs and are known as poor responders.
This may be because of interference with FSH action due
to proteins. An autoimmune basis where there could be
presence of antibodies against granulosa cells, or defective
angiogenesis, autocrine or paracrine alterations leading to
decreased quantities of certain intraovarian peptides could be
the cause. There could be a genetic basis with FSH-receptor
polymorphism. Low diffusion of exogenous gonadotropins
has also been proposed. Evaluation of the ovarian reserve
forms an integral part of workup of these women.
Ch-13.indd 200 18-01-2014 12:12:32

Ovarian Reserve and Fertility in Older Women 201
Age and Fertility

Effect of age is seen on all the reproductive organs affecting
fertility.
Ovary
1. Decreasing population of follicles in the ovary that are
responsive to stimulation are seen. During embryonic
development, the number of oogonia peak by 20 weeks
of gestation to approximately 7 million oocytes. At birth
this number declines to 1–2 million germ cells and by
20 years only 250,000 to 300,000 remain, decreasing to
about 25,000 by age of 30–35 years, and 6,000 by age of
40 years.1
2. Oocytes show high incidence of chromosomal abnor
malities because of advancing maternal age. During IVF
the fertilization rate declines with advancing age and an
increasing proportion of the residual unfertilized eggs
showed abnormal chromosomes. It is this decline in the
number and quality of oocytes that hampers fertility.
Uterus
Uterine senescence may be partially responsible for the
decrease in fertility associated with increasing age. It is clear
that uterine factor plays only a small part in this decline.
With surrogacy it has been proven that even an older uterus
is capable of reproductive functions when stimulated. There
are various theories put forward for poor reproductive perfor
mance of the uterus with age.
1. Number of pinopodes in the uterine endothelium may be
drastically decreased, thus hindering implantation.
2. Uterus may become fibrous with poor blood supply and
has decreased ability to synthesize prostaglandins.
Ch-13.indd 201 18-01-2014 12:12:32

3. Reactive oxidative species produced in the reproductive

tract of older women is thought to decrease implantation.
4. There is an increase in the incidence of fibroids and
endometriosis in older women.
Tube
1. Deciliation of the Fallopian tube endothelium occurs
leading to decreased efficiency of tubal transport.
2. Increased incidence of pelvic inflammatory disease in
older women may lead to damaged tubes.
Management of Older Women with a Fertility

Problem
It is advisable to initiate investigations at an early stage. It
is important to exclude factors such as fibroids, incipient
ovarian failure, and endometrial polyps, which are less
likely to affect younger women. Fibroids of significant size
or location should generally be removed prior to any form of
assisted conception. Smoking appears to expedite the ovarian
aging process.
More recent molecular research has indicated a genetic
etiology for the age diminished ovarian reserve. There is
evidence to show a decline in oocyte quality with increasing
maternal age. With DNA fragmentation, the rates of
chromosomal abnormalities were found to be significantly
higher in older women when their unfertilized oocytes were
analyzed following IVF. A significantly higher amount of
disassociated chromatids was found in older women. For
women less than 34, the rate of genetic aberrations was 24%,
between 35 and 39 years the rate was 52%, and women 40
years and above had a rate of 95.8%.2
Ch-13.indd 202 18-01-2014 12:12:32

Assessment of the Ovarian Reserve
With intensified research on reproductive aging, methods to
measure the number, quality and reproductive potential of
the remaining ovarian follicle pool have evolved and been
given the name of ‘Ovarian Reserve Tests’. These tests are
indicated in those groups of patients at high risk of ovarian
failure (Table 13.1).
No single test for assessment of ovarian reserve is adequate,
so a combination of following tests is recommended (Table
13.2).
Basal Follicle Stimulating Hormone Levels

Raised early follicular FSH level is one of the earliest indi
cations of reproductive aging (Table 13.3). It has been shown
that women with elevated FSH levels have a higher minimum
Table 13.1: Indications for testing ovarian reserve

1. Age more than 35 years
2. Unexplained infertility regardless of age
3. Family history of early menopause
4. Previous ovarian surgery
• Cystectomy
• Ovarian drilling
• Unilateral oophorectomy
• Chemotherapy
• Radiation
5. Smoking
6. Demonstrated poor response to exogenous gonadotropin stimulation
Ch-13.indd 203 18-01-2014 12:12:32

threshold level of FSH required to initiate sustained follicular

development.3
Table 13.2: Ovarian reserve tests

1. Clinical variables--age, history of canceled cycles
2. Blood tests
• Basal FSH
• Day 2 or 3 serum estradiol
• Basal inhibin B
• Mullarian inhibiting substance
3. Dynamic tests
• Clomiphene citrate challenge test
• D
ynamic assay of estradiol and inhibin B after GnRHa stimulation
test (GAST)
• Exogenous FSH ovarian reserve test (EFORT)
4. Ultrasound
• Antral follicle count
• Ovarian volume
• Ovarian stromal peak systolic velocity, including waveform and
pulsatility index
Table 13.3: Basal follicle stimulating hormone level

FSH levels IU/L
<9 Reassure
9–10 Suboptimal
10–12 Decreased ovarian reserve
12–17 Markedly reduced ovarian reserve
17–20 Poor prognosis
> 20 No pregnancy
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Early Follicular Phase Estradiol Levels
Elevated estradiol level in early follicular phase is an indicator
of diminished ovarian reserve and has been associated with
poor results. Early elevation of serum estradiol level reflects
advanced follicular development and early selection of
dominant follicle seen in older women due to rising FSH levels.
A premature elevation of estradiol may suppress FSH causing
masking of an elevated day 3 FSH. Hence, it is better if both
FSH and estradiol are measured, to eliminate false negative
results. Basal E2 level of more than 80 pg/ml is associated
with poor follicular response and development.
Early Follicular Phase Inhibin B Levels

Inhibin A is secreted predominantly in the luteal phase and
inhibin B in the follicular phase by granulosa cells. Inhibin B
may, therefore, be a direct marker of ovarian reserve.4
Inhibin B levels decline with increasing age due to
decreased number of follicles and decreased secretion by
the granulosa cells. Since inhibin is decreased, there is poor
negative feedback and FSH level is increased. Low levels of
inhibin B on day 3 are associated with a poor outcome of IVF.
Its role is limited because of less reliability and difficult serum
estimation. A value of more than 45 pg/ml is taken as normal.
Anti-Müllerian Hormone
Like inhibin levels of anti-Müllerian hormone reflect the
health of the granulosa cell. The anti-Müllerian hormone and
antral follicle count correlates well with age even in women
under 40 years whereas FSH and inhibin B predominantly
changes in women more than 40 years of age.5
It has been seen that <1 pmol/l shows a extremely poor
response and cycle should be canceled. 1-5 pmol/l are still at
risk of poor response and short stimulation protocols should
Ch-13.indd 205 18-01-2014 12:12:32

be used. Response is found to be adequate when values are

between 5–15 pmol/l. Between 15 to 25 pmol/l there is risk
of hyperstimulation and caution should be used. More than
25 pmol/l there is high risk of hyperstimulation6 (Table 13.4).
Using a cut-off value of 8.1 pmol/L, plasma AMH assessment
could predict poor ovarian reserve on a subsequent IVF cycle
with a sensitivity of 80% and a specificity of 85%. Plasma
AMH assessments are superior to FSH in identifying women
with reduced ovarian reserve. Anti-müllerian hormone
assessment should be considered as a useful adjunct to FSH/
oestradiol levels and antral follicle count when estimating
ovarian reserve.7
Ovarian Sensitivity Index

Ovarian sensitivity index (OSI) is calculated dividing the total
administered FSH dose by the number of retrieved oocytes.
AMH and OSI show a highly significant negative correlation
that is stronger than the one between AMH and the total
number of retrieved oocytes and between AMH and the total
FSH dose. OSI reflects quite satisfactory the AMH level and
may be proposed as a surrogate of AMH assay in predicting
ovarian responsiveness to FSH in IVF. Being very easy to
Table 13.4: AMH values predicting ovarian reserve

Value of AMH (pmol/l) Ovarian response
<1 Extremely poor response and cycle should be
canceled
1–5 At risk of poor response and short stimulation
protocols should be used
5–15 Response adequate
15–25 Chances of hyperstimulation. Caution to be
applied
>25 High chances of severe OHSS
Ch-13.indd 206 18-01-2014 12:12:32

calculate and costless, its use could be proposed where AMH
measurement is not available or in developing countries
where limiting costs is of primary importance.8
Ovarian Volume and Antral Follicle Count

There is growing evidence that both ovarian volume and
number of antral follicles within the ovaries are useful
indicators of ovarian reserve and response to superovulation
(Table 13.5).9 Decreased ovarian volume is a sign of aging
and may be observed earlier than rise in FSH level. Small
ovaries are associated with poor response to superovulation.
Antral follicle count may be helpful in determining
stimulation protocol, as it is the most reliable determinant
of oocytes retrieved per starting FSH dose. Antral follicle
count predicts ovarian response, but not embryo quality,
implantation or pregnancy rate.10
Basal Ovarian Stromal Blood Flow
Undetectable basal ovarian stromal blood flow in at least one
ovary is related to low ovarian reserve in infertile women and
is linked to the pathophysiology of ovarian aging.11
On 3D ultrsonography, the vascularization index, flow
index, and vascularization flow index were significantly lower
in ovarian stroma (P<.05) in the poor responder compared
with the women with a normal response.12
Table 13.5: Antral follicle count

<4 Poor
4–7 Low count—high dose of FSH needs to be given
8–12 Slightly reduced
> 12 Normal
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Clomiphene Challenge Test (CCT)

It is a provocative and sensitive test of ovarian reserve that
takes into account the endocrine dynamics of the cycle
after stimulation with clomiphene. In normal women, there
is a transient increase of FSH and LH with clomiphene. LH
increases more than FSH. In women with a decreased ovarian
reserve, FSH increases much more because a smaller follicle
cohort in aging women produce less inhibin resulting in
decreased negative feedback. Baseline FSH and LH levels are
evaluated and then the patient is given clomiphene citrate
from day 5 to day 9 in a dose of 100 mg/day. The FSH and
LH levels are evaluated again on day 10. The value of FSH
should not be more than 26 IU. Elevated levels are strongly
suggestive of a decreased reserve and should be taken
into account during controlled ovarian hyperstimulation
protocols.13 It has been seen that women who have a
normal day 3 FSH and an elevated day 10 level have the
same prognosis as one with an elevated day 3 FSH level. An
abnormal clomiphene challenge test is seen in 10% of all
infertile women, being higher in older women and those with
unexplained infertility.14 Positive predictive value is 90% for
both day 3 FSH and clomiphene challenge test. Both tests have
a poor sensitivity of 7 to 26% and good specificity of 98%.15
Basal FSH and the CCT are similar in predicting the ability to
achieve a clinical pregnancy in women undergoing infertility
treatment. With either test, a normal result is not useful, but
an abnormal result virtually confirms that pregnancy will not
occur with treatment. When compared with basal FSH, CCT
has hardly any additional value.16,17
GnRHa Stimulation Test (GAST)

This provides a more reliable assessment than mere basal
assays. GnRHa produces an initial rise in LH, FSH, inhibin
Ch-13.indd 208 18-01-2014 12:12:32

B and estradiol. This initial increase in estradiol is a better
predictor than basal FSH, and FSH:LH ratio.18 The test
evaluates the change in serum E2 levels between cycle day
2 and 3 after administering 1 mg of subcutaneous leuprolide
acetate. Four different patterns of E2 levels were noted.
Patients with E2 elevations by day 2 and decline by day 3
had better implantation and pregnancy rates than those with
either no rise in E2, or persistently elevated E2 levels. The
GAST has a rather good ability to predict poor response
in IVF. However, comparing the predictive accuracy and
clinical value of the GAST with a day 3 antral follicle count
(AFC) and inhibin B, it appeared that neither a single nor a
repeated GAST performed better. In addition, the predictive
ability toward ongoing pregnancy is poor. Therefore, the use
of the GAST as a predictor of outcome in IVF should not be
advocated.19,20
Exogenous FSH Ovarian Reserve Test (EFORT)

This is a dynamic test. Originally, the test was developed to
improve the predictive value of day 3 FSH values in controled
ovarian hyperstimulation for IVF. The E2 level is recorded on
cycle day 3 before the administration of 300 IU of purified
FSH. Another level of E2 is done 24 hours after giving FSH.
It was postulated that the dynamic increase in E2 of more
than 30 pg/ml would be predictive of a good response in a
subsequent IVF cycle.
Advantages of Ovarian Reserve Testing

1. In high-risk populations, it affects treatment decisions.
2. Frankly abnormal tests may persuade women to look for
other alternatives.
3. Borderline values may persuade them to take advantage
of a rapidly decreasing opportunity.
Ch-13.indd 209 18-01-2014 12:12:32

4. Abnormal ovarian reserve test may signify an aging ovum

even in women of younger age making them a population
at increased risk of fetal aneuploidy, justifying prenatal
diagnostic studies.
In the recent years, these tests are occupying an increasingly
important place in the workup of infertile women. Although
they are reliable, rigid interpretation is discouraged as each
treatment cycle may be different from the next.
Treatment of Patients with reduced ovarian

reserve
A number of options are there for these women. They are
often termed as poor responder as they do not respond to the
regular stimulation protocols (See chapter 14).
1. Superovulation with IUI: It may be tried if patients do not
demonstrate marked decrease in ovarian reserve.
2. Pretreatment with oral contraceptives followed by gona
dotropins: In patients who are estrogen deficient with a
high gonadotropin level, ovulation can be accomplished
by first suppressing pituitary gonadotropins with estrogen
and then giving hMG for ovarian stimulation. The idea of
giving ethynylestradiol 0.05 mg/day was to reduce the level
of FSH and LH thus withdrawing the downregulatory effect
of elevated gonadotropins on LH and FSH receptors and
restoring sensitivity of the remaining follicles. When FSH
and LH reach normal values gonadotropins stimulation is
started with 150 IU of FSH. If E2 after 5 days is less than 35
pg/ml the dosage of FSH is increased up to 375 IU. If E2
does not rise beyond 50 pg/ml despite maximum dose of
5 ampules the cycle should be canceled.
3. High dose of gonadotropins: Since these patients are poor
responders, they are started with a gonadotropin dose of
Ch-13.indd 210 18-01-2014 12:12:32

150 IU/day and may be increased to 450 IU/day for an
effect.21
4. Short GnRH agonist protocol: It is useful as its flare effect
gives high levels of FSH that these patients require.22
5. Oocyte donation: It is an important option in cases
of infertility with advanced age. In 1984, the first live
birth with oocyte donation and IVF was reported.
Synchronization of recipient and donor is to be achieved
in oocyte donation protocol. In women who are
menstruating daily oral estradiol of 4 to 8 mg is given till
day of transfer when it is increased to 6 mg/day. Length
of estrogenic exposure can vary from 6 to 38 days as seen
in various studies. Usually a 14 day period is sufficient.
Patients are down-regulated with GnRH agonists prior
to estradiol administration. Optimal time of embryo
transfer is 2 to 4 days after progesterone administration
that is given as 400 to 600 mg intravaginally or 100 mg
intramuscularly. After pregnancy test is positive estradiol
is increased to 8 mg/day. Replacement therapy is carried
out till 60 days. If the woman is amenorrheic then 3 to
6 months of estrogen and progesterone are given till
minimum 3 months of bleeding, an uterocervical length
of 5 to 6 cm and an endometrial thickness of 8 to 9 mm is
achieved.
6. Cryopreservation of oocyte or embryo: It is an important
option for women at risk of decreasing ovarian reserve.
Embryo cryopreservation gives better results than oocyte
preservation with a pregnancy rate of 20 to 30% per
transfer of 2 to 3 embryos. Because of fragility of the
meiotic spindle and formation of ice crystals, the success
of oocyte preservation is limited, but is steadily improving.
7. Ovarian transplant: The ovarian transplant can be
orthotopic (at ovarian site) or heterotopic (another site).
The main obstacle to the success of this technique is
Ch-13.indd 211 18-01-2014 12:12:32

poor oocyte viability. It is a treatment that will become

accessible in the years to come.
Fertility in older women is a challenge being faced with
increasing frequency ovarian reserve testing can only help in
guiding the therapist on the lines of treatment and its success
rate. A combination of test should be done to improve
accuracy. Cryopreservation of embryo or oocyte is becoming
an important option for women at risk of decreased ovarian
reserve as those who undergo treatment for cancer.
References
1. Faddy MJ, Gosden RG, Gougeon A, Richardson SJ, Nelson
JF. Accelerated disappearance of ovarian follicle in midlife:
implications for forecasting menopause. Hum Reprod.
1992;7:1342-6.
2. Demario MA, Davis OK, Rosenwaks Z. The role of maternal
age in assisted reproductive technologies. Reprod Med Review.
1999;7:141-60.
3. Seifer DB, Scott RT, Bergh PA, Abrogast LK, Friedman CI,
Mack CK, et al. Women with declining ovarian reserve may
demonstrate a decrease in day 3 serum inhibin B before a rise
in day 3 FSH. Fertil Steril. 1999:72:63-5.
4. Balasch J, Creus M, Fabregues, et al. Inhibin, FSH, and age as
predictors of ovarian response in IVF cycles stimulated with
GnRHa treatment. Am J Obstet Gynaecol. 1996;175:1226-30.
5. van Rooij IA, Broekmans FJ, Scheffer GJ, Looman CW,
Habbema JD, de Jong FH, et al. Serum anti-Mullerian hormone
levels best reflect the reproductive decline with age in normal
women with proven fertility: A longitudinal study. Fertil Steril.
2005;83(4):979-87.
6. Nelson SM, Yates RW, Flemming R. Serum anti-Müllerian
hormone and FSH: prediction of live birth and extremes of
response in stimulated cycles—implications for individualization
of therapy. Hum Reprod. 2007;22(9):2414-21.
Ch-13.indd 212 18-01-2014 12:12:32

7. Tremellen KP, Kolo M, Gilmore A, Lekamge DM. ANZJOG.
2005;45:20-4.
8. Biasoni V, Patriarca A, Dalmasso P, Bertagna A, Manieri
C, Benedetto C, et al. Ovarian sensitivity index is strongly
related to circulating AMH and may be used to predict ovarian
response to exogenous gonadotropins in IVF. Reprod Biol
9. Lass A, Brinsden P. The role of ovarian volume in reproductive
medicine. Hum Reprod. 1999;5:256-66.
10. Hsu A, Arny M, Knee AB, Bell C, Cook E, Novak AL, et al.
Antral follicle count in clinical practice: analyzing clinical
relevance. Fertil Steril. 2011;95(2):474-9.
11. Younis JS, Haddad S, Matilsky M, Radin O, Ben-Ami
M. Undetectable basal ovarian stromal blood flow in
infertile women is related to low ovarian reserve. Gynecol
Endocrinol. 2007;23(5):284-9.
12. Pan HA, Wu MH, Cheng YC, Wu LH, Chang FM.
Quantification of ovarian stromal Doppler signals in poor
responders undergoing in vitro fertilization with three-
dimensional power Doppler ultrasonography. Am J Obstet
Gynecol. 2004;190(2):338-44.
13. Vanushpolsky EH, Hurwitz S, Tikh E, Racowsky C. Predicting
usefulness of cycle day 10 follicle stimulating hormone level
in clomiphene citrate challenge test for in vitro fertilization
outcome in women younger than 40 years of age. Fertil Steril.
2003;80:111.
14. Scott RT, Leonardi MR, Hofmann GE, Illions EH, Neal GS,
Navot D. A prospective evaluation of clomiphene citrate
challenge test screening of the general infertility population.
15. Jain T, Soules MR, Collins JA. Comparison of basal follicle
stimulating hormone versus clomiphene citrate challenge test
for ovarian reserve screening. Fertil Steril. 2004;82:180-6.
16. Hendriks DJ, Mol BW, Bancsi LF, te Velde ER, Broekmans
FJ. The clomiphene citrate challenge test for the prediction
of poor ovarian response and nonpregnancy in patients
undergoing in vitro fertilization: a systematic review. Fertil
Steril. 2006;86(4):807-18.
Ch-13.indd 213 18-01-2014 12:12:32

17. Jain T, Soules MR, Collins JA. Comparison of basal follicle-

stimulating hormone versus the clomiphene citrate challenge
test for ovarian reserve screening. Fertil Steril. 2004;82(1):180-5.
18. Amir R, Stuart L, Sappho M, Mandy D, Raul M, Geoff T, et al.
Dynamic assays of inhibin B and oestradiol following buserelin
acetate administration as predictors of ovarian response in IVF.
Hum Reprod. 2000;15:2297-301.
19. Hendriks DJ, Broekmans FJ, Bancsi LF, Looman CW, de Jong
FH, te Velde ER. Single and repeated GnRH agonist stimulation
tests compared with basal markers of ovarian reserve in the
prediction of outcome in IVF. J Assist Reprod Genet. 2005
Feb;22(2):65-73.
20. Maheshwari A, Gibreel A, Bhattacharya S, Johnson NP.
Dynamic tests of ovarian reserve: a systematic review
of diagnostic accuracy. Reprod Biomed Online. 2009
May;18(5):717-34.
21. Surrey ES, Schoolcraft WB. Evaluating strategies for improving
ovarian response of the poor responder undergoing assisted
reproductive techniques. Fertil Steril. 2000;73:667-76.
22. Sharara FI, McClormick HD. Use of microdose GnRH-agonist
protocol in women with low ovarian volumes undergoing IVF.
Hum Reprod. 2001;16:500-3.
Ch-13.indd 214 18-01-2014 12:12:33

cHAPTER
14
Ovarian Stimulation for the
Poor Responder
Surveen Ghumman
About 10 to 15% of women have a poor ovarian response

during ovarian stimulation. This could be because of
advanced ovarian age, decreased ovarian function due
to chemotherapy, radiotherapy or surgery or a premature
ovarian failure (Table 14.1).
Table 14.1: Causes of poor ovarian response

1. Diminished ovarian reserve
2. Decreased number of FSH receptors in granulosa cells
3. Inappropriate local vascular network for the distribution of
gonadotropins
4. Presence of autoantibodies against granulosa cells
5. Defective signal transduction after FSH-receptor binding
6. Presence of a special FSH receptor-binding inhibitor in the follicular
fluid
7. Lowered circulating gonadotropin surge-attenuating factor (GnSAF)
bioactivity
Ch-14.indd 215 18-01-2014 12:13:59

How Do we Define a Poor Responder?

No exact definition has been selected so far. Low ovarian
response is confirmed only after the patient has failed
ovarian stimulation following an accepted `standard’ ovarian
stimulation regimen.
Different authors have applied different criterion. A poor
responder could be one with any of the following1:
1. No. of follicles after a standard-dose ovarian stimulation
protocol: Varies with different authors < 3 to <5 on the
day of hCG administration.
2. No. of oocytes after a standard-dose ovarian stimulation
protocol: Varies with different authors < 3 to <5.
3. Peak estradiol level at time of hCG also correlated with
follicular development: < 500 pg/ml.
4. Excessive requirements of gonadotropins: > 450 IU1.
5. Prolonged stimulation.
6. Basal FSH more than 10.
Prediction
There are a number of tests that predict a poor ovarian reserve
(See chapter on poor ovarian reserve).
1. Basal day 3 FSH.
2. CC challenge test.
3. Inhibin B.
4. AMH.
5. Ovarian volume.
6. Antral follicle count.
Treatment
A number of therapeutic alternatives have been tried mostly
alteration of stimulation protocol and addition of adjuvants.
Ch-14.indd 216 18-01-2014 12:13:59

Ovarian Stimulation for the Poor Responder 217
Complementary alternative therapy and options like oocyte
donation have also been considered (Table 14.2).
Table 14.2: Protocols for poor responders

1. Gonadotropins
• CC and hMG
• High dose FSH/hMG
• Use of recombinant vs purified urinary FSH
• Luteal initiation of FSH
• Low dose minimal stimulation protocols
2. GnRH agonist protocol
• Flare GnRH agonist protocols – short and ultrashort
• Minidose GnRH agonists
3. Antagonist
• Only antagonist
• Antagonist with agonist
4. Adjuncts
• Use of LH
• Growth hormone or GH-releasing factor or pyridostigmine
• Oral contraceptives
• Adjunctive use of nitric oxide (NO)-donors (L-arginine)
• Glucocorticoids
• Testosterone and DHEAS
• Letrozole
• Luteal estradiol
• Aspirin
5. Natural cycle
6. CAM therapy (Complementary and alternative medicine)
7. Donor oocytes
Ch-14.indd 217 18-01-2014 12:13:59

Stimulation Protocols
Long Protocol
In a study on comparison of long agonist protocol with
antagonist protocol, there were no significant differences
in the cycle cancelation rates, duration of stimulation,
consumption of gonadotropins, and mean numbers of mature
follicles, oocytes and embryos obtained in poor responders.
The implantation rates were similar, but the number of
embryos transferred and pregnancy rate were significantly
higher for the antagonist group.2
High Doses of Gonadotropins

High doses of gonadotropins up to 600 IU/day have been
used but clear advantage with these high doses has not been
seen in any study. A study conducted to assess optimal dose
of gonadotropin after microdose gonadotropin-releasing
hormone analog (GnRHa) flare cycles in poor responders
showed a clinical pregnancy rate of 13.1%, 15.3%, and
16.1% for 300, 450 and 600 IU, respectively of FSH. There
were no significant differences in the age, peak serum E2
concentration, days of stimulation with rFSH, total number
of M2 oocytes retrieved, number of embryos transferred,
clinical pregnancy rates, and cancelation rates of stimulation
and embryo transfer between the three groups except for total
rFSH dosage. The study concluded that there is no need to
use doses above 300 IU of rFSH to increase the pregnancy
rate in microdose cycles.3
On comparing 375 IU/day gonadotropin to the 450 IU/
day in poor responders, the additional 75 IU/day does not
give any improvement in either embryology or pregnancy
outcomes.4
Ch-14.indd 218 18-01-2014 12:13:59

Use of Recombinant FSH Versus Purified urinary FSH
Small studies indicate better results with recombinant rather
than purified FSH with a pregnancy rate of 33% versus
6%. However, larger randomized trials are needed to give
definitive proof.5
Use of Recombinant FSH Versus Human Menopausal

Gonadotropin
A recent study showed that recombinant follicle-stimulating
hormone (rFSH) has no advantage over urinary human
menopausal gonadotropin (hMG) on ovarian performance or
the outcome of IVF–ET in poor responders’ IVF cycles. There
were no statistical differences in numbers of follicles, oocytes
recovered, cycle characteristics, or pregnancy rates between
hMG and rFSH-stimulated cycles.6
Luteal Initiation of FSH

The initiation of FSH in luteal phase may increase the number
of recruited follicles by opening the recruitment window
earlier, in the preceding cycle. However, no study showed
an advantage.
Stop Agonist Regime

These regimens are characterized by the use of relatively low
doses of GnRH agonists commencing in the mid-luteal phase
of the cycle and usually ending at the time of menses or shortly
thereafter, in combination with high doses of gonadotropins.
A clinical pregnancy rate per transfer of 32% was achieved.7
Microdose Protocol
Microdose of GnRH agonist are given with the idea of
suppressing raised LH but not downregulating severely.
Ch-14.indd 219 18-01-2014 12:13:59

GnRH agonist is given from the midluteal phase of the

previous cycle to the onset of menstruation in the next cycle.
Then high doses of gonadotropins (hMG/FSH) were given. The
low dose and half duration of GnRHa therapy lessened the
suppression of the response of the ovaries to COH compared
with the regular long protocol of GnRHa downregulation
therapy leading to better results.
Flare Protocol
GnRH agonists are given on the first day of period and
stopped after 3 days.
Advantages:
1. Ovarian suppression is not excessive as GnRH agonist is
stopped before down regulation; hence, a better response
to gonadotropin stimulation could be achieved.
2. The initial stimulation of the GnRH receptors releases the
FSH and this enhances the effect of exogenous FSH that is
started after 3 days.
Standard Flare Protocol
Buserelin 0.5 mg is given for the first 3 days. A low cancelation
rate (11.3%) and a good pregnancy rate (29%) was found.8
On comparing the flare-up versus the luteal GnRH agonist
regimen, higher pregnancy rates (20.4% versus 11.7%) were
observed with flare protocol.9 Results of flare protocol were
similar to antagonist protocol.10
Microdose Flare Protocol
Several microdoses have been tried in an attempt to identify a
dose, which causes endogenous FSH release with no increase
in LH, progesterone and androgen secretion seen with classical
flare protocol. Leuprolide 40 µg was given for 3 days followed
Ch-14.indd 220 18-01-2014 12:13:59

by FSH. Smaller doses up to 20 µg has been tried. These studies
show a trend toward improved results but larger studies are
needed to support this issue.11 Microdose leuprolide acetate
(LA) (50 mg twice daily) starting on the second day of withdrawal
bleeding is also given. Stimulation protocol with decapeptyl
involves giving oral contraceptives (OC) from day 21. On third
day of OC cessation 0.005 mg decapeptyl is started twice daily.
FSH with hMG on 2nd day of decapeptyl 450 to 750 IU/day
is given. Microdose GnRHa flare-up protocol and multiple
dose GnRH antagonist protocol seem to have similar efficacy
in improving treatment outcomes of poor responder patients.12
GnRH Antagonist
In a study stimulation started with clomiphene citrate
(100 mg/daily, from cycle days 2 to 5) combined with the
appropriate dose of gonadotropins (mean 375 IU/day). The
GnRH antagonist cetrorelix was started on cycle day 6 at
a dose of 0.25 mg/day. There were increased number of
retrieved oocytes per cycle and increased pregnancy rates per
transfer (23.5% versus 10%).13
GnRH Antagonist Along with Agonists

Protocol:
• Decapeptyl on first day of period for 3 days in a dose of
0.1 mg. Start maximal FSH dose from day 3 with flexible
antagonist protocol.
• Decapeptyl 0.1 mg from day 21 to period and then stop
it. Start FSH maximal dose on day 2 along with antagonist
when lead follicle more than 13 mm.
The available limited data, derived from small or
preliminary studies, do not show any advantage from the use
of GnRH antagonists.
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Mild Stimulation Protocols

The women with mild ovarian stimulation had lower duration
of stimulation, total doses of gonadotropins used, serum E2
level on hCG day, the number of retrieved oocytes, and the
number of mature oocytes than conventional stimulation.
However, there is no significant difference in the number
of good embryos, the number of transferred embryos, the
cancelation rate, or the clinical pregnancy rate. In older
women over 37 years old, the clinical pregnancy rate and live
birthrate were higher when compared with the conventional
protocol. In poor responder groups, mild ovarian stimulation is
more cost-effective and patient friendly than conventional IVF
and should be considered for poor responders over 37 years
old.1,14
Modified Natural Cycle

Modified natural cycle (MNC) treatment consists of giving
human menopausal gonadotropin (hMG) 150 IU/day IM
if serum estradiol was ≤ 50 pg/ml on day 2 or 3 of the
menstrual cycle.15 GnRH antagonists prevent LH surge and
therefore, improve the results of natural IVF cycles. The GnRH
antagonist should be started at day 8, at the daily dose of
0.25 mg. The natural cycle is a successful option in treatment
of poor responders and implantation failure.16
Adjuvants
Androgens in Poor Responder

It is believed that androgens may amplify the FSH effects on
the ovary improving ovarian response and that granulosa
cell stimulation by FSH is actually an androgen-modulated
process.
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Testosterone: Pretreatment with 12.5 mg transdermal
testosterone gel (TTG) has been applied daily for 21 days
in the cycle preceding COS with GnRH antagonist protocol
for IVF in poor responders. It may be given as transdermal
20 µg/kg per day during the 5 days preceding gonadotropin
treatment. It was associated with an increase in clinical
ovarian stimulation for IVF.17
DHEA: It was suggested that DHEA supplementation
appears to augment ovarian stimulation with gonadotropins
in poor responders, resulting in improved oocyte yields.
Cumulative DHEA effects may have possible effects on
follicle recruitment. In a study with DHEA, a significant
decrease in cycle day 3 estradiol levels was found. There
was an increased number of >17 mm follicles (3 versus 1.9)
and MII oocytes (4 versus 2.1).18 DHEAS is given as 25 mg of
micronized tablet tid, for at least four to twelve weeks prior to
IVF cycle.
A recent systemic review concluded that transdermal
testosterone pretreatment seems to increase clinical
ovarian stimulation for IVF. However, there is insufficient
data to support a beneficial role of DHEA in the probability of
pregnancy in poor responders undergoing ovarian stimulation
for IVF.19
Growth Hormone (GH) and GH-releasing Factor or Pyridostigmine

GH stimulates ovarian steroidogenesis, leading to follicular
development and enhances the ovarian response to
FSH mediated via the IGF-1.20 Dose is 4 to 12 IU. GH is
administered SC, starting on the day of ovarian stimulation
with gonadotropins.
Pyridostigmine is an acetylcholinesterase inhibitor leading
to increase in acetylcholine, which increases GH secretion.
Ch-14.indd 223 18-01-2014 12:13:59

This approach was evaluated in a randomized study in that

poor responders were given 120 mg/day pyridostigmine
orally, from the day of downregulation until the day of hCG,
along with a long luteal GnRH agonist regimen (triptorelin
0.1 mg on day 21, hMG/FSH 300 IU/day, im). Compared
with placebo, pyridostigmine was associated with a improved
pregnancy rates (25.7% versus 11.4%).21
A recent Cochrane review 2010 showed a statistically
significant difference in both live birthrates and pregnancy
rates favoring the use of adjuvant growth hormone in
in vitro fertilization protocols in women who are
considered poor responders without increasing adverse events.
The result needs to be interpreted with caution, the included
trials were few in number and there was a small sample size.
Therefore, before recommending growth hormone adjuvant in
in vitro fertilization further research is necessary to fully define
its role.22,23
Glucocorticoids
Dexamethasone may directly influence follicular development
and oocyte maturation or may increase serum GH. It may
also affect endometrium by immunosuppression. Only study
conducted was on normal responders and showed lower
cancelation rate. More RCT are needed before a conclusion
can be drawn of its advantage in poor responders.
Adjunctive use of Nitric Oxide (NO)-Donors (L-arginine)

NO may be involved in follicular selection and maturation,
possibly due to its contribution in periovulatory vasodilatory
modulation. Better results were seen in a study with GnRH
agonist flare-up regimen, high doses of purified FSH and
orally administered L-arginine.24
Ch-14.indd 224 18-01-2014 12:13:59

LH
In a recent study, exogenous LH supplementation
was consistently associated with higher peak estradiol
concentrations. The use of hMG in long GnRH agonist cycles
was associated with a 3–4% increase in live birthrate. There
was insufficient evidence to make definitive conclusions
on the need for exogenous LH activity in GnRH antagonist
cycles or the benefit of recombinant LH and hCG protocols.
Poor responders and patients 35 years of age and older may
benefit from exogenous LH.25 Additional exogenous LH
activity in the form of either recombinant luteinizing hormone
or low-dose recombinant hCG is unnecessary in microdose
cycles to increase pregnancy rates.26
Combined Oral Contraceptive (COC) Pills

COC administration prior to the GnRH agonist protocol was
associated with higher pregnancy rates and lower cancelation
rates. It suppresses endogenous gonadotropins, and at the
same time (through its estrogen component), produces and
sensitizes more estrogen receptors.27
Luteal Estradiol
Poor responders aged <35 years may be treated with the
aggressive luteal estradiol/gonadotropin-releasing hormone
antagonist (E2/ANT protocol to improve cycle.28
Aspirin
No improvement secondary to aspirin intake was found
in IVF outcome in poor responders.29
Ch-14.indd 225 18-01-2014 12:13:59

Letrozole
The GnRH antagonist with letrozole protocol is an effective
protocol that may be used in poor ovarian responders. Study
has shown it has better results than flare protocol.30
Complementary and Alternative Medicine

Acupuncture: Currently available literature does not
provide sufficient evidence that adjuvant acupuncture
improves IVF clinical pregnancy rate.31
Other Options
Oocyte Donation
Oocyte donation forms an important option for these women
as they are unable to yield oocytes but endometrium can be
prepared.
Cryopreservation of oocyte or embryo
Those with decreasing ovarian reserve embryo or oocyte
cryopreservation can be offered.
There is insufficient evidence to support the routine use of
any particular intervention either for pituitary downregulation,
ovarian stimulation or adjuvant therapy in the management
of poor responders to controlled ovarian stimulation in IVF.
More robust data from good quality RCTs with relevant
outcomes are needed.32
References
1. Yoo JH, Cha SH, Park CW, Kim JY, Yang KM, Song IO, et al.
Comparison of mild ovarian stimulation with conventional
ovarian stimulation in poor responders. Clin Exp Reprod
Med. 2011;38(3):159-63.
Ch-14.indd 226 18-01-2014 12:13:59

2. Cheung LP, Lam PM, Lok IH, Chiu TT, Yeung SY, Tier CC,
et al. GnRH antagonist versus long GnRH agonist protocol
in poor responders undergoing IVF: a randomized controlled
trial. Hum Reprod. 2005;20(3):616-21.
3. Berkkanoglu M, Ozgur K. What is the optimum
maximal gonadotropin dosage used in microdose flare-up cycles
in poor responders? Fertil Steril. 2010;94(2):662-5.
4. Dilbaz S, Demir B, Cinar O, Dede S, Aydin S, Beydilli G,
et al. Does 75 IU difference improve the cycle performance
in poor responders? Comparison of daily 375 versus 450 IU
gonadotropin doses. Gynecol Endocrinol. 2011;27(12):1001-6.
5. Raga F, Bonilla-Musoles F, Casan EM, Bonilla F. Recombinant
follicle stimulating hormone stimulation in poor responders
with normal basal concentrations of follicle-stimulating
hormone and estradiol: improved reproductive outcome. Hum
Reprod. 1999;14:1431-4.
6. Eskandar M, Jaroudi K, Jambi A, Archibong EI, Coskun
S, Sobande AA. Is recombinant follicle-stimulating hormone
more effective in IVF poor responders than human menopausal
gonadotrophins? Med Sci Monit. 2004;10(1):PI6-9.
7. Faber BM, Mayer J, Cox B, Jones D, Toner JP, Oehninger S,
et al. Cessation of gonadotropin-releasing hormone agonist
therapy combined with high-dose gonadotropin stimulation
yields favorable pregnancy results in low responders. Fertil
Steril. 1998;69:826-30.
8. Padilla S, Dugan K, Maruschak V, Shalika S, Smith R. Use of the
flare-up protocol with high dose follicle stimulating hormone
and human menopausal gonadotropins for in vitro fertilization
in poor responders. Fertil Steril. 1996;65:796-9.
9. Toth TL, Awwad JT, Veeck L, Jones HWJr, Muasher SJ. Suppression
and fare regimens of gonadotropin-releasing hormone agonist:
use in women with different basal gonadotropin values in an in
vitro fertilization program. J Reprod Med. 1996;41:321-6.
10. Akman MA, Erden HF, Tosun SB, Bayazit N, Aksoy E, Bahceci
M. Comparison of agonistic flare-up protocol and antagonistic
multiple dose protocol in ovarian stimulation of poor
responders: results of a prospective randomized trial. Hum
Reprod. 2001;16(5):868-70.
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11. Schoolcraft W, Schlenker T, Gee M, Stevens J, Wagley

L. Improved controlled ovarian hyperstimulation in poor
responder in vitro low ovarian response to stimulation for IVF.
12. Kahraman K, Berker B, Atabekoglu CS, Sonmezer M, Cetinkaya
E, Aytac R, et al. Microdose gonadotropin-releasing hormone
agonist flare-up protocol versus multiple dose gonadotropin-
releasing hormone antagonist protocol in poor responders
undergoing intracytoplasmic sperm injection-embryo transfer
cycle. Fertil Steril. 2009;91(6):2437-44.
13. Craft I, Gorgy A, Hill J, Menon D, Podsiadly B. Will GnRH
antagonists provide new hope for patients considered difficult
responders’ to GnRH agonist protocols? Hum Reprod.
1999;14:2959-62.
14. Mohsen IA, El Din RE. Minimal stimulation protocol using
letrozole versus microdose flare up GnRH agonist protocol in
women with poor ovarian response undergoing ICSI. Gynecol
Endocrinol. 2013;29(2):105-8.
15. Lou HY, Huang XY. Modified natural cycle for in vitro
fertilization and embryo transfer in normal ovarian responders.
J Int Med Res. 2010;38(6):2070-6.
16. Elizur SE, Aslan D, Shulman A, Weisz B, Bider D, Dor J.
Modified natural cycle using GnRH antagonist can be an
optional treatment in poor responders undergoing IVF. J Assist
Reprod Genet. 2005;22(2):75-9.
17. Kim CH, Howles CM, Lee HA. The effect of transdermal
testosterone gel pretreatment on controlled ovarian stimulation
and IVF outcome in low responders. Fertil Steril. 2011;95(2):679-
83.
18. Sönmezer M, Ozmen B, Cil AP, Ozkavukçu S, Taşçi T, Olmuş
H, et al. Dehydroepiandrosterone supplementation improves
ovarian response and cycle outcome in poor responders.
19. Bosdou JK, Venetis CA, Kolibianakis EM, Toulis KA, Goulis
DG, Zepiridis L, et al. The use of androgens or androgen-
modulating agents in poor responders undergoing in vitro
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Reprod Update. 2012;18(2):127-45.
20. Jia N, Kalmijn J, Hseuh A. Growth hormone enhances
FSH induced differentiation of cultured rat granulosa cells.
Endocrinology. 1986;118:1401-9.
21. Chung-Hoon K, Hee-Dong C, Yoon-Seok C. Pyridostigmine
co-treatment for controlled ovarian hyperstimulation in low
responders undergoing in vitro fertilization ± embryo transfer.
22. Duffy JM, Ahmad G, Mohiyiddeen L, Nardo LG, Watson A.
Growth hormone for in vitro fertilization. Cochrane Database
Syst Rev. 2010 Jan 20;(1):CD000099.
23. Kolibianakis EM, Venetis CA, Diedrich K, Tarlatzis
BC, Griesinger G. Addition of growth hormone to gonadotropins
in ovarian stimulation of poor responders treated by in-vitro
Reprod Update. 2009;15(6):613-22.
24. Battaglia C, Salvatori M, Maxia N, Petraglia F, Facchinotti F,
Volpe A. Adjuvant L-arginine treatment for in-vitro fertilization
in poor responder patients. Hum Reprod. 1999;14:1690-7.
25. Hill MJ, Levy G, Levens ED. Does exogenous LH in ovarian
stimulation improve assisted reproduction success? An appraisal
of the literature. Reprod Biomed Online. 2012;24(3):261-71.
26. Berkkanoglu M, Isikoglu M, Aydin D, Ozgur K. Clinical effects
of ovulation induction with recombinant follicle-stimulating
hormone supplemented with recombinant luteinizing hormone
or low-dose recombinant human chorionic gonadotropin in the
midfollicular phase in microdose cycles in poor responders.
Fertil Steril. 2007;88(3):665-9.
27. Lindheim S, Barad D, Witt B, Ditkoff E, Sauer M. Short-term
gonadotrophin suppression with oral contraceptives benefits
poor responders prior to controlled ovarian hyperstimulation.
J Assist Reprod Genet. 1996;16:745-7.
28. Shastri SM, Barbieri E, Kligman I, Schoyer KD, Davis
OK, Rosenwaks Z. Stimulation of the young poor responder:
comparison of the luteal estradiol/gonadotropin-releasing
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hormone antagonist priming protocol versus oral contraceptive

microdose leuprolide. Fertil Steril. 2011;95(2):592-5.
29. Frattarelli JL, McWilliams GD, Hill MJ, Miller KA, Scott RT Jr.
Low-dose aspirin use does not improve in vitro fertilization
outcomes in poor responders. Fertil Steril. 2008;89(5):1113-7.
30. Yarali H, Esinler I, Polat M, Bozdag G, Tiras B. Antagonist/
letrozole protocol in poor ovarian responders for
intracytoplasmic sperm injection: a comparative study with the
microdose flare-up protocol. Fertil Steril. 2009;92(1):231-5.
31. El-Toukhy T, Sunkara SK, Khairy M, Dyer R, Khalaf
Y, Coomarasamy A. A systematic review and meta-analysis of
acupuncture in vitro fertilisation. BJOG. 2008;115(10):1203-13.
32. Shanbhag S, Aucott L, Bhattacharya S, Hamilton MA, McTavish
AR. Interventions for ‘poor responders’ to controlled ovarian
hyperstimulation (COH) in in-vitro fertilisation (IVF). Cochrane
Database Syst Rev. 2007 Jan 24;(1):CD004379.
Ch-14.indd 230 18-01-2014 12:13:59

cHAPTER
15
Endometrial Receptivity—
A Vital Role
Surveen Ghumman
Despite progress and research in the field of infertility, the

rate of live birth rate with IVF has not gone beyond 40%.
In 75% of the failed cases, there is no cause for failure
other than implantation forming a major obstacle to ART.
The complexities of embryo apposition to invasion of the
epithelium are only partly understood at the molecular level
and still present a challenge to the infertility specialist. Both
partners, the mother as well as the embryo, play equal roles
in the embryo-maternal dialog.
Definition: Endometrial receptivity can be defined as the
histological and molecular changes occurring in a temporal
and spatial manner in the endometrium so as to facilitate
embryonic implantation.
Endometrial receptivity (ER) involves molecular as well
as histological changes occurring in a temporal and spatial
manner in the endometrium so as to facilitate embryonic
implantation. Under the influence of estrogen and
progesterone, the endometrium undergoes these important
Ch-15.indd 231 18-01-2014 12:17:10

changes so as to make it receptive to the implanting embryo

and this period is known as the ‘Window of Receptivity’. It
lasts for approximately 4 days usually from day 20 to 24 in
women with a 28 day menstrual cycle. The key factor for
implantation is the synchrony between embryo development
and endometrial receptivity. The ability of the decidua to
respond optimally to the invading trophoblasts is determined
by endocrine and end organ interactions that long precede
ovulation. There are many causes of poor endometrial
response (Table 15.I).
The implantation process, as described by Enders, consists
of the three important phases.1
Table 15.1: Causes of poor endometrial response

Poor endometrial response Causes
Poor hormonal environment Suboptimal estrogens
Suboptimal progesterones
Out of phase development
Excessive estrogen levels
Hyperprolactinemia
Hyperandrogenemia
Infections Endometritis
Tuberculosis
Chlamydia
Anatomical Uterine septum
Foreign bodies Leiomyomas
• Submucous
• Multiple/Large Intramural
Endometrial polyps
Lost intrauterine devices
Iatrogenic Vigorous curettage
Adhesions Intrauterine synechiae
Drugs Clomiphene citrate
Endometrial Squamous metaplasia
Calcification/Ossification
Ch-15.indd 232 18-01-2014 12:17:10

Endometrial Receptivity—A Vital Role 233
1. Apposition: The blastocyst at this phase ceases to move freely
in the uterine cavity and comes in close proximity to the
uterine epithelium. This is facilitated not only by absorption
of uterine fluid but also by elevating the endometrial surface
toward the blastocyst, by pinopode formation.
2. Adhesion: It is believed that the sulfhydryl groups of
the endometrium are chemotactic for the embryo.2
This approximation leads to an interaction between the
trophoectoderm and the endometrial epithelial cells
leading to the attachment of the blastocysts to the uterine
lining. The attachment can only occur if the embryo has
successfully hatched out of the zona pellucida. In cases
of zona hardening and improper hatching, the embryo
will be unable to adhere to the endometrium. Hence,
Assisted Hatching procedures are useful in a select group
of patients. Blastocyst culture has taught us that the
blastocyst is sticky and will readily adhere, a quality that
makes it survive in the endometrium.
A number of adhesion molecules have been identified
that are secreted by the endometrial cells and facilitate
adhesion. There are:
– Integrins: Integrins are maximally expressed in the
endometrium during the implantation window.
The integrins a1b1 and a4b1 are co-expressed in
the endometrial epithelial cells in varying amounts.
However, a5b3 integrin has been maximally studied
as a potential marker for endometrial receptivity. It is
secreted under the influence of progesterone during
the implantation window. Low levels of this integrin
were found in women with unexplained infertility,
attending for IVF, ICSI compared to fertile controls.3
– Osteopontin: Osteopontin is a glycoprotein whose
expression is increased in the endometrium during the
implantation window, i.e. 7 days after the LH peak.
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Osteopontin and its receptor alpha (v) beta (3) integrin

have recently been proposed as a major complex to
promote embryo attachment, and thus, they would be
useful as markers of endometrial receptivity.4
– Mucin 1(MUC 1): This cell surface mucin is abundantly
expressed during the implantation window.5 Glandular
MUC 1 levels were found to be diminished in patients
with recurrent miscarriages.
3. Invasion: This involves epithelial penetration and
placentation. The trophoectoderm cells, taking advantage of
the loss of polarity and tight junctions between the epithelial
cells that occurs during this period, invades into the
endometrium. The trophoblasts produce serine proteases
and matrix metalloproteinases that help to digest the matrix.
Several factors affect the process of implantation (Table
15.2).
Table 15.2: Factors that affect implantation
1. General
• Age
• Hormonal control of endometrial preparation
• Endometriosis
• Hydrosalpinx
2. Uterine factors
• Endometrial receptivity
• Congenital uterine abnormalities
• Fibroids/Polyps
• Endometritis
• Poor uterine artery blood flow
3. Immunological function
• Antiphospholipid syndrome
• Lupus erythematosis
• Rheumatoid arthritis
• Hashimoto’s thyroiditis
4. Embryological
• Aneuploidy in embryos
• Spindle damage
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Histological Changes
The most significant morphological change observed during
this period is the development of pinopodes, which are closely
associated with the development of endometrial receptivity
and could be an important histological marker.6 Pinopodes
are large cytoplasmic protrusions of the apical membranes
of the secretary cells after they lose their microvilli. They
develop 4–5 days after ovulation, i.e. day 18 of a 28 day
cycle and are fully developed by day 20 after that they start
regressing, largely disappearing by day 22. They are thought
to have a pinocytotic function and are involved in the apico-
basal transport of fluids and macromolecules toward the
stroma.
The other important change seen at this time is the
decrease in cell polarity and tight junctions between cells
thus assisting in trophoblastic invasion.
Biochemical and Molecular Changes

The various phases of implantation involve synchronized
interplay between a variety of molecules. These molecules,
expressed at the three stages of implantation, are in accordance
with the needs of that phase (Table 15.3).
Biochemical Markers of Endometrial Receptivity

Mucins: These are highly glycosylated large molecules
found on the apical site of the endometrial epithelial cells
and are believed to play a role in attachment. Mucin named
MAG’s (mouse ascites Golgi) use as a marker for ER has been
suggested and 60% of women with unexplained infertility
have an abnormal MAG expression.7
Ch-15.indd 235 18-01-2014 12:17:10

Table 15.3: Molecules at three stages of implantation

1. Apposition – Chemokines
• Interleukin-8 (IL-8)
• Monocyte chemoattractant protein-1 (MCP-1)
• Regulated on activation, normal T-cell expressed and secreted
(RANTES)
2. Adhesion
• Cytokines LIF, IL-1
• Trophonin, tastin, osteopontin
• Uteroglobin
• Glycodelin A
• Growth factors IGFBP1, HBEGF
• Integrins alpha V beta 3
• HOXA10 gene
3. Invasion – Proteolytic enzymes
• Serine proteases
• Metalloproteases
• Collagenases
Integrins: These are transmembrane glycoprotiens belonging

to the family of cell-adhesions molecules and promote cell-cell
binding. Defects of integrin expression leads to disordered
endometrial function The alpha5 beta3 integrins are emerging
as important markers of endometrial receptivity and are
absent in cases of unexplained infertility,8 luteal phase defect,
endometriosis and hydrosalpinx.9
Trophinin: It is an intrinsic membrane protein important
for cell adhesion whereas tastin (trophinin assisting protein)
is a cytoplasmic protein.10 It has been observed that trophinin
concentrates on the endometrial surface at possible sites for
blastocyst attachment.
Growth Factors: Epidermal growth factor (EGF) and
HBEGF (heparin binding epidermal growth factor) have a role,
both in attachment and penetration during the implantation
process.11 Insulin like growth factor binding protein 1
(IGFBP1) also plays an important role in embryo implantation.
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Increased levels of IGFBP1 are seen at maternal-fetal interface
in severe preeclampsia that is characterized by inadequate
placentation.
Cytokines: Cytokines are low molecular weight soluble
proteins involved in regulating cellular activity.12 They act
as messengers within the immune system and between the
immune system and other systems of the body. The presence
of cytokines is sensed by the cell by means of specific
cytokine receptors. Cytokines may be pro-inflammatory or
anti-inflammatory in nature (Table 15.4). The cytokines that
play an important role in the cascade of events that lead
to implantation are leukemia inhibiting factor (LIF) that is
decreased in women with unexplained infertility,13 and
colony-stimulating factor (CSF) that interacts with the receptors
on trophoectoderm and promotes blastocyst attachment. The
most potent anti-inflammatory cytokine is interleukin (IL).10
Calcitonin: It is secreted under the influence of progesterone
in the uterine lumen 4 days post ovulation. It causes changes
in the calcium signaling leading to redistribution of critical
cell adhesion molecules or junctional complexes at the site
of implantation, preparing it for contact with the trophoblast.
HOXA 10 is a hormone-regulated endometrial
transcription factor gene that appears during the window of
implantation. Homeobox A10 is a protein that is encoded by
Table 15.4: pro- and anti-inflammatory cytokines

Pro-inflammatory Cytokines Anti-inflammatory cytokines
Interleukin-2 (il2) Interleukin-4 (il4)
Interferon gamma (ifn) Transforming growth factor beta (tgfb)
Interleukin-1 (il1) Interleukin 10 (il10)
Tumor necrosis factor alpha Interleukin 6 (il6)
(tnfa)
Leukemia inhibitory factor (lif)
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Hoxa-10 gene. It was discovered that maternal expression of

Hoxa-10 transcription factor is necessary for female fertility
and diminished Hoxa-10 expression has been demonstrated
in women with infertility.14
Cyclo-oxygenase-2 (COX-2): It is the rate limiting enzyme
in prostaglandin biosynthesis. Prostaglandins are involved
in increase vascular permeability during implantation and
decidualization. Targeted disruption of COX-2 in mice
produces reproductive failures in the female.15
Fibronectin: During implantation contact between
fibronectin and peri-implantation blastocyst elevates
intracellular calcium that strengthens trophoblast adhesion
through protein redistribution.16
Corticotropin-releasing hormone (CRH): The hypothalamic
neuropeptide CRH as well as its receptors have been identified
in decidualized endometrial stroma as well as the trophoblast
cells. It is believed that it may play a role in local immune
phenomenon associated with embryo implantation.17
Immunological Aspects of Endometrial Implantation

The conceptus is a foreign allograft to the mother as it contains
paternal antigens. The appropriate interaction between
the preimplantation embryo and maternal endometrium
is controlled by cytokines and growth factors and its
receptors. Both the cytokines and growth factors may react
through ‘embryo endometrial dialog’ by helpful or harmful
responses. According to these responses either pregnancy is
maintained or rejected. During blastocyst implantation, the
maternal endometrial response to the invading embryo has
characteristics of an aseptic acute inflammatory response yet
once implanted the embryo suppresses this response and
prevents its rejection.
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Th1 vs Th2 Response of Endometrium
In pregnancy, the Th1 subset of cytokines are downregulated
and the Th2 subset are upregulated. It is well known that the
reproductive steroid hormones, particularly progesterone,
in addition to its widely recognized effects on endometrial
epithelial and stromal cells and spiral arteries, affect the
activities of T cells and natural killer cells in the decidua, thus
inducing active immune tolerance against the fetal antigens.18
It immunomodulates and makes Th2 response predominate
for pregnancy continuation.
Decidual antigen-presenting cells including dendritic cells
(DCs) and CD14(+) macrophages, as mediators of the first
encounter with fetal antigens, appear to be critically involved
in the initiation of primary immune response by regulating
innate and adaptive immunity.19 Interleukin-15, produced by
them, permits the proliferation and differentiation of CD3(–)
CD16(–) CD94(+) NKG2A(+) CD56(+bright) and decidual
NK cells that identify trophoblast cells. Large granular
lymphocytes (LGL) comprise 70 – 80% of the endometrial
leukocyte population and play a role in implantation and
maintenance of pregnancy.
Natural Killer Cells

The role of natural killer (NK) cells in human implantation
has recently attracted attention. Women with unexplained
recurrent abortion and infertile women in whom multiple
attempts at embryo transfer have failed, show elevated levels
of peripheral and endometrial CD56 (+), CD16 (+), NK
cells. Daily administration of prednisolone for 3 days has
been reported to reduce the percentage of peripheral blood
NK cells. It is possible that steroid had beneficial effect on IVF
outcome through reduction of NK cells.20
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T Regulatory (T Reg) Cells

These cells are essential for maternal tolerance of the
conceptus. Inadequate number of T reg cells or their
functional deficiency is linked with infertility miscarriage
and preeclampsia. There is potential to use these cells as
therapeutic agents for reproductive pathologies.21
Several lines of evidence suggest that the human leukocyte
antigen (HLA)-G plays a key role in the regulation of human
pregnancy.22
The Fas – FasL System and Immune Tolerance

Jiaang and Vacchio showed that placental trophoblast can
induce fas mediated cell death of T cells that recognize
fetal antigens as foreign.23 This would protect the fetus from
harmful effects of maternal cell-mediated immunity. FasL
is present both in the villous cytotrophoblast and in the
extravillous trophoblast.
Newer Molecules Identified in Endometrial Implantation

Search is on through the field of proteomics and metabolomics
for newer molecules that play a key role in implantation. The
ones that are currently being investigated are:
• Glycodelin A is a progesterone-induced endometrial
glycoprotein that has been amply documented to play
a role in down-modulation of the maternal immune
response to fetal allo-antigens and to be indispensable for
the maintenance and progression of pregnancy.24
• Uteroglobin is a progesterone binding protein, a member
of the anti-inflammatory gene family and possibly a novel
cytokine. Secretory uteroglobin is found in endometrial
tissue homogenates in highest levels of expression during
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the early and mid luteal phase strongly suggesting an
involvement of uteroglobin in endometrial preparations
for implantation.25
• Osteoprotegerin (OPG), a soluble receptor of the tumor
necrosis factor family, and its ligand, the receptor activator
of nuclear factor-B ligand (RANKL), are emerging as
important regulators of vascular pathophysiology. OPG is
a positive regulator of microvessel formation in vivo that
is required for successful embryo nidation.26
Endometrial Vascular Changes

• There are marked changes in the vascularity of the
endometrium during the menstrual cycle as demonstrated
by Doppler. The lowest impedance to blood flow is
during the secretory phase around implantation. This
increase in vascularity leads to endometrial (epithelial
and stromal) growth and leads to efficient distribution as
well as expression of molecular biomarkers required for
preparation of the endometrium for implantation. Levels
of vascular endothelial growth factor increase in the
endometrium to facilitate implantation.
Role of Chronic Endometritis in Endometrial

Receptivity
Chronic endometritis may be:
1. Tubercular endometritis.
2. Nonspecific chronic endometritis.
Tuberculosis and chronic nonspecific endometritis
has a high incidence in unexplained infertility, recurrent
implantation failure and abortions.
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Tubercular Endometritis
Tuberculosis is an infection that can lie latent and be
reactivated at any time. Balance of Th2 to Th1 may be
disturbed by tubercular bacilli leading to implantation
failure or pregnancy loss. Mycobacterium may inhibit basal
production of progesterone and stimulatory effect of hCG.
Hence, it may cause a luteal phase effect and lead to failure of
implantation. A direct antigonadotropin effect has been seen,
and women with tuberculosis have needed higher doses of
gonadotropins for response. They have a higher basal FSH
showing a poor ovarian reserve.27
A high incidence of implantation failure has been seen
in women with genital tuberculosis and it is suggested
that latent tuberculosis should be considered in young
Indian patients presenting with unexplained infertility with
apparently normal pelvis and non-endometrial tubal factors
or those with repeated IVF failure.28
Chronic Nonspecific Endometritis

Chronic endometritis is a persistent inflammation of
endometrial lining that may be asymptomatic or accompanied
by mild symptoms like pelvic pain, abnormal uterine bleeding,
dyspareunea and vaginal discharge. It can be caused by
infection, intrauterine contraceptive device, submucosal
leiomyoma and endometrial polyp. Chronic endometritis
occurred in 22% of IVF program, 14% unexplained infertility,
23.6% women with history of first trimester miscarriage and
30.3% of recurrent implantation failure.29 Cases with bacterial
vaginosis have a high incidence of chronic nonspecific
endometritis (45%vs 5.2%) and should be screened.30
Pathogenesis of implantation failure with chronic
endometritis is shown in Figure 15.1. Endometrial lymphocytes
play a critical role in endometrial receptivity. There were
Ch-15.indd 242 18-01-2014 12:17:10

Fig. 15.1: Pathogenesis of implantation failure with chronic endometritis
lower % of CD56(+), CD16, CD56 whereas CD3 was

significantly higher in cases of chronic endometritis.
Diagnosis of Chronic Nonspecific Endometritis

It can be diagnosed by histopathology, culture or hysteroscopy.
Histopathological features include plasma cells, lymphocytes,
macrophages, eosinophils, spindle stroma, epithelial changes,
vasculitis, hyperemia, mucosal edema, micropolyps and
adhesions.
Problems with diagnosing chronic endometritis (CE):
1. No typical findings at clinical examination or ultrasound
2. Diagnosis relies on histology that has the following
problems
– Number of plasma cells does not correlate with
symptoms
– Intensity of inflammation showed no association with
patient’s duration of symptoms
Ch-15.indd 243 18-01-2014 12:17:11

– 16% pathological underdiagnosis mostly because of

non-recognition of plasma cells as they are obscured
by mononuclear cell infiltrate, plasmacytoid stromal
cell and abundant stromal mitosis.
Immunohistochemistry with syndecan 1:
Immunohistochemistry with syndecan 1 (a proteoglycan
found on the surface of plasma cells) would detect
these cells.31,32 It should be used for detection, only in
high-risk groups like those with recurrent implantation
failure and abortions, unexplained infertility, abnormal
uterine bleeding where no cause found and those with
characteristic milieu of CE in that plasma cells not
found on hematoxylin and eosin (H&E) stain.
3. Endometrial cultures—There can be contamination from
vaginal and endocervical contents. Demonstration of
organism does not imply its pathogenic significance. A
poor concordance is seen between endocervical, vaginal
and endometrial cultures.33 Hence, an endometrial culture
should be sent to confirm micro-organism responsible for
endometritis. Antimicrobial therapy should be initiated in
chronic nonspecific endometritis only after organism is
identified since, besides chlamydia and gonococcus, other
organisms like E. coli, Staphylococcus, Streptococcus and
U. urealyticum have a high incidence.
4. Hysteroscopy: The findings on hysteroscopy are:
– Focal or diffuse hyperemia
– Mucosal edema
– Adhesions
– Micropolyps.
A high degree of inflammation is necessary for
development of micropolyps. Hysteroscopy is not a useful
screening test for chronic endometritis in asymptomatic
women - low prevalence population.
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Chromohysteroscopy—On introduction of methylene
blue dye, areas stained with dye can detect chronic
endometritis as dye is taken up by damaged endometrium.
These areas may be sent for biopsy. Detection rate of chronic
endometritis is improved with a targeted biopsy. Observation
of diffuse light blue staining without dark areas strongly
suggests a normal endometrium free of endometritis. In a
study the power of dark staining for detection of endometritis
was calculated as follows—sensitivity 69.2%, specificity
74%, positive predictive value 40.9% and negative predictive
value 90.2%.34
Current Strategies to Assess Endometrial

Receptivity
The implantation rates even today are not as yet efficient as
those in a natural conception cycle. Unfortunately, there are
no universally accepted markers of endometrial receptivity
and currently a working definition of a receptive versus non-
receptive endometrium is incomplete.
Tests that assess receptivity can be grouped under two
major headings (Table 15.5) (Fig. 15.2).
I. Tests that assess endometrial changes:
i. Endometrial aspiration/biopsy:
A. Endometrial Histopathology: This is done by
endometrial biopsy taken during the late luteal
phase. This was the gold standard to assess
endometrial maturity. However, there are
limitations to this procedure as it is preformed
in the late luteal phase and hence may give
information only of invasion phase. It is
representative of the endometrial changes within
the cycle and cycle variations are well known.
However, it cannot be carried out in the cycle
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Table 15.5: Methods of endometrial evaluation

I. Tests to assess endometrial changes
1. Endometrial aspiration/biopsy
• Endometrial histopathology
• Study of pinopodes
• Endometrial culture-AFB/Bactec
• PCR for tuberculosis
2. Ultrasonography & Doppler, MRI
3. Hormonal evaluation
4. Hysteroscopy for anatomical and infectious cause
II. Markers of the embryo-endometrial dialogue
• Biochemical markers – endometrial proteins
• Uteroglobin & Glycodelin A
in which the patient is undergoing ART. It does

not reflect the endometrium as a whole, regional
variations being frequently encountered.
B. Study of Pinopodes: Pinopodes are studied by
scanning electron microscopy (SEM). Though a
better indicator of endometrial receptivity, it is
expensive, not universally available and cannot
be carried out during an IVF cycle.
C. Culture: Culture should be sent for AFB or
Bactec and for other organisms like Chlamydia,
gonococcus, E. coli, Staphylococcus, Streptococcus
and U. urealyticum
D. PCR: PCR for tuberculosis should be sent.
ii. Ultrasound and Doppler: Transvaginal sonography
is a simple noninvasive modality that is being
increasingly used to assess endometrial receptivity.
Both endometrial thickness and echogenic pattern
have been studied as potential markers of endometrial
receptivity. Calculating total endometrial volume by a
new 3D software is more objective than endometrial
thickness alone. Using Doppler the impedance to
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Fig. 15.2: Evaluation and management of poor endometrium
blood flow in the uterine artery is expressed as the

pulsatility index (PI) and is the lowest at the time of
implantation.
a. Endometrial thickness: It is generally accepted
that if the thickness is < 7 mm on ultrasound
the implantation is poor. Similarly endometrial
Ch-15.indd 247 18-01-2014 12:17:11

volume of <2.5 cc is associated with a poor

pregnancy rate.
b. Echogenicity: Endometrial character is hypoechoic
compared to the surrounding myometrium in
the proliferative phase. As thickness increases a
distinct triple line/multilayered pattern is seen and
is considered to be predictive of implantation.
Further under the influence of progesterone, the
endometrium undergoes secretory changes and
becomes more isoechoic and then hyperechoic.
A non-multilayered endometrium is associated
with poor implantation.
c. Endometrial vascularity: Sub- and intra-endometrial
vascularity is a prognostic factor for implantation
if endometrium is more than 7 mm irrespective
of the morphological index. Uterine perfusion is
maximum during the mid-luteal phase. PI < 3 is
associated with increased pregnancy rate. Absence
of sub-endometrial blood flow on the day of LH
surge is related to implantation failure.
Spiral artery perfusion is evaluated by color/
pulse Doppler and the endometrium has been
divided into 4 zones.
Zone 1—Only myometrial vessels surrounding
endometrium are seen
Zone 2—Vessels penetrate through the hypere
chogenic endometrial edge
Zone 3—Vessels reach the internal endometrial
hypoechogenic zone
Zone 4—Vessels reach up to the endometrial
cavity
A good vascularity in zone 3 and 4 relates to the
surface of the endometrium suggesting a good
endometrial receptivity.
Ch-15.indd 248 18-01-2014 12:17:11

iii. Hormonal levels: are of not much use for assessment
of endometrial receptivity.
iv. Hysteroscopy: Hysteroscopy may detect anatomical
lesions missed earlier. Hysteroscopy may show
evidence of endometritis in the form of focal or
diffuse hyperemia, white spots, micropolyps and
intrauterine adhesions.
II. Markers of the Embryo-endometrial dialog:
i. Evaluation of the various biomarkers are mostly
research tools. Kits for evaluation of integrins and
mucins are now commercially available. (Table 15.3)
ii. Peripheral NK cells: The pNK cell levels reflect changes
in dNK cell levels. This implicates that pNK cell level
is a clinically useful marker to predict pregnancy
outcome.35
Treatment of Poor Uterine Receptivity

Treatment of poor endometrial receptivity must be done
according to the cause (Fig. 15.2).
Estrogens
Where endometrial response is suboptimal as often occurs
with clomiphene citrate, treatment is given by supplementing
estrogen from day 7–21 of cycle or till plasma estradiol is
400–700 pg/ml. Premarin 0.625 mg/day was used earlier;
however, with the advent of natural estrogens, the drug of
choice is estradiol valerate 2–8 mg per day orally from 8th
day of cycle. Vaginal estradiol gel can also be administered.36
However, recent studies have not supported the use of
estrogen.
Ch-15.indd 249 18-01-2014 12:17:11

Change of Ovulation Induction Regime

Patients on clomiphene may show persistently poor
endometrial response due to its antiestrogenic effect on
endometrium. In such cases drug may be changed to
letrozole, tamoxifen or gonadotropins.
• Letrozole: Letrozole does not have an antiestrogenic
effect on the endometrium because of its short half-life
and absence of estrogen receptor blockage.
• Tamoxifen: It is a selective estrogen receptor modulator.
It causes raised estrogen levels not only due to multi-
follicular development but also due to a direct action
on the endometrial estrogen receptors, hence leading
to a favorable response on the cervical mucus and
endometrium. It is an alternative to clomiphene where
there is persistently poor endometrial response.
• Gonadotropins: Use of gonadotropins will enhance the
estrogenic effect on the endometrium.
Drugs to Improve the Endometrial Blood Flow

• Aspirin: Low dose aspirin, 75 mg/day reduces platelet
aggregation and may enhance endometrial blood flow.37
• Sildenafil: It is given in a dose of 25 mg four times a
day intravaginally for 3–10 day to improve endometrial
vascularity.38 It is a type 5 specific phosphodiesterase
inhibitor. Pulsatility index decreases from 3 to 2.1 whereas
there is no effect in the placebo group. This, however, is an
observational study and is not supported by randomized
control trials. It should be used with caution as it has side
effects like headache, hypertension and occasional death.
• Nitroglycerin: It was thought to be useful because of its
vasodilating effect and was given in a dose of 800 μg
Ch-15.indd 250 18-01-2014 12:17:11

sublingually 3 minutes before embryo transfer in IVF
or 5 mg daily patch prior to the day of embryo transfer.
However, a double blind prospective randomized
placebo controlled trial showed that NTG treatment on
the day before embryo transfer was no more effective than
placebo in improving the implantation rates.39
• L-arginine: Nitric oxide (NO) is formed from L-arginine
and leads to increased vascularity and improves blood
flow in the ovarian follicle and endometrium. It is given
in a dose of 16 g/day in poor responders and implantation
failures. However, randomized placebo controlled trials
are lacking on this subject except one in poor responders.40
Immune Suppression/Potentiation
Administration of intravenous immunoglobulins (IVIG) has
been tried in patients with high titers of antiphospholipid
antibodies to mitigate its harmful effects on nidation. It
has also been tried in patients with prior failed IVF cycles
to improve endometrial receptivity. In one observational
study early IVIG therapy was associated with improved
success of IVF.41 Elevated NKT cells in recurrent pregnancy
loss or implantation failure can be ameliorated with IVIG
treatment, and result in successful pregnancy.42
Leukocyte immunotherapy (LIT) by paternal leukocytes
was reported to be successful in a paper published from
Germany.43 In 20 patients with a history of unsuccessful sterility
treatment, paternal leukocytes are injected into the mother
in an attempt to alter the maternal immune response, thus
making it favorable for implantation. However, a Cochrane
review on the use of paternal leukocytes and intravenous
immunoglobulins, analyzed 28 trials and showed no benefits
of such treatment over placebo.44
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Reducing uterine Contractility

Reducing uterine contractility will give a better contact of the
embryo with the endometrium:
1. Ritodrine: Administration of this drug has shown better
pregnancy rate in randomized controlled trials.
2. Piroxicam: In a randomized controlled trial 10 mg of
piroxicam 1 to 2 hour before embryo transfer showed
20% improvement in pregnancy rate. Recent studies,
however, have shown no improvement in success rate.45
Luteal Phase Support

Treatment consists of giving micronized progesterone per
vaginum or per rectal in a dose of 200–400 mg in two divided
doses. However, the intramuscular route in a dose of 50–
100 mg daily gives more sustained levels of progesterone.
Dydrogesterone can also be given orally in a dose of 20–30
mg/day in divided doses. hCG administration in a dose of 2500
IU every 3 days would provide luteal support. Progesterone
production is improved by hCG in normally functioning corpus
luteum whereas its effect is minimal if there is a malfunctioning
corpus luteum.
Surgical Evaluation and Treatment

Lysis of uterine synechiae: In cases of adhesion following
curettage or endometritis, hysteroscopic lysis of adhesions
should be done. Patients are treated with oral estrogens for
1 to 3 cycles following this to allow the endometrium to
regenerate.
Drainage of hydrosalpinx: It is seen that fluid from
hydrosalpinx impairs implantation. Hence, drainage of
hydrosalpinx or salpingectomy should be performed
laparoscopically prior to ART procedures.46 In cases with dense
Ch-15.indd 252 18-01-2014 12:17:11

peritubal adhesions, e.g. genital kochs, tubal delinking at the
cornual end will prevent the backflow of hydrosalpinx fluid.
Medical Treatment of Endometritis

Treatment of endometritis is a must. If tubercular etiology is
present, antitubercular treatment is given. In case of chronic
nonspecific endometritis, it is imperative to identify the
organism by an endometrial culture and give antimicrobial
therapy accordingly. In case biopsy shows chronic non-
specific endometritis but culture is negative, a course of
metronidazole and azithromycin is given. Often these
infections are difficult to eradicate and antibiotics may be
needed for a longer period. The response to treatment is seen
in 50%.
Treatment of other Hormonal Pathologies

Hyperprolactinemia is treated with dopamine agonists.
Hyperandrogenemia is treated with antiandrogenic drugs.
This may improve endometrial receptivity.
Endometrial Preparation for

Frozen Embryo Transfer
Many regimes have been used for endometrial preparation
in donor oocytes or frozen ET. Estradiol supplementation
is started with 2 mg/twice a day and increased up to 2
mg/thrice a day depending on endometrial response.
17 beta-estradiol transdermal patches at steadily increasing
dosage from 100 to 300 µg have been given for at least 12
days. This was increased by 100 µg after 7 days.
A recent Cochrane review showed no difference in
pregnancy rate when no treatment was compared to
Ch-15.indd 253 18-01-2014 12:17:11

aspirin, steroids, ovarian stimulation, or human chorionic

gonadotropin (hCG) prior to embryo transfer. No significant
benefit for using GnRH agonists was found. Starting
progesterone on the day of oocyte pick-up (OPU) or the day
after OPU produced a significantly higher pregnancy rate
than when recipients started progesterone the day prior to
OPU. So there is insufficient evidence to recommend any one
particular protocol for endometrial preparation over another
with regard to pregnancy rates after embryo transfers.47
It is important for a successful pregnancy to have a good
endometrium. Preparation of the endometrium involves a
systematic interplay of hormones, cytokines, growth factors
and many as yet unidentified molecules. Diagnostic tests for
endometrial quality have limitations (Fig. 15.2). There are
a number of biomarkers suggested but none of them is an
undisputed biomarker. Improving endometrial quality can
be challenging. Many suggested therapies are still empirical.
Considerable research is ongoing in this area.
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clinical review of cases from 2002 to 2007. Int J Gynecol
Pathol. 2010;29(1):44-50.
33. Cicinelli E, De Ziegler D, Nicoletti R, Tinelli R, Saliani N, Resta
L, et al. Poor reliability of vaginal and endocervical cultures for
evaluating microbiology of endometrial cavity in women with
chronic endometritis. Gynecol Obstet Invest. 2009;68(2):108-15.
34. Küçük T, Safali M. ”Chromohysteroscopy” for evaluation of
endometrium in recurrent in vitro fertilization failure. J Assist
Reprod Genet. 2008;25(2-3):79-82.
35. Park DW, Lee HJ, Park CW, Hong SR, Kwak-Kim
J, Yang KM. Peripheral blood NK cells reflect changes in
decidual NK cells in women with recurrent miscarriages. Am J
Reprod Immunol. 2010;63(2):173-80.
Ch-15.indd 257 18-01-2014 12:17:12

36. Elkind-Hirsch KE, Phillips K, Bello SM, McNicho M, de Ziegler

D. Sequential hormonal supplementation with vaginal estradiol
and progesterone gel corrects the effect of clomiphene on
the endometrium in oligo-ovulatory women. Hum Reprod.
2002;17(2):295.
37. Zhao M, Chang C, Liu Z, Chen LM, Chen Q. Treatment
with low-dose aspirin increased the level LIF and integrin
b3 expression in mice during the implantation window.
Placenta. 2010;31(12):1101-5.
38. Sher G, Fisch JD. Effect of vaginal sildenafil on the outcome of
in vitro fertilization (IVF) after multiple IVF failures attributed to
poor endometrial development Fertil Steril. 2002;78(5):1073-6.
39. Ohl J, Lafebvre-Maunoury C, Wittemer C, Nisand G, Laurent
MC, Hoffman P. Nitric oxide donors for patients undergoing
IVF: A prospective, double blind, randomised, placebo
controlled trial. Hum Reprod. 2002;17(10):2615-20.
40. Battaglia C, Salvatori M, Maxia N, Petraglia F, Facchinetti F,
Volpe A. Adjuvant L-arginine treatment for in vitro fertilisation
in poor responder patients. Hum Reprod. 1999;14(7):1690-7.
41. Sher J, Salazer C. Clinical experience with IVIg treatment in
patients with failed IVF pregnancies:report of 30 consecutive
patients. Am J Reprod Immunol. 2000;44(2):121-4.
42. van den Heuvel MJ, Peralta CG, Hatta K, Han VK, Clark
DA. Decline in number of elevated blood CD3(+) CD56(+)
NKT cells in response to intravenous immunoglobulin
treatment correlates with successful pregnancy. Am J Reprod
Immunol. 2007;58(5):447-59.
43. Kuhn U, Campo R, Hinney B, Neumeyer H, Criel A, Gordts S,
et al. Immunization with paternal lymphocytes: improvement
of pregnancy rate in sterility patients (Article in German). Z
Gerburtshilfe Perinatol. 1993;197(5);209-14.
44. Porter TF, LaCoursiere Y, Scott JR. Immunotherapy for recurrent
miscarriage. Cochrane Database of Systematic Reviews. 2006,
Issue 2. Art. No.: CD000112. DOI: 10.1002/14651858.
CD000112.pub2
Ch-15.indd 258 18-01-2014 12:17:12

45. Dal Prato L, Borini A. Effect of piroxicam administration before
embryo transfer on IVF outcome: a randomized controlled
trial. Reprod Biomed Online. 2009;19(4):604-9.
46. Li L, Xu BF, Chen QJ, Sun XX. Effects of hydrosalpinx on
pinopodes, leukaemia inhibitory factor, integrin beta3 and
MUC1 expression in the peri-implantation endometrium. Eur J
Obstet Gynecol Reprod Biol. 2010;151(2):171-5.
47. Glujovsky D, Pesce R, Fiszbajn G, Sueldo C, Hart RJ, Ciapponi
A. Endometrial preparation for women undergoing embryo
transfer with frozen embryos or embryos derived from donor
oocytes. Cochrane Database Syst Rev. 2010;(1):CD006359.
Ch-15.indd 259 18-01-2014 12:17:12

cHAPTER
16
Luteal Phase Defect
Surveen Ghumman, Neerja Goel
Luteal phase defect has remained a disorder of controversy

since its description as a clinical entity by Jones in 1949.1
Luteal phase defect is characterized by inadequate endo
metrial maturation due to a qualitative or quantitative disorder
in corpus luteum function.
Progesterone secreted by the corpus luteum is essential
for the initiation and maintenance of normal gestation.
Luteal support remains essential till about the seventh week
of gestation, by that time the trophoblast acquires sufficient
steroidogenic capacity to support the pregnancy. When preg
nancy occurs chorionic gonadotropins are responsible for the
prolongation of corpus luteum function. Normal formation
and function of the corpus luteum and optimal endometrial
preparation is a prerequisite for both nidation and normal
progress of early pregnancy. This is dependent on normal
follicular and ovulatory phase endocrine events.
Pathophysiologic Mechanism
During folliculogenesis, there is a complex interplay between
GnRH pulsatile patterns, FSH release and activity within the
Ch-16.indd 260 18-01-2014 12:17:51

Luteal Phase Defect 261
growing follicle, and peripheral steroid feedback. Disturbance
in any of these factors leads to possible mechanisms for
development of luteal phase defect (Fig. 16.1).
It was observed that there was a significantly low
progesterone receptor content on endometrial glandular
nucleus in luteal phase defect group. This resulted in a
deficient endometrial response to progesterone stimulus.
The result is a poorly prepared endometrium either due to
inadequate progesterone receptor induction during the folli
cular phase or insufficient peripheral progesterone levels
reaching the endometrium from the ovary leading to abnormal
implantation or early pregnancy wastage.2
Why Luteal Support is needed in ART Cycles?

1. Supraphysiological estrogen levels seen in controlled
ovarian hyperstimulation protocols may induce premature
luteolysis.
Fig. 16.1: Pathophysiology of luteal phase defect
Ch-16.indd 261 18-01-2014 12:17:51

2. Follicular phase downregulation may impair luteal phase

luteinizing hormone release.
3. Some protocols may give only pure FSH thus, leading to a
relatively low LH value.
4. Ovarian aspiration may cause disruption of granulosa
cells leading to aberrant steroidogenesis.
5. Controlled ovarian stimulation accelerates endometrial
maturation hindering implantation.
The ability of the endometrium to respond to progesterone
is an acquired property depending on the induction of
adequate progesterone receptors by estradiol during the
follicular phase of the cycle.
Hence, there is a concern in IVF/ICSI cycles of luteal
phase defect and luteal phase is supported by progesterone,
hCG, sometimes estradiol as a routine. Recently, single dose
of GnRH agonist has also been tried.
Diagnosis of Luteal Phase Inadequacy

In general, a deficient luteal phase will be found in less than
10% of women who seek evaluation for infertility. It is mostly
seen in:
1. Hyperprolactinemia.3
2. Elevated circulating androgens.
3. Oligo-ovulation.
4. Extremes of reproductive age.
5. Treatment with ovulation inducing agents or ovarian
suppressive agents.
6. Patients with history of recurrent abortion.
7. Endometriosis.4
8. Following discontinuation of suppressive medical
therapies.
9. Strenuous exercise.
Ch-16.indd 262 18-01-2014 12:17:51

Diagnosis is based on endometrial histopathology,
basal body temperature, low luteal progesterone levels
and transvaginal sonography. There are other tests like
decidual prolactin, steroid receptor studies and endometrial
biochemical markers that can be done (Table 16.1).
Endometrial Biopsy
Two endometrial biopsies out of phase by 2 days obtained
in 2 consecutive cycles are diagnostic of luteal phase defect.
However, endometrial biopsy has a large interobserver error.
Biopsy sites can also cause inconsistencies in findings.
Basal Body Temperature

It was seen that if a suspicious but ovulatory basal body
temperature was present, a luteal phase defect was found
Table 16.1: Techniques for diagnosis of luteal phase defects

1. Basal body temperature charts—monophasic or rise of temprature
for less than 11 days
2. Luteal phase progesterone levels—less than 10 ng/ml
3. Transvaginal ultrasonography and Doppler studies
Sonographic evidence of aberrant luteolysis
i. Persistent perifollicular reaction
ii. Rupture of follicle of <17 mm
iii. Poorly formed or ill-defined dominant follicle
iv. Luteinized unruptured follicle
v. Lutein cyst formation
vi. Absence of corpus luteum
vii. Lack of endometrial echogenicity on 7th postovulation day
4. Endometrial biopsy and histopathology—lag of 2 days
5. Serum prolactin measurement
6. Decidual prolactin measurement4
7. Steroid hormone receptor analysis
8. Biochemical markers for endometrial receptivity
Ch-16.indd 263 18-01-2014 12:17:51

in 80% cases on biopsy. If luteal phase is shorter than 11

days it correlates with a 6.25 days endometrial histological
lag.5 Ovulation occurring on day 18 to 19 correlates with
poor follicular progression, premature LH surge, equivocal
progesterone levels and biopsy specimens with glands and
stroma out of phase.
Low Progesterone Levels in Luteal Phase

More than 3 ng/ml of progesterone signifies ovulation.
However, a level of more than 10 ng/ml is needed for
adequate luteal support. Since there is pulsatatility of
progesterone release these values cannot be depended upon.
Color and Pulsed Doppler Ultrasound

It is being used for diagnosis of luteal phase defect.
Significantly lower resistance indices were seen in the
uterine, arcuate, radial, and spiral arteries of the ovulatory
group in the mid-luteal phase, which was inversely related to
the progesterone level.6 Blood flow impedance in the corpus
luteum and spiral arterioles is used to assess luteal adequacy.
Sonographic criteria for aberrant luteolysis is shown in Table
16.1 (see Chapter 14).
Treatment of Luteal Phase Defect

Treatment is considered by allaying the factors responsible
like hyperprolactinemia, uterine septum, etc and addition of
progesterone (Fig. 16.2). The therapy is broadly categorized
into two:
1. Increasing progesterone levels
a. Progesterone supplementation
b. hCG
Ch-16.indd 264 18-01-2014 12:17:51

Fig. 16.2: Management of luteal phase defect
Ch-16.indd 265 18-01-2014 12:17:52

2. Improving folliculogenesis
a. Clomiphene
b. Human menopausal gonadotropins
Progesterone Supplementation
Progesterone or its derivative is the treatment of choice
because of effective endometrial decidualization with
no teratogenicity. Initiation of progesterone therapy after
missing menses is not adequate, because the nidation site
has not been properly prepared. Hence, in patients of luteal
inadequacy progesterone supplementation should commence
after ovulation so as to avoid early abortion. Progesterone
supplementation is continued till 10 weeks of gestation
as at this time placenta takes over the role of progesterone
production.
Micronized Progesterone
Micronized progesterone can be given orally, vaginally or
parenterally.
Oral Administration: Though progesterone is absorbed orally,
more than 90% is metabolized during the first hepatic pass
limiting its efficacy. Many micronized forms have become
available to overcome this problem. Micronization in
combination with lipophilic vehicles enhances absorption.
Metabolites of orally administered progesterone may produce
a hypnotic effect.7
Vaginal Administration: There is increased bioavailability
and reduced variability when progesterone is given
vaginally or rectally compared to oral route. This sustained
level produces a more physiologic endometrial response.
Micronized progesterone may exert a direct effect on the
uterus by blocking the rejection of the embryo. It does not
cause drowsiness or sleepiness but is inconvenient because of
Ch-16.indd 266 18-01-2014 12:17:52

vaginal discharge. Patient is advised the use of progesterone
vaginal suppositories after ovulation is confirmed. In a
dose of 200 to 400 mg per day in two divided doses. This
produces concentration similar to the luteal phase that is
maximal within 1 to 8 hours and decrease over 24 hours.
Vaginal gel also produces endometrial response as good or
better than the intramuscular route.8 Pregnancy outcomes
were comparable for progesterone replacement with vaginal
gel and intramuscular progesterone in an oocyte donation
program.9 A polysyloxane vaginal ring containing 1 gram of
natural progesterone has been tried in IVF patients. It provides
a continuous release of 10 to 20 nmol/L for 90 days.10 There
has been increasing evidence of preferential drug distribution
to the uterus after vaginal application. This is called the ‘first
uterine pass effect’. The mechanism of uterine tropism of
vaginal progesterone can be explained by various theories.11
1. Passive diffusion through the tissues.
2. Passage through the cervical canal.
3. Absorption through venous or lymphatic systems.
4. Countercurrent transport between fluids flowing in
opposite directions.
Advantages of Vaginal Administration: Convenience and
acceptability and a high tissue level making it unnecessary to
monitor serum progesterone levels.
Intramuscular Administration: It is the most reliable
route to achieve desired concentration of progesterone. It
is rapidly absorbed and peak level is reached in 8 hours.
Serum progesterone levels remain sustained compared to
other routes as it is administered in an oil vehicle. It has the
disadvantage of inconvenience of daily injections and pain or
abscess formation at injection site. Allergic reactions may be
seen. Intramuscular dose is 50 to 100 mg per day.
Ch-16.indd 267 18-01-2014 12:17:52

Dehydrogesterone
It is a retroprogesterone or stereoisomer of progesterone. It is
closest to native progesterone. It was found that pregnancy
and implantation rate was similar whether progesterone or
dehydrogesterone was given in the luteal phase following IVF
and ET. It is given in a dose of 20 to 30 mg/day.12
Synthetic Progestational Agents

These should not be used to treat luteal phase inadequacy
as they may have a luteolytic effect on the corpus luteum
and can produce glandular stromal disparity, worsening the
situation.13 Use of 19-nor-progestins is contraindicated in
early pregnancy as it can masculinize a female fetus and may
cause cardiovascular and limb defects.
Results
Supplementation has proven effective in correcting abnormal
endometrial histology in more than 80% of these cases.
Pregnancy rates in treated infertile patients with luteal phase
inadequacy have ranged from 50 to 80%.14
Human Chorionic Gonadotropin (hCG)

Administration of hCG stimulates the corpus luteum to
produce progesterone. It is ineffective in the presence of
inadequate number of LH receptors or a malfunctioning corpus
luteum, which is hyporesponsive to hCG. hCG is effective
if there is a specific defect in postovulatory LH secretion
or in trophoblastic hCG production. The steroidogenic
response differs with timing of hCG. If given at LH surge
there is no increase in E2 or progesterone concentration.
Ch-16.indd 268 18-01-2014 12:17:52

Given on luteal day 5 it produces a marked steroidogenic
response that remains throughout luteal phase. In mid-luteal
phase on administration of hCG, progesterone levels reach
early pregnancy levels but are not sustained. In late luteal
phase progesterone response is shorter. This uncertainty of
response, injectable mode of administration and difficulty in
interpreting a positive pregnancy test prevent it from being
the first choice of therapy. As hCG has a longer half-life than
LH, it is advantageous in treating inadequate luteal function.
In order to achieve complete luteinization of the preovulatory
follicle, 10,000 IU of hCG should be administered at the
time of ovulation followed by a dose of 2500 IU every 3 to
4 days. Treatment is stopped after the 12th postovulatory day
to avoid a high incidence of psuedopregnancy and with the
assumption that if pregnancy is achieved exogenous hCG
should no longer be necessary. The long half-life of hCG
renders pregnancy testing invalid for 7 days after the last hCG
injection.
Estradiol Supplementation in luteal Phase

Supplementation in the luteal phase with different doses of
estradiol is being used in doses of 2 mg, 4 mg and 6 mg/day.
In initial studies conducted significantly higher implantation
rate and pregnancy rate were recorded in those who
received low dose E2 supplementation compared with no
substitution (PR 23.1% vs 32.8%). The best implantation and
pregnancy results were found in the group with high dose
E2 supplementation (PR 51.3%).15 However, more recent
studies showed no difference in terms of number of oocytes
retrieved, embryos transferred, pregnancy and implantation
rates.16
Ch-16.indd 269 18-01-2014 12:17:52

GnRH Agonist in the luteal Phase

Single dose: The exact mechanism is still not known. It was
suggested that GnRH agonist can help in the maintenance
of the corpus luteum, acting directly on the endometrium
via local receptors, a direct effect on the embryos or by
some combination of these possibilities. A single dose
of GnRH agonist (0.5 mg leuprolide acetate) was administered
subcutaneously on day 6 after ICSI. A meta-analysis
showed that the luteal-phase single-dose GnRH-agonist
administration can increase implantation rate in all cycles
and clinical pregnancy rate and ongoing pregnancy rate in
cycles with GnRH antagonist ovarian stimulation protocol.17
GnRH agonist addition during the luteal phase significantly
increases the probability of live birthrates.18
Multiple dose: 200 mg intranasal buserelin followed
by 100 mg every day or alternate day up to day 14 of the
luteal phase is given in multiple dose protocol. Intranasal
administration of buserelin could be effective in triggering
ovulation and in providing luteal support. This treatment was
associated with a good pregnancy rate (28%) with IUI.19
How long Should luteal phase Support Continue?

A study showed that after FSH/GnRH antagonist cycles,
the withdrawal of progesterone supplementation in early
pregnancy, with normally increasing β-hCG levels on the 16th
day postembryo transfer, had no significant clinical impact in
terms of ongoing pregnancy rates beyond 12 weeks. When
comparing the groups where progesterone was continued till
7 weeks to that when it was stopped at 16th day, the ongoing
pregnancy rate beyond 12 weeks was 82% versus 73%,
abortion before or after 7 weeks of gestation 9% versus 12%,
Ch-16.indd 270 18-01-2014 12:17:52

and 8% versus 10%, and bleeding episodes were14% versus
19%.20
Which is the Most Appropriate luteal Support?

A recent Cochrane review 2011 showed a significant effect
in favor of progesterone for luteal phase support. Overall, the
addition of other substances such as estrogen or hCG did not
seem to improve outcomes. No evidence favoring a specific
route or duration of administration of progesterone was
identified. hCG, or hCG with progesterone, was associated
with a higher risk of OHSS and should therefore be avoided.
There were significant results showing a benefit from addition
of GnRH agonist to progesterone for the outcomes of live
birth, clinical pregnancy and ongoing pregnancy. The review
concluded that progesterone seems to be the best option as
luteal phase support.21
Stimulation of Folliculogenesis
The ability of the endometrium to respond to progesterone is
an acquired property depending on the induction of adequate
progesterone receptors by estradiol during the follicular phase
of the cycle. Patients who do not respond to progesterone
supplementation may be having inadequate progesterone
receptors. Therapy aimed at improving folliculogenesis may
promote endometrial receptively, thus providing luteal phase
adequacy.
Clomiphene Citrate
It has been seen that the functional capacity of the corpus
luteum is dependent upon the normal growth and maturation
of the preovulatory follicle. Emergence of dominant ovarian
follicle, proliferation of granulosa layer, induction of LH
Ch-16.indd 271 18-01-2014 12:17:52

receptors, endometrial proliferation, progesterone receptors

induction and finally stimulation of the LH surge itself are all
important prerequisites of the follicular phase for subsequent
normal luteal function. Downs and Gibson have shown
that the therapeutic efficacy of clomiphene appears directly
related to the magnitude of the luteal defect.22
Despite reports of its efficacy in the treatment of luteal
phase defect some authors regard such use of clomiphene
as inappropriate due to the deleterious influence of the drug
at the ovarian, endocervical and endometrial levels. On the
endometrial level, clomiphene interferes with induction of
endometrial progesterone receptors and limits the population
of receptors ultimately available for a good endometrial
secretory response. This predisposes to delay in endometrial
maturation that could be recognized as a luteal phase defect.
The higher luteal phase E2 levels that frequently occur in
clomiphene treated cycles may also interfere with the process
of endometrial decidualization. It has been seen that after
repeated administration, a significant amount of clomiphene
is retained in the circulation thus interfering with estrogen
induced progesterone receptor replenishment during the
luteal phase. Thus, the treatment that has been successfully
initiated with clomiphene may require further treatment in
the luteal phase as there is no guarantee of continued normal
luteal function. Thus, it is clear that optimal use of clomiphene
citrate requires careful titration to establish the dose that will
produce the desired effects.
Human Menopausal Gonadotropins (hMG)

hMG can be used in treating luteal phase inadequacy by
directly stimulating folliculogenesis. It is expensive and carries
risks of multiple pregnancy and ovarian hyperstimulation. It is
only used if previous trials with clomiphene and progesterone
Ch-16.indd 272 18-01-2014 12:17:52

prove unsuccessful. However, Check et al treated infertile
patients of luteal phase defect with ultra low dose of 75 IU
and showed that this regimen was effective in correcting
infertility related to luteal phase defect because of follicular
maturation defects.23
Luteal phase defect is an important cause of infertility
and recurrent pregnancy loss. Treatment of luteal phase
inadequacy is aimed at correcting identifiable disorders
(such as hyperprolactinemia or a uterine septum), stimulating
folliculogenesis or corpus luteum function, or providing end
product (progesterone) replacement. Natural progesterone is
the drug of choice for supplementation with intramuscular or
vaginal route being equally effective.
References
1. Jones GES. Some newer aspects of the management of
infertility. JAMA. 1949;141:1123-9.
2. Jacobs MH, Balasch J, Gonzalez-Merlo JM, Vanrell JA,
Wheeler C, Strauss JF 3rd, et al. Endometrial cytosolic and
nuclear progesterone receptors in the luteal phase defect. J
3. Garzia E, Borgato S, Cozzi V, Doi P, Bulfamante G, Persani L, et
al. Lack of expression of endometrial prolactin in early implan
tation failure: A pilot study. Hum Reprod. 2004;19(8):1911-6.
4. Cunha-Filho JS, Gross JL, Bastos de Souza CA, Lemos NA,
Giugliani C, Freitas F, et al. Physiopathological aspects of
corpus luteum defect in infertile patients with mild/minimal
endometriosis. J Assist Reprod Genet. 2003;20(3):117-21.
5. Downs K, Gibson M. Basal body temperature graph and the
luteal phase defect. Fertil Steril. 1983;40:466-8.
6. Dal J, Vural B, Caliskan E, Ozkan S, Yucesoy I. Power Doppler
ultrasound studies of ovarian, uterine, and endometrial blood
flow in regularly menstruating women with respect to luteal
phase defects. Fertil Steril. 2005;84(1):224-7.
Ch-16.indd 273 18-01-2014 12:17:52

7. Arafat ES, Hargroove JT Maxson WS, Desiderio DM, Wentz

AC, Anderson RN. Sedative and hypnotic effects of oral
administration of micronized progesterone may be mediated
through its metabolites. Am J Obstet Gynecol. 1988;159:1203-9.
8. Gibson WE, Toner JP, Hamacher P, Kolm P. Experience with
a novel vaginal progesterone preparation in a donor oocyte
program. Fertil Steril. 1998;69:96-101.
9. Berger BM, Phillips JA. Pregnancy outcomes in oocyte donation
recipients: vaginal gel versus intramuscular injection progesterone
replacement. J Assist Reprod Genet. 2012;29(3):237-42.
10. Zegers-Hochschild F, Balmaceda JP, Fabres C, Alam V, Mackenna
A, Fernandez E, et al. Prospective randomised trial to evaluate
the efficiency of a vaginal ring releasing progesterone for IVF and
oocyte donation. Hum Reprod. 2000;15(10):2093-7.
11. Cicinelli E, Borraccino V, Petruzzi D, et al. Pharmacodynamics
and endometrial effects of the vaginal administration
of unmodified progesterone in an oil based solution to
postmenopausal women. Fertil Steril. 1996;65:860-2.
12. Ganesh A, Chakravorty N, Mukherjee R, Goswami
S, Chaudhury K, Chakravarty B. Comparison of oral
dydrogestrone with progesterone gel and micronized
progesterone for luteal support in 1,373 women undergoing
in vitro fertilization: a randomized clinical study. Fertil
Steril. 2011;95(6):1961-5.
13. Allenbach M, Hellnig G. The endometrium in natural and
artificial luteal phase. Human Reprod. 1988;3:165-68.
14. Wentz AC, Herbert CM, Maxon WS, Gernier CH. Outcome of
progesterone treatment of luteal phase inadequacy. Fertil steril.
1984;41(6):856-62.
15. Lukaszuk K, Liss J, Lukaszuk M, Maj B. Optimization of
estradiol supplementation during the luteal phase improves the
pregnancy rate in women undergoing in vitro fertilization-embryo
transfer cycles. Fertil Steril. 2005;83(5):1372-6.
16. Tonguc E, Var T, Ozyer S, Citil A, Dogan M. Estradiol
supplementation during the luteal phase of in vitro fertilization
cycles: a prospective randomised study. Eur J Obstet Gynecol
Reprod Biol. 2011;154(2):172-6.
Ch-16.indd 274 18-01-2014 12:17:52

17. Oliveira JBA, Baruffi R, Petersen CG, Mauri AL, Cavagna
M, Franco JG Jr. Administration of single-dose GnRH agonist in
the luteal phase in ICSI cycles: a meta-analysis. Reprod Biol
18. Kyrou D, Kolibianakis EM, Fatemi HM, Tarlatzi TB, Devroey
P, Tarlatzis BC. Increased live birthrates with GnRH agonist addition
for luteal support in ICSI/IVF cycles: a systematic review and meta-
analysis. Hum Reprod Update. 2011;17(6):734-40.
19. Pirard C, Donnez J, Loumaye E. GnRH agonist as novel luteal
support: results of a randomized, parallel group, feasibility
study using intranasal administration of buserelin. Hum
Reprod. 2005;20(7):1798-804.
20. Kyrou D, Fatemi HM, Zepiridis L, Riva A, Papanikolaou
EG, Tarlatzis BC, Devroey P. Does cessation of progesterone
supplementation during early pregnancy in patients treated with
recFSH/GnRH antagonist affect ongoing pregnancy rates? A
randomized controlled trial. Hum Reprod. 2011;26(5):1020-4.
21. van der Linden M, Buckingham K, Farquhar C, Kremer
JA, Metwally M. Luteal phase support for assisted
reproduction cycles. Cochrane Database Syst Rev. 2011 Oct
5;(10):CD009154.
22. Downs KA, Gibson M. Clomiphene citrate therapy for luteal
phase defects. Fertil Steril. 1983;39(1):34-8.
23. Check JH, Fine W. Similar pregnancy and abortion rates after
treatment with low dose hMG versus pure FSH in women with
luteal phase defect. Clin Exp Obstet Gynecol. 1997;24(1):5-7.
Ch-16.indd 275 18-01-2014 12:17:52

cHAPTER
17
Complications of
Ovulation Induction
Surveen Ghumman
With increasing progress in ovulation induction strategies

the indication for their use have expanded. As the result of
this we are dealing with an increasingly growing population
facing the complications of these therapies. Adverse effects
of ovarian stimulation may be divided into immediate and
delayed effects.
Immediate Effects
1. Drug specific side effects.
2. Effects of ovarian overstimulation
• Multiple pregnancy
• Ovarian hyperstimulation syndrome.
Long-term Problems
1. Risk of ovarian cancer.
The drug specific side effects have been dealt with in
previous chapters. This chapter deals with ovarian hyper
stimulation syndrome, multiple pregnancy and risk of ovarian
cancer.
Ch-17.indd 276 18-01-2014 12:21:23

Complications of Ovulation Induction 277
Ovarian Hyperstimulation Syndrome

Ovarian hyperstimulation syndrome (OHSS) is one of the
known complications of controlled ovarian stimulation. It is
a syndrome with a wide spectrum of clinical and laboratory
symptoms and sign, due to a fluid shift from the intravascular to
the third space because of increased intravascular permeability,
manifesting as ascites, pleural effusion, hemoconcentration,
oliguria, electrolyte imbalance and hypercoagulability. It is
accompanied by ovarian enlargement.
Incidence
OHSS is classified as mild, moderate and severe with the
incidence ranging from 3 – 23% of inductions.1 The incidence
varies with the ovarian stimulation protocols and the risk
profile of the population being treated.
• Mild OHSS : 8–23%
• Moderate OHSS : 0.005–7%
• Severe : 0.005–2%
It occurred in 0.008 to 23% of hMG/hCG cycles and 0.6
to 14% in GnRH–a/hMG/hCG cycle.
Classification
It presents after hCG administration or rise of hCG due to an
early pregnancy. It can be ‘early onset’, within 3–7 days of
hCG administration, or ‘late onset’ 12 to 17 days after hCG
because of early pregnancy.
1. Golan’s Classification: Golan proposed an acceptable
classification with greater practical advantages (Table
17.1). It incorporates clinical signs, symptoms,
ultrasonographic findings and laboratory findings to yield
three stages and five grades of OHSS severity.2
Ch-17.indd 277 18-01-2014 12:21:23

Table 17.1: Golan’s classification of OHSS2

Grade Mild Moderate Severe
1. Abdominal
discomfort/
distension
2. Features of grade 1
along with nausea,
vomiting and/or
diarrhea. Ovaries
enlarged 5–12 cm
3. Features of mild
OHSS and USG
evidence of
ascites
4. Feature of moderate
OHSS plus clinical
evidence of ascites and/
or hydrothorax with/or
difficulty in breathing
5. All of the above plus
change in blood
volume, increased
blood viscosity due to
hemoconcentration,
coagulation
disturbances and
diminished renal
perfusion and function
2. Navot’s Classification (Table 17.2): This classification

further defined the severest degree of OHSS as given by
Golan into severe and critical life-threatening stage based
on a multitude of clinical and biochemical findings.3 In
this classification generalized edema and liver dysfunction
are considered additional signs of severe OHSS whereas
adult respiratory distress syndrome, a tense ascitis, severe
Ch-17.indd 278 18-01-2014 12:21:23

Table 17.2: Clinical signs and laboratory criteria of ovarian

hyperstimulation syndrome3
Mild to moderate Severe Critical
Ovarian enlargement 5–12 cm >12 cm Variable
Abdominal Moderate Severe Tense
distension
Clinical ascitis None Yes Tense
Hydrothorax None Possible Yes
Pericardial effusion None Infrequent Infrequent
Decreased renal None Infrequent Frequent
function
Renal failure None None Possible
Thromboembolism None None Possible
ARDS None None Possible
Hemoconcentration <45% 45–55% >55%
(hematocrit)
WBC count <15,000 15,000–25,000 >25,000
Liver enzymes Normal Elevated Elevated
Creatinine (ng/ml) <1.0 1.0–1.5 >1.6
Creatinine clearance >100 50–100 <50
(ml/min)
hemoconcentration (>55%) and profound leukocytosis

(>25,000) are signs of the severest life-threatening form
and need aggressive medical and surgical intervention.
Pathophysiology of Ovarian Hyperstimulation

Syndrome
The complicated pathophysiology of OHSS has still yet not
been completely elucidated.
Ch-17.indd 279 18-01-2014 12:21:23

Two major events are, however, recognized.

1. Neovascularization: Neovascularization leads to increased
vascularity.
2. Increased vascular permeability of mesothelial surfaces:
The increased capillary permeability of the ovarian vessels
and other mesothelial surfaces leads to acute fluid shift
to the third space (Fig. 17.I). This is triggered by release
of vasoactive substances secreted by the ovary under the
influence of hCG. These are prorenin and active renins,
interleukins, nitric oxide, and vascular endothelial growth
factor.
Fig. 17.I: Pathophysiology of OHSS
Ch-17.indd 280 18-01-2014 12:21:24

Clinical Features
The clinical features associated with OHSS are due to the shift
of fluid into the third space by vascular permeability (Tables
17.1 and 17.2). The patient may have clinical features like:
• Lower abdominal pain and distension.
• Symptoms of nausea, vomiting and diarrhea.
• Progressive lethargy
• History of decreased urine output.
• Increased pulse rate, shortness of breath, fluid collection
at the base of lungs.
• Significant fluid electrolyte imbalance.
• Dehydration in severe cases.
• Hypercoagulability of blood causing thrombosis.
Fatal Complications
1. Vascular Complications: Venous compression due to enlarged
ovaries and ascitis, immobility and a state of hypercoagubility
causes deep vein thrombosis. Cerebrovascular complications
subsequent to thromboembolic phenomenon may lead to
hemiplegia and carotid artery embolism.
2. Liver Dysfunction: The increased permeability in hepatic
vasculature leads to edema, damage to hepatic cells and
altered hepatic function.These changes may persist for 60
days.
3. Respiratory Complications: Ascitis, pleural effusion and
ARDS are due to fluid shift into the third space.
4. Renal Complications: Prerenal failure occurs due to
hypovolemia secondary to fluid transudate.
5. Gastrointestinal Complications: Gastrointestinal symptoms
may be the initial symptoms a patient presents with, and
these help to diagnose the syndrome early.
6. Adnexal Torsion: The enlarged ovaries can undergo
torsion leading to an acute abdomen.
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Management of OHSS
The most effective treatment of OHSS is precise prediction
and active prevention. This can be done effectively with the
combined use of ultrasonography and serum estradiol levels.
Prevention
Identify Patients who are at High Risk

This is the first step in prevention (Table 17.3). Monitoring of
induction of ovulation is done to identify high-risk cases. A
number of factors are related to increased risk of OHSS:
1. Size and number of follicles: Women with a large
number of follicles (>15), decreased fraction of large
follicles and a high proportion of small and intermediate
size follicles, are more prone to OHSS.
Table 17.3: Risk factors for OHSS

Predicting factors High risk Low risk
Age Young (<35 years) Older (>36 years)
Cause of anovulation Polycystic ovarian Hypogonadotropic
disease hypogonadism
Build Asthenic habitus Heavy build
Number of follicles Multiple follicles Fewer follicles (<20)
(>35)
Ultrasonography of “Necklace” sign Absent
ovary present
Outcome of IVF cycle Pregnancy No pregnancy
Luteal supplementation hCG luteal Progesterone/no
supplementation supplementation
Ovulation induction GnRH agonist GnRH antagonist
protocol protocol protocol
History of OHSS Present Absent
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2. Serum estradiol: At serum estradiol levels of 4000 pg/
ml or above hCG is withheld though studies have even
quoted values above 3500 pg/ml.
3. Age: Young patients are more prone to develop OHSS.
4. Built: Thin patients are at higher risk of OHSS.
5. PCOS: At the start of the cycle PCOS patients have a large
number of small follicles that are all likely to respond
to the dose of gonadotropins once the FSH threshold is
reached. This would lead to hyperstimulation.
6. OHSS in previous cycle: A history of OHSS in previous
cycle, increases risk of recurrence in next cycle.
7. Protocol of ovarian stimulation: GnRH agonist protocol
has higher risk of OHSS compared with an antagonist
protocol.
8. Pregnancy: Patient who conceived, and more so with
multiple pregnancy, were more prone to OHSS.
9. Trigger for inducing follicular rupture: If hCG was
used as a trigger for follicular rupture there were higher
chances of OHSS.
10. Luteal support: With hCG as a luteal support, the
chances of development of OHSS were higher.
11. Basal anti-Mullerian hormone (AMH): The basal serum
AMH level predicted OHSS with a sensitivity of 90.5%
and specificity of 81.3%.4
Withholding hCG
The criterion for withholding hCG varies in different centers.
It is mostly based on more than one parameter like number
and size of follicles, estradiol levels, slope of rise of estradiol,
history of OHSS in previous cycle and presence of PCOS.
I. Level of estradiol: hCG is withheld when estradiol
levels are more than 3000 pg/ml. Incidence of severe
OHSS was 1% if serum estradiol levels are 3000 – 3999
pg/ml and it increases to 5.97% if the levels are more
Ch-17.indd 283 18-01-2014 12:21:24

than 4000 pg/ml. Hence, many prefer to take a cut-off

value of 4000 pg/ml. However, many cases of OHSS
can occur in normal estradiol levels and often, high
estradiol levels may lead to no overstimulation.5
Slope of rise of the plasma estradiol level: If values are
more than doubling during 2–3 days (steep slope) then it
should be regarded as a serious warning sign, and hCG
should be withheld in that cycle.
II. Number of follicles on ultrasonography: When there is
an increase in fraction of the small and intermediate size
follicles there was greater chance of OHSS developing.
Presence of 15–20 follicles that are mainly immature
(9 mm) should be taken as a cut-off. The final decision
must see multiple parameters.
Delaying hCG (Coasting)

hCG can be delayed and a GnRH agonist or an antagonist
can be started.
Agonist Coast: Withholding gonadotropins causes decreased
FSH that causes downregulation of LH receptors reducing
number of granulosa cell available for luteinization and
a concomitant decrease in vasoactive substances causing
OHSS. The optimum time to start coasting is when the lead
follicle reaches 16 mm in diameter and estradiol levels are
high. hCG is delayed, while GnRH agonist is continued
witholding hMG till E2 falls below 3,000 pg/ml. At this level
hCG is given. Longer period of coasting beyond 5 days, is
associated with lower pregnancy rates.6 However, coasting
for 1 or 2 days can be used successfully to prevent OHSS
without compromising IVF cycle outcome.7
Antagonist Coast: When a patient undergoing an IVF cycle
with long protocol is at high risk of severe OHSS, rescuing
the cycle by withdrawing the agonist and replacing it with
an antagonist and triggering ovulation with an agonist bolus
Ch-17.indd 284 18-01-2014 12:21:24

could be considered without jeopardizing the safety of the
patient while retaining the opportunity for success of the
cycle.9 Administration of daily GnRH antagonist in high-
risk patients for OHSS who were down-regulated by GnRHa
resulted in rapid drop of E2 and decrease in incidence of
OHSS.10
A recent Cochrane review has concluded that coasting with

GnRH agonist has no beneficial role in preventing OHSS.8
Decreasing Dose of hCG

Lower dosage may avoid hyperstimulation by exerting shorter
periods of stimulation. 5,000 IU of hCG is given instead of
10,000 IU as an ovulation trigger.
Use of GnRH Agonist as a Trigger

Since period of stimulation is lesser with GnRH agonist surge,
there is no hyperstimulation. The pregnancy rates are similar
after an agonist or hCG trigger.11 However, some studies
have reported a lower ongoing pregnancy rate after GnRHa
trigger.12
The excellent conception rates reported in recipients
receiving embryos originating from donor cycles or in women
receiving frozen embryos originating from fresh cycles during
which GnRHa was used to induce oocyte maturation suggest
that it does not adversely affect the quality of the oocyte
or embryo. A defective corpus luteum function resulting
from the relatively short endogenous luteinizing hormone
surge may be causing detrimental effects on endometrial
receptivity. Aggressive luteal phase support and monitoring
is, therefore, essential in view of the overwhelming evidence
suggestive of abnormal luteal phase steroid profile. This may
be achieved by the use of adequate estradiol and progesterone
Ch-17.indd 285 18-01-2014 12:21:24

supplementation in the luteal phase and the first trimester.13

After modified luteal support there is now a non-significant
difference of 6% in delivery rate in favor of hCG triggering.14
A recent Cochrane review (2011) recommends use on
GnRH agonist as ovulation trigger in patients at high risk of
OHSS.15
Luteal Phase Support

Progesterone, intravaginally or intramuscularly, is given for
luteal support instead of hCG when patients are at high risk
of OHSS.
Follicle Aspiration
Follicle aspiration was found to decrease the incidence of
OHSS.16 Hence, if women are showing signs of being at risk
of hyperstimulation, follicles should be aspirated.
Post-oocyte retrieval Albumin or

Hydroxyethyl Starch Administration
Albumin helps by increasing serum oncotic pressure and
reversing the leakage of fluid into the third space. Albumin
has a half-life of 10–15 days, and needs timely administration
at oocyte recovery, in a dose of 50 –100 g. The disadvantage is
its oncotic action lasts for less than 36 hours, following which
it moves into the interstitial compartment drawing fluid out
of the intravascular space. A recent Cochrane review (2011)
states there is limited benefit from intravenous albumin but
better results with hydroxyethyl starch in preventing OHSS.17
Cryopreservation of Embryo and Subsequent Replacement

OHSS decreases by the tenth day if no pregnancy occurs,
but continues for a longer time with viable pregnancy.
Ch-17.indd 286 18-01-2014 12:21:24

Cryopreservation of embryos helps decrease chances of
OHSS due to pregnancy. However, a recent Cochrane review
did not support this.18
Steroids
Methyl prednisolone has been tried in cases of OHSS.19
However, most studies have not shown a protective effect.
Step-up low Dose Regime of Gonadotropins

Low dose of gonadotropins are given in cases at high risk for
hyperstimulation like PCOS and gradually stepped up.
Metformin
Addition of metformin to ovulation induction regimen in
polycystic ovarian disease results in decreased incidence of
OHSS (Cochrane review 2009).20
Dopamine Agonists
The dopamine receptor 2 agonists cabergoline and bromocriptine
inactivate VEGF receptor-2 and prevent increased vascular
permeability.
Carbagoline: It is given in a dose of 0.5 mg/d administered
from the day of human chorionic gonadotropin for 8 days.21 It
is considered a safe and effective medication.
Bromocriptine: Bromocriptine also decreased incidence of
OHSS.22
Quinagolide: Quinagolide appears to prevent moderate/
severe early OHSS while not affecting treatment outcome. A
study showed an incidence of moderate/severe early OHSS
of 23% in the placebo group and 12%, 13% and 4%in the
quinagolide 50, 100 and 200 mg/day groups, respectively.23
Ch-17.indd 287 18-01-2014 12:21:24

Avoidance of Excessive Gonadotropin Stimulation

The only reliable way to eliminate the risk of ovarian
hyperstimulation syndrome (OHSS) is complete avoidance
of gonadotropin ovarian stimulation
i. Individualizing dose and low ovarian stimulation
protocols: The CONSORT (CONsistency in rFSH
Starting dOses for individualized tReatmenT) dosing
algorithm individualizes recombinant human follicle-
stimulating hormone doses for assisted reproduction
technologies, assigning 37.5 IU increments according
to easily available patient characteristics (basal follicle-
stimulating hormone, body mass index, age, and antral
follicle count) that have been proven to accurately
predict ovarian response to ovarian stimulation.24
ii. Natural cycle ART: IUI or IVF without ovarian stimulation
can lead to complete elimination of OHSS in high-risk
cases.
iii. IVM: IVM is a treatment option in many centres.
Although IVM may not replace standard IVF, it plays
an increasingly important role in assisted reproductive
technology, especially in the settings of high responders
and those patients at risk of OHSS.25
Investigation and Monitoring of an OHSS Patient

1. General Condition: General condition is monitored by
regular charting of vital signs, weight charts, abdominal girth
measurement and a strict fluid balance record (Table 17.4).
2. Biochemical tests: A complete biochemical assessment
includes hematocrit, electrolytes, liver function tests,
kidney function tests and coagulation profile. Blood gases
and acid-base balance is required if there is a respiratory
Ch-17.indd 288 18-01-2014 12:21:24

Table 17.4: Investigation and monitoring of OHSS patient

1. General condition: It is monitored by regular charting of:
a. Vital signs
b. Weight charts
c. Abdominal girth measurement
d. Strict intake output chart
2. Biochemical tests:
a. Hematocrit
b. Electrolytes
c. Liver function tests
d. Kidney function tests
e. Coagulation profile
f. Blood gases and acid-base balance
g. Serum bhcg to rule out pregnancy
3. Ultrasonographic examination: It is done to evaluate
a. Ovarian size
b. Amount of ascites
c. Presence of hydrothorax
d. Pregnancy, whether single or multiple
or renal compromise. Serum bhCG is done to rule out

pregnancy. Serum and urinary osmolarity and urinary
electrolytes may be needed in more severe forms of the
disease. The frequency of these tests is guided by the
severity of the disease.
3. Ultrasonographic examination: Ultrasound gives
important information on ovarian size, amount of ascites,
presence of hydrothorax or pericardial effusion, and
detection of pregnancy, whether single or multiple.
4. Chest X-ray: A chest X-ray can rule out pleural effusion.
5. Serun b-hCG: It is done to confirm pregnancy making the
women at a high risk for developing severe disease.
6. Invasive hemodynamic monitoring: When OHSS
becomes critical monitoring of pulmonary artery pressure
and central venous pressure may be required.
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Treatment
The condition usually resolves within 10–14 days. Treatment
is based on severity of the disease.
Mild OHSS
In mild cases the treatment is usually conservative and is
done at outpatient level with close follow-up.
Grade I
1. Reassure
2. Plenty of fluids
3. Avoid exertion
4. Counsel on warning signs.
Grade II
1. Serum electrolytes, hematocrit and ultrasonography
should be done.
2. Minimize physical activity and take plenty of fluids.
3. Analgesics and antiemetics may be used if required.
4. Intake output monitoring.
5. Drug Therapy:
i. Role of GnRH antagonists: If given on day 6 after oocyte
retrieval in women with OHSS 4 days, combined
with luteal phase support using exogenous estradiol
and progesterone OHSS regressed.26 In women on
antagonist regime, antagonist administration was re-
initiated if OHSS developed and continued daily for a
week, while all embryos were cryopreserved.
ii. Role of GnRH agonists. This resolved the OHSS.
A marked decrease of hematocrit (Ht), WBC count,
ovarian volume and ascitic fluid has been observed
during 1 week of follow-up.27
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iii. Carbogoline: Carbogoline is given as 0.5 mg/day.
It reduces hemoconcentration and ascites in hyper
stimulated women undergoing assisted reproduc
tion.28
Reassess if:
1. Increase in weight more than 2 kg.
2. Worsening of symptoms.
Indication of Hospitalization
Hospitalization should be considered in higher grades of the
disease or if condition worsens and patient is not responding
to treatment.
I. In cases of grade II or III admission is required, if there is:
1. Intolerable nausea and vomiting
2. Hypotension
3. Signs of pleural effusion
4. Ascitis
5. Hematocrit >48%
6. Potassium level >5.0 mg/L
7. Serum creatinine >1.2 mg
II. All cases of grade IV and V should be hospitalized.
Severe OHSS
Aim of therapy after admission:
1. Correction of circulatory volume electrolyte imbalance
2. Maintenance of renal function
3. Prevention of thrombosis.
1. Maintenance of intravascular volume and electrolyte
imbalance: The aim must be to restore normal intravascular
volume and preserve adequate renal function. Colloid
expander may be used for this purpose, but they have the
disadvantage that after a short while they redistribute into
the extravascular space worsening the ascitis. Low salt
albumin is the expander of choice and is given in a dose
Ch-17.indd 291 18-01-2014 12:21:24

of 50–100 gram every 2 to12 hours. It reverses hematocrit

changes, improves renal function and is safe from viral
contamination. Other options tried are mannitol, dextran
and fresh frozen plasma. Dextran can cause ARDS. Only
if there is hyponatremia, normal saline with or without
glucose is the crystalloid used for replacement. Up to 1.5
to 3 liters may be needed. Other electrolyte imbalances
like hyperkalemia are corrected.
2. Prevention of thrombosis: Low dose heparin should be
given, as prophylaxis, in cases where there is an altered
coagulation profile.
3. Diuretics: These drugs are usually not used but can be
given after hemodilution is achieved if oliguria is persisting
or in cases of pulmonary edema.
4. Dopamine: Dopamine may help to avoid fluid and salt
retention by improving the renal blood flow in oliguric
patient.
5. Management of ascitis: Paracentesis under ultrasound
guidance is done where there is severe discomfort,
compromise of venous return leading to a decreased
cardiac output and hypotension, renal compromise,
respiratory distress or hemoconcentration unresponsive to
medical therapy. Repeat aspiration may be required.
6. Paracentesis of hydrothorax: This should be done if
dyspnea is present because of severe pleural effusion.
Critical OHSS
Critical OHSS causes multisystem failure and requires
multidisciplinary intensive care.
1. Renal failure: Dopamine central venous pressure line and
hemodialysis may be required in severe cases.
2. Pulmonary compromise: Arterial blood gas monitoring,
thoracocentesis or assisted ventilation is required if they
do not respond to basic treatment.
Ch-17.indd 292 18-01-2014 12:21:24

3. Thromboembolic events: Patients with thromboembolic
episodes require therapeutic anticoagulation with heparin.
4. Termination of pregnancy: If critical condition does not
improve one may consider termination of pregnancy.
5. Laparotomy: Laparotomy is required if the cysts undergo
torsion, hemorrhage or rupture. Laparoscopic unwinding
can be done in cases of torsion.
OHSS is an iatrogenic complication of controlled ovarian
stimulation and may sometimes lead to life-threatening
complications. Prevention is the best way to manage OHSS.
Proper monitoring is essential and a balance between a
conservative and aggressive approach is ideal to prevent
unnecessary cycle cancelation.
Multiple Pregnancy
Multiple pregnancy may occur when ovulation induction is
done with clomiphene, GnRH agonists and gonadotropins
with an incidence of 5 to 10%, 7 to 10% and 16 to 40%,
respectively. The greater relative increase in incidence is more
with triplets and quadruplets (58%) compared to twins (18%).29
Multiple pregnancy causes increased incidence of preterm
delivery, preeclampsia and abnormal bleeding. Cerebral palsy
rates are 0.2% in singleton, 1.2% in twins and 4.5% in triplets.
Besides this there may be a social burden on the family in
bringing up twins. Fetal reduction is offered if there are triplets
or more. Transvaginal sonography guided reduction is done
at 8–9 weeks and transabdominally at 11 to 12 weeks with
aspiration of the gestational sac or injection of cardiotoxic
drug (KCl) into fetus. (see Chapter 13). The contribution of
superovulation and ovulation induction to the multiple
pregnancy epidemic is substantial.30 Strict guidelines should
be followed so as to minimize these multiple births. Close
monitoring is essential and presence of no more than 3 mature
Ch-17.indd 293 18-01-2014 12:21:24

follicles should be there for administration of hCG. Transfer

of more than 3 embryos in IVF cycle should be discouraged.
Ovarian Cancer and Ovulation Induction

Earlier studies suggested a three times increased risk of
ovarian cancer in women who had used ovulation inducing
drugs.31 There were reports of increased incidence of ovarian
epithelial dysplasia in relation to intake of ovulation induction
drugs in women who had later undergone hysterectomy
and bilateral oophorectomy.32 It is thought that epithelial
inclusion cysts formed at each ovulation are stimulated to
undergo malignant transformation by gonadotropins that
normally become elevated at menopause. This predicts that
agents which provoke multiple ovulation by gonadotropin
stimulation will increase the risk of ovarian cancer. An
alternative theory is that gonadotropins may not be mutagenic
but mitogenic (provoke a pre-existing tumor). It need not be
a causal relationship but a stimulation of an already existing
lesion. However, reports of large increases in ovarian cancer
risk associated with fertility medications have not been
replicated by more recent investigations.33 Some studies do
report an increased incidence of borderline ovarian tumors.34
This was seen particularly with hMG. The association was
not demonstrated with invasive tumors. No significant excess
risk was associated with treatment with ovulation induction.35
It should also be kept in mind that cancers are over
diagnosed in infertile women because of the close medical
surveillance, which may also contribute to the early detection
of cancers. However, it has been recommended that these
drugs should not be used for more than 6 cycles consecutively
and not more than a total of 12 cycles. It is therefore
appropriate to use the smallest doses of ovarian stimulation
for the shortest duration needed for clinical effectiveness.
Ch-17.indd 294 18-01-2014 12:21:24

Ovulation induction should be individualized to prevent
problems of OHSS and multiple pregnancy. High-risk women
should be kept under close surveillance. Women should be
counseled about these problems before starting treatment.
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GT, Alexopoulou E, et al. Live births after management of
severe OHSS by GnRH antagonist administration in the luteal
phase. Reprod Biomed Online. 2009;19(6):789-95.
27. Lainas TG, Sfontouris IA, Zorzovilis IZ, Petsas GK, Lainas
GT, Kolibianakis EM. Management of severe early ovarian
hyperstimulation syndrome by re-initiation of GnRH antagonist.
Ch-17.indd 297 18-01-2014 12:21:24

28. Alvarez C, Martí-Bonmatí L, Novella-Maestre E, Sanz R, Gómez

R, Fernández-Sánchez M, et al. Dopamine agonist cabergoline
reduces hemoconcentration and ascites in hyperstimulated
women undergoing assisted reproduction. J Clin Endocrinol
Metab. 2007;92(8):2931-7.
29. Hecht BR. The impact of assisted reproductive technology on
incidence of multiple gestation. In Keith LG, Papiernik E’Keith
DM, Luke B (Eds). Multiple Pregnancy London: Parthenon.
1995;175-90.
30. Legro RS. Superovulation and multiple birth: in search of
kryptonite. Fertil Steril. 2012;97(4):793-4.
31. Whittemore AS, Harris R, Itnyre J, Halpern J. Characteristics
related to ovarian cancer risk: collaborative analysis of 12
US case controlled studies. I Methods. Collaborative Ovarian
Cancer Group. Am J Epidemiol. 1992;136:1175-83.
32. Nieto JJ, Crow J, Sundaresan M, Constantinovici N, Perrett
CW, MacLean AB, et al. Ovarian epithelial dysplasia in
relation to ovulation induction and nulliparity. Gynecol Oncol.
2001;82(2):344-9.
33. Brinton LA, Moghissi KS, Scoccia B, Westhoff CL, Lamb EJ.
Ovulation induction and cancer risk. Fertil Steril. 2005;83(2):261-
74.
34. Ayhan A, Salman MC, Celik H, Dursun P, Ozyuncu O, Gultekin
M. Association between fertility drugs and gynaecologic
cancers, breast cancer, and childhood cancers. Acta Obstet
Gynecol Scand. 2004;83(12):1104-11.
35. Calderon-Margalit R, Friedlander Y, Yanetz R, Kleinhaus
K, Perrin MC, Manor O, et al. Cancer risk after exposure
to treatments for ovulation induction. Am J Epidemiol.
2009;169(3):365-75.
Ch-17.indd 298 18-01-2014 12:21:24

cHAPTER
18
Selective Multifetal
Pregnancy Reduction
Shweta Mittal, Deepak Chawla, Abha Majumdar
The incidence of multifetal pregnancies has increased

dramatically over the past two decades, mainly because of
the widespread use of ovulation induction agents and assisted
reproduction techniques.1 These techniques have been a
matter of concern since twin and higher order pregnancies
have long been associated with an increased risk of maternal
complications as well as a high prevalence of perinatal and
neonatal morbidity and mortality.
The most common complication is preterm delivery, with
twins having an average gestational age at delivery of 36 to
37 weeks; triplets, 34 weeks; quadruplets, 29 to 31 weeks,
and quintuplets, even earlier. In addition, researchers have
shown an increased incidence of low birth weight, gestational
diabetes mellitus, pregnancy-induced hypertension and
greater requirement of neonatal hospital admission with
multifetal pregnancy.
A couple has several options when faced with a multifetal
pregnancy.
Ch-18.indd 299 18-01-2014 12:21:42

1. They can electively terminate the multifetal pregnancy

with the intent to conceive again. Since the pregnancy
is most likely wanted, achieved at great psychological
and economic cost and with no guarantee of future con
ceptions, this option is usually the least desirable.
2. The couple can attempt to proceed with the pregnancy.
Even though there are reports of survival of some or all
quadruplets and quintuplets, there is still significant risk
of long-term morbidity. Survival with six or seven fetuses,
although reported, is extremely rare. There are no reports
of any fetal survivals with eight or more fetuses.
3. The couple can choose multifetal pregnancy reduction.
Selective fetal reduction in triplets is still controversial.
The procedure of multifetal pregnancy reduction (MFPR)
has, in recent years, become both clinically and ethically
accepted as a therapeutic option in pregnancies with four
or more fetuses, and in multifetal pregnancies in which
one or more of the fetuses has congenital abnormalities.2
MFPR results in better pregnancy outcome, regardless of
the initial number of fetuses.3 In a study of IVF-conceived
triplets, selective reduction of the pair to a singleton
pregnancy was associated with a significantly greater
likelihood of delivery at ≥34 weeks. On average, reduction of
the pair was associated with 52 days longer gestation.4
The pregnancy loss subsequent to fetal reduction has been
reported as ranging from 0 to 40%.
Methods of Multifetal Pregnancy Reduction5

• Transcervical aspiration of the gestational sac
• Transvaginal puncture and embryo aspiration
• Intrathoracic injection of potassium chloride, by both
transabdominal and transvaginal approaches.
Ch-18.indd 300 18-01-2014 12:21:42

Selective Multifetal Pregnancy Reduction 301
Transcervical Aspiration
Some authors have used transcervical aspiration of the
gestational sac. This method, however, was thought to be
associated with an increased incidence of fetal loss due to
infection caused by introduction of bacteria from the cervix,
or due to cervical incompetence brought about by cervical
dilatation.
Transvaginal Puncture and Embryo Aspiration

Fetal reduction very early in gestation (6 to 8 weeks) by the
transvaginal puncture and embryo aspiration has also been
reported with fairly good pregnancy outcome.6 However, this
method might have some theoretical limitations, such as:
a. Use of general anesthesia.
b. Possibility of spontaneous fetal reduction at this stage of
gestation.
c. Inability to perform early fetal screening, such as nuchal
translucency test which is done at 10 to 12 weeks of
gestation.
d. Possibility of introducing infections.
Intrathoracic Injection of Potassium Chloride by

Transabdominal and Transvaginal Approach
Multifetal pregnancy reduction using intrathoracic injection
of potassium chloride, by both the transabdominal and the
transvaginal approaches, has been reported. No method has
yet been proven to be superior to the others.
Although several techniques of multifetal pregnancy
reduction have been reported, the most popular is however
the intrathoracic injection of potassium chloride by the
transabdominal approach at 10 to 12 weeks gestation. It is
logical to perform a detailed ultrasonographic fetal anomaly
Ch-18.indd 301 18-01-2014 12:21:42

scan prior to the reduction (Fig. 18.1). This will allow the
reduction to be performed more selectively and will decrease
the chance of delivery of a chromosomal or structurally
abnormal fetus.
Intracranial Injection of Potassium Chloride

In certain cases of MFPR, where difficulty is encountered in
reaching the thorax due to the fetal position as well as the
location of membranes and placenta, an alternative approach
may be the insertion of the needle to the fetal cranium. This
approach enables a technically easier procedure than the
intrathoracic approach. However, the use of this technique
should be reserved for selected cases of MFPR only by
experienced operators and centers.7
Pre-procedural Preparation
1. Counseling of the couple regarding the procedure and its
possible complications.
2. Informed written consent.
3. Prophylactic antibiotic administration.
4. Patient may be admitted for a day in the hospital.
Fig. 18.1: USG showing triplets
Ch-18.indd 302 18-01-2014 12:21:42

Transvaginal Procedure of Fetal Reduction8
This procedure is done between 8 and 9 weeks of gestational
age under general anesthesia. Strict aseptic conditions should be
maintained throughout the procedure. Patient is placed in dorsal
lithotomy position. Cleaning of vagina is done with povidone
iodine solution. Needle guide is attached to the transvaginal
probe. Begin with transvaginal ultrasound examination of all
the fetuses. Choose the correct path of the needle avoiding the
path of the blood vessels. A 35 cm 18 gauge needle with a stylet
is introduced through a guide and advanced through the vaginal
wall, uterine wall into the fetal sac. The stylet is removed and a
21 gauge needle 40 cm long is introduced into the fetal thorax.
2 ml of 2 mEq of potassium chloride is injected. Fetal asystole is
observed and needle is removed.
Transabdominal Procedure of Fetal Reduction5

This procedure is performed between 10 and 12 weeks of
gestational age, under local anesthesia. Prior to the procedure
ultrasound examination of all the fetuses is performed (Figs
18.2 and 18.3; See accompanying interactive CD-Rom).
Fig. 18.2: Ultrasound machine
Ch-18.indd 303 18-01-2014 12:21:42

Fig. 18.3: Ultrasound showing triplets before the procedure
Abdomen is prepared with povidone iodine solution.

Fetus nearest to the ultrasound probe is selected (Fig. 18.4).
Spinal needle no. 21 with stylet is advanced through
the abdominal and uterine wall into the fetal sac. Stylet is
removed (Fig. 18.5).
Syringe is loaded with 2 ml of 2 mEq potassium chloride
(Fig. 18.6).
Fig. 18.4: Selection of fetus nearest the ultrasound probe
Ch-18.indd 304 18-01-2014 12:21:42

Fig. 18.5: Insertion of needle
Fig. 18.6: Loading of syringe
The needle is visualizing on ultrasound and advanced

into the fetal thorax (Fig. 18.7).
After the needle is advanced in the fetal thorax potassium
chloride is injected. Needle is removed after confirming fetal
cardiac asystole (Fig. 18.8). Cardiac activity of other fetus is
confirmed.
Post-procedural second look ultrasound is done after few
hours and another scan a few days later.
Ch-18.indd 305 18-01-2014 12:21:43

Fig. 18.7: Visualization of needle tip
Fig. 18.8: Injection of intrathoracic potassium chloride
Complications
1. Leaking per vaginum.
2. Bleeding per vaginum.
3. Abortion or loss of remaining fetuses.
4. Infection.
Ch-18.indd 306 18-01-2014 12:21:43

Advantages of Transvaginal Procedure
Feasibility of the procedure at an earlier gestational age.
However, the physician should be familiar with the procedure
before applying it for routine use.
Advantages of Transabdominal Route

1. A more detailed USG of the fetuses can be performed and
nuchal thickness can be assessd as it is measured between
10 and 12 week gestational age.
2. Chances of spontaneous reduction of multifetal pregnancy
is ruled out.
3. Lower risk of infection.
No decision in a high-order-multiple pregnancy is easy,
and parents may understandably review their choices for years
afterward, wondering if they should have chosen differently.
References
1. Gonen R, Heyman E, Asztalos EV, Ohlsson A, Pitson LC, Shennan
AT, et al. The outcome of triplet, quadruplet and quintuplet
pregnancies managed in a perinatal unit: obstetric neonatal and
follow-up data. Am J Obstet Gynecol. 1990;162:454-9.
2. Berkowitz RL, Lynch, L, Chitkara U, Wilkins IA, Mehalek KE,
Alvarez E. Selective reduction of multifetal pregnancies in the
first trimester. N Engl J Med. 1988;318:1043-7.
3. Antsaklis A, Anastasakis E. Selective reduction in twins and
multiple pregnancies. J Perinat Med. 2011;39(1):15-21.
4. Skiadas CC, Missmer SA, Benson CB, Acker D, Racowsky C.
Impact of selective reduction of the monochorionic pair in
in vitro fertilization triplet pregnancies on gestational length.
Fertil Steril. 2010;94(7):2930-1.
5. Wapner RJ, Davis GH, Johnson A, Weinblatt VJ, Fischer RL,
Jackson LG, et al. Selective reduction of multifetal pregnancies.
Lancet. 1990;335:90-3.
Ch-18.indd 307 18-01-2014 12:21:43

6. Mansour RT, Aboulghar MA, Serour GI, Sattar MA, Kamal

A, Amin YM. Multifetal pregnancy reduction: modification
of the technique and analysis of the outcome. Fertil Steril.
1999;71(2):380-4.
7. Lembet A, Selam B, Bodur H, Ergin T, Demirel C. Intracranial
injection with KCl: an alternative method in selected
cases of multifetal pregnancy reduction. Fetal Diagn
Ther. 2009;26(3):134-6.
8. Shalev J, Frenkel Y, Goldenberg M, Shalev E, Lipitz S, Barkai
G, et al. Selective reduction in multiple gestations: pregnancy
outcome after transvaginal and transabdominal needle-guided
procedures. Fertil Steril. 1989;52:416-20.
Ch-18.indd 308 18-01-2014 12:21:43

cHAPTER
19
Ultrasonography and
Color Doppler Imaging in
Ovulation Induction
Reeti Sahani
Reproductive organs of a woman during her fertile years

shows daily changes which are very diverse. They can easily
be viewed and assessed with modern imaging techniques
such as sonography and color Doppler imaging.
Examination Technique
Sonographic examination of the female pelvic organs is the
most commonly performed using the following approaches:
1. Transabdominal (TAS).
2. Transvaginal (TVS).
3. Transperineal (less frequently).
A thorough ultrasound examination of the pelvis should
include both complete transabdominal and transvaginal studies.
The techniques are complementary, not mutually exclusive
unless limited information is needed (e.g. follicle size) or
extenuating circumstances dictate otherwise (e.g. patient refusal).
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Ovaries
The ovaries are generally situated on either side of the uterus. A
search along the internal iliac artery would most often find the
ovary located anterior to the vascular bifurcation into anterior
and posterior branches. The blood supply is from the ovarian
artery and branches of uterine artery (Figs 19.1A and B).
Figs 19.1A and B: Ovarian artery
Ch-19.indd 310 18-01-2014 12:27:35

Ultrasonography and Color Doppler Imaging in Ovulation 311
Uterus
Uterus receives its supply via the uterine artery, a branch of the
internal iliac artery. From the uterine artery arise perforating
branches, which extend through the serosa. Endometrium in
midcycle has a triple layered appearance (Figs 19.2A and B).
It derives its supply from arcuate branches of the uterine
arteries. Radial arteries, branch of arcuate arteries, extend
through the myometrium to just outside the endometrium
(Fig. 19.3) where they form terminal branches of two types:
straight and coiled. The straight branches (basal arteries)
supply the basalis layer of the endometrium. The coiled bran
ches (spiral arteries) traverse the endometrium and supply the
functionalis layer.
Figs 19.2A and B: Typical triple layer endometrium
Ch-19.indd 311 18-01-2014 12:27:35

Fig. 19.3: Endometrial vascularity
Color Doppler Imaging (CDI)

Purpose of CDI
• Identify cyclical endometrial and follicular neovascularity
followed by regression in neovascularity.
• Determine changes in vascularity.
• Quantify blood flow.
Indices used for Quantifying in CDI

• Resistive index.
• Pulsatility index.
• SD ratio.
CDI in Ovarian Physiology and Cycle Changes

The ovarian arterial supply exhibits different flow
characteristics during the different phases of a normal
menstrual cycle (Fig. 19.4). These phases are:
• Early follicular phase index values of arteries are relatively
high (days 5–7).
Ch-19.indd 312 18-01-2014 12:27:35

Fig. 19.4: Resistance ovarian waveform pattern
• Late follicular phase index values (days 11–13) are high.

• Early luteal phase index values (days 15–17) are low.
• Late luteal phase index values (days 26–28) rise.
The variations are believed to be hormone related and
reflect changes in vascular compliance.1
Ovarian artery blood flow is detectable when the dominant
follicle reaches a size of 12 to 15 mm. The resistance index
(RI) is 0.54 ± 0.04 and declines the day before ovulation
(Fig. 19.5). Moderate RI value of 0.55 and increased flow
velocity in subendometrial vessels indicate favorable uterine
receptivity (Fig. 19.6).
Fig. 19.5: Low resistance pattern
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Fig. 19.6: Blood flow velocity waveforms of the sub-endometrial vessels on

the day of ET
During ovarian stimulation, the waveform and index value

differences normally noted between the two ovaries may be
absent. Bilaterally, the ovarian arterial blood supply may
demonstrate pulsatility waveforms typical of low impedance.
During the stimulation process, ultrasound has its greatest
contribution in monitoring follicular development and
guiding the oocyte harvesting procedure.
Grayscale evaluation of ovarian follicles can help
distinguish physiologic from insufficient or abnormal
cycles according to the growth of the follicle. Transvaginal
color Doppler can be employed to assess the physiologic
development of the follicles through depiction of flow
parameters2 (Figs 19.7 to 19.9). Four grades of perifollicular
flow on color Doppler are seen (Table 19.1).
a. Normal blood flow surrounding a corpus luteum around
entire periphery. In realtime imaging, virtually the entire
corpus luteum displayed color flow (Fig. 19.7A).
b. Normal blood flow surrounding a corpus luteum (90%)
(Fig. 19.7B).
c. Moderate 50% perifollicular flow (Fig. 19.7C).
d. More than 75% perifollicular flow (Fig. 19.7D).
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Ch-19.indd 315 18-01-2014 12:27:36

Figs 19.7A to D: Corpus luteal flow
Fig. 19.8: Normal robust flow
Optimal stromal artery flow in the ovary has also been

assessed. The peak systolic velocity should be more than 10
cm/sec for a good pregnancy rate (Table 19.2).
3D ultrasound is much more accurate for volume
assessment of the follicle. Presence of cumulus increases
the surety of the presence of a mature ovum in the follicle.
Ch-19.indd 316 18-01-2014 12:27:36

Fig. 19.9: Abnormal anemic flow
Table 19.1: Optimal perifollicular flow

CDI/power Doppler to assess follicle circumference vascularization
1. Grade 1 < 25%
2. Grade 2 25–50%
3. Grade 3 50–75%
4. Grade 4 > 75%
Table 19.2: Optimal stromal artery flow

• Peak systolic velocity > 10 cm/sec
• Pulsatility index—is not indicative
• Resistive index is not indicative except for hyperstimulation
(RI < 0.48)
3D US and 3D PD when used with 2D US and color Doppler

for pre-hCG follicular assessment would definitely improve
pregnancy rates in IUI cycles.3
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CDI in Uterine Physiology

The uterine vessels examined during the cycle are the uterine
artery, spiral artery and vessels at the endomyometrial
junction to note the following:4
• Proliferation of spiral arteries
• Growth of spiral arteries toward the endometrium
• Increased vascularity in the endometrium
• Increased flow in the main uterine arteries.
Uterine Artery
The general pattern of uterine blood flow throughout the
menstrual cycle is that perfusion increases in response to
rising plasma estrogen and progesterone and decreases with
the periovulatory fall in estrogen.5 The lowest pulsatility index
(PI) values are seen around days 8 and 21, while the highest
values are seen around days 1, 14 and 17. Significant changes
in diastolic blood flow at the different times of the cycle may
not be noted. In general; the index values for the uterine artery
ipsilateral to the ovary containing the dominant follicle are
lower than the contralateral artery (Figs 19.10 and 19.11).
Other patterns of uterine artery blood flow have been
described. When the uterine arteries were interrogated at
the level of the uterine cornua, the PI reached its peak by
day 11 and remained relatively constant until day 16. The
lowest values were generally seen around days 1 and 21.
At this anatomic level, end-diastolic flow was commonly
absent during the early follicular phase (Fig. 19.12) but it was
demonstrable by the luteal phase.
The cyclical changes reflected by the flow velocity
waveforms and index values appear to be mediated by
the reproductive hormones. The baseline evaluation (pre
treatment) demonstrated a narrow systolic spectral flow
pattern with a mean PI of 5.2 ± 0.4. Evaluations performed
Ch-19.indd 318 18-01-2014 12:27:36

Fig. 19.10: Doppler waveform of uterine artery ipsilateral to dominant

follicle ovary
Fig. 19.11: Doppler waveform of uterine artery contralateral to dominant

follicle ovary
Ch-19.indd 319 18-01-2014 12:27:37

Fig. 19.12: Near absent end-diastolic flow during follicular phase
on days 13–14, showed a spectral tracing that was broader

with an uninterrupted diastolic component. The mean PI was
1.5 ± 0.2. On days 26 to 27, no significant differences were
noted (mean PI = 1.7 ± 0.3).6,7 Uterine artery RI is given a
score of 0–48 (Table 19.3).
Endometrium
Endometrial morphology: In preparation for implantation, the
endometrium undergoes transformations by increased blood
Table 19.3: Optimal uterine artery RI score

RI Score
< 0.7 4
0.7–0.8 2
> 0.8 0
Ch-19.indd 320 18-01-2014 12:27:37

flow and uterine oxygen consumption. The cells in the stroma
and epithelium increase and there is a generalized edema.
The endometrium and periendometrial area is divided
into 4 zones (Table 19.4). These zones give it the typical
preovulatory triple line appearance that is an indicator of
good uterine receptivity (Fig. 19.13).
Endometrial vascularity: Endometrial zonal neovascularity
is of prime importance for embryo transfer and is determined
at the following levels:
• Subendometrial
• Basal
• Mid zone
• Inner layer.
The spiral arteries, like the endometrium, are remarkably
responsive to the hormonal changes occurring in the
menstrual cycle. These include:9
Table 19.4: The endometrial and periendometrial areas have the

following four zones
• Zone 1 2 mm thick area surrounding the hyperechoic outer
layer of the endometrium
• Zone 2 The hyperechoic outer layer of the endometrium
• Zone 3 The hypoechoic inner layer of the endometrium
• Zone 4 The endometrial cavity
Fig. 19.13: Triple layer endometrial thickness
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• Endothelial proliferation
• Wall thickening and coiling.
These vessels play an important role in implantation. The
chances for a normal implantation may be reduced if the
spiral arterioles are inadequately developed.
It is possible to see variations in the depth of vascular
penetration before, during and after the midcycle. In patients
with uterine artery PIs of more than 3.0, preliminary results have
not revealed any successful pregnancies in IVF patients unless
there is vascularity demonstrated either within zone 3 or within
zones 3 and 4 prior to transfer10 (Figs 19.14A and B, and 19.15).
Figs 19.14A and B: Normal zone 3 blood flow is demonstrated on this

endovaginal image
Ch-19.indd 322 18-01-2014 12:27:37

Fig. 19.15: Vascular penetration on power Doppler to zone 4
An optimal score based on imaging vascularity taking

into consideration number of vessels and endometrial power
Doppler area, is used for assessment (Table 19.5 and Fig. 19.16).
The color Doppler findings in unsuccessful cycles may
relate to the histologic findings. A majority demonstrated an
immature endometrium at the time of embryo transfer. The
abnormalities included a variety of patterns, all indicating a
lack of secretory transformation, suggesting poor endometrial
receptivity for implantation.11
Endometrial thickness (ET): Thickness of endometrium is
also important for implantation. Less than 7 mm gives a poor
pregnancy rate (Table 19.6).
Table 19.5: Optimal endometrial score and vascularity

quantification
Characteristic Scoring
• Number of vessels
3 and above Score of 3
1–3 Score of 2
Absent Score of 0
• Endometrial power Score of 4
Doppler area of > 5 mm sq
• PSV, RI and PI not reliable
Ch-19.indd 323 18-01-2014 12:27:38

Fig. 19.16: Imaging in optimal endometrial score
Table 19.6: Optimal endometrial score

ET Score
• < 7 mm 0
• 10–11 mm 2
• 12 mm and above 3
In cycles resulting in pregnancy, mean endometrial

thickness was higher compared to cycles with negative
outcomes. Higher serum estradiol is associated with higher
endometrial thickness and pregnancy rates. Women achieving
pregnancy and pregnant women with endometrium thicker
than 9 mm were younger. Follicle stimulation was better
with higher endometrial thickness. After adjustments for age,
no statistical difference was found in endometrial thickness
between agonist and antagonist protocols.12
Endometrial volume on 3D ultrasound: With the 3D
ultrasound being used to assess endometrial receptivity, the
volume estimation of endometrium is done. The endometrial
volume was measured by area tracing from the fundus to the
internal cervical os in a number of parallel slices 1 to 2 mm
apart. An ideal volume is 2–7 mL (Fig. 19.17).13
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Fig. 19.17: Endometrial volume on 3D ultrasound
Ultrasonographic Scoring of Uterine Receptivity

A scoring system for endometrial receptivity has been done
taking into account endometrial thickness, pattern and
vascularity. It also includes the appearance of myometrium
(Table 19.7).
Another score was devised for patients undergoing IVF
to assess the uterine receptivity (Table 19.8). The maximum
score was 7 and the cutoff value was 5.
Table 19.7: Scoring system for uterine receptibity

Uterus Nature Score Nature Score
ET >7 4 <7 0
ET pattern Triple layer 3 Others 0
Myometrium Homogenous 2 0
Uterine artery PI < 3 4 PI > 3 0
End-diastolic flow Present 4 Absent 0
Endometrial Present 3 Absent 0
vascularity
Total score 20 0
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Table 19.8: Two-dimensional ultrasonographic scoring system

for evaluation of uterine receptivity in patients undergoing
IVF-ET procedures11
Characteristic Score
Endometrial thickness, mm
6–8 0
9–14 2
>15 1
Endometrial morphology
Triple line 0
Homogenous hyperechoic 2
Hypoechogenic with hyperechogenic borders 1
Sub-endometrial blood flow (RI)
Absent 0
>0.55 1
=0.55 3
Maximum score* 7
*The cutoff value was 5.
Scoring on evaluation of 3D ultrasonography of

endometrium included endometrial volume, vascularity and
morphology. The maximum score was 7 with a cutoff score
of 5 (Table 19.9).
Comparison of 3D and 2D Ultrasonography for

Assessment of Endometrial Receptivity
On comparing the sensitivity, specificity, positive predictive
value, negative predictive value and efficiency of the 2D
and 3D ultrasound assessment of endometrial receptivity no
significant difference was found (Table 19.10).
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Table 19.9: Three-dimensional ultrasonographic scoring system

for evaluation of uterine receptivity in patients undergoing
IVF-ET procedures11
Characteristic Score
Endometrial volume, mL
<2 0
2–7 2
>7 1
Endometrial morphology
Triple line 0
Homogenous hyperechogenic 2
Hypoechogenic with hyperechogenic borders 1
Sub-endometrial blood flow (FI)
<11 0
11–15 3
>15 1
Maximum score* 7
*The cutoff value was 5
Table 19.10: Comparison between 2D and 3D ultrasonographic

scoring systems in the assessment of endometrial receptivity in
patients undergoing IVF-ET procedures11
Ultrasonographic Sensitivity% Specificity% PPV% NPV% Efficiency%
2D cD 97.0 41.0 64.0 92.6 70.1
3D PD 97.0 39.3 63.7 92.3 69.5
NPV indicates negative predictive value; PPV, positive predictive value; 2D cD, 2D
color Doppler ultrasonography; 3D PD, 3D power Doppler ultrasonography.
Ultrasonography and color Doppler imaging can help to

predict the success rates in assisted reproduction (Table 19.11).
Ch-19.indd 327 18-01-2014 12:27:38

Table 19.11: Factors predicting higher pregnancy rates

• Endometrium—Triple layer appearance and 12 mm thickness
• Endometrial power Doppler area > 5 mm sq
• Myometrium appears homogenous
• Uterine artery PI < 3
• Uterine artery end-diastolic flow present
• Perifollicular circumfrential vascularity > 75%
• Ovarian stromal arteries—PSV > 10 cm/sec
Ultrasound imaging of the female pelvis has helped us to

understand, identify, diagnose, treat and manage the infertile
patient. The endovaginal scanning and Doppler imaging
has enabled us to extend our evaluation further. It is now
possible to perform a sonographic physiologic assessment of
the structures we visualize.
References
1. Fleischer Ac, Kepple DM, Vasquez J. conventional and color
Doppler transvaginal sonography in gynecologic infertility.
Radiol Clin North Am. 1992;30:693-702.
2. Fleischer AC, Daniell JF, Rodier J, Lindsay AM, James AE Jr.
Sonographic monitoring of ovarian follicular development. J
Clin Ultrasound. 1981;9:275-80.
3. Panchal S, Nagori cB. PrehcG 3D and 3D power Doppler
assessment of the follicle for improving pregnancy rates in
intrauterine insemination cycles. J Hum Reprod Sci. 2009
Jul;2(2):62-7.
4. Kurjak A, Kupesic-Urek S, Schulman H, Zalud I. Transvaginal
color flow Doppler in the assessment of ovarian and uterine
blood flow in infertile women. Fertil Steril. 1991;56:870-73.
5. Steer cV, campbell S, Pampiglione JS, Kingsland cR, Mason
BA, Collins WP. Transvaginal color flow imaging of the uterine
Ch-19.indd 328 18-01-2014 12:27:38

arteries during the ovarian and menstrual cycles. Hum Reprod.
1990;5:3915.
6. Steer CV, Campbell S, Tan SL, Crayford T, Mills C, Mason BA,
et al. The use of transvaginal color flow imaging after in vitro
fertilization to identify optimum uterine conditions before
embryo transfer. Fertil Steril. 1992;57:372-6.
7. Sterzik K, Grab D, Sasse V, Hütter W, Rosenbusch B, Terinde
R. Doppler sonographic findings and their correlation with
implantation and in an invitro fertilization program. Fertil
Steril. 1989;52:825-28.
8. Friedler S, Shenker JG, Herman A, Lewin A. The role of
ultrasonography in the evaluation of endometrial receptivity
following assisted reproductive treatments: a critical review.
Hum Reprod. 1996;2:323-35.
9. Fleischer AC. Ultrasound imaging—2000: Assessment of
utero-ovarian blood flow with transvaginal color Doppler
sonography; potential clinical applications in infertility. Fertil
Steril. 1991;55:684-91.
10. Applebaum M, Cadkin AV. Decidual flow—an early sign of
pregnancy. Ultrasound Obstet Gynecol. 1992;2:65.
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12. Giannaris D, Zourla A, chrelias c, Loghis C, Kassanos
D.Ultrasound assessment of endometrial thickness: correlation
with ovarian stimulation and pregnancy rates in IVF cycles.
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13. Kurjak A, Zalud I. Transvaginal color Doppler in the study
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N, Schenker JG (Eds). Advances in Assisted Reproductive
Technologies. New York: Plenum Press. 1990;5414.
Ch-19.indd 329 18-01-2014 12:27:38

Index
Page numbers followed by f refer to figure and t refer to table
A transvaginal procedure 307

vaginal administration 267
Abdominal Amenorrhea 4, 158, 163, 173,
cramps 180 177, 181
distension 279 Amitryptilene 172
girth measurement 289 Amount of ascites 289
Abdominopelvic discomfort 25 Amoxapine 172
Abnormal anemic flow 317f Anastrazole 34
Abortion 152, 306 Androgen receptor
Absence of corpus luteum 263 expression 189
Acanthosis nigricans 118 Anovulation and tests for
Acarbose 39, 125 ovulation 1
Accuracy of test 8 Antagonizing androgens 119
Acid-base balance 289 Anti-Müllerian
Acne 118 hormone 191, 205
Addison’s disease 159
tailored protocols 53
Adenoma with stalk
Antiphospholipid syndrome 234
compression 172
Antipsychotic drugs 177
Adjunctive use of nitric
Antral follicle count 204, 207,
oxide 217, 224
207t, 216
Adnexal torsion 281
Adrenal function assessment 17 Appearance of ovary after
Advantages of drilling 147f
GnRH Aromatase inhibitors 34
agonists 78 Ascitis 291
antagonists over GnRH Aspiration of single lead
agonist in ART 85 follicle 110
pulsatile therapy 165 Aspirin 217, 225, 250
ovarian reserve testing 209 Assessment of ovarian
recombinant FSH 63 reserve 203
transabdominal route 307 Atresia 12
Index.indd 331 21-01-2014 12:19:56

B hypogonadotropic
hypogonadism 156f
Basal poor ovarian response 215t
anti-Müllerian hormone 283 CC challenge test 216
body temperature 4, 263 Central retinal vein occlusion 23
follicle stimulating hormone Cerebral radiotherapy 2
levels 203, 204, 204t Cervical mucus 22
ovarian stromal blood Chemotherapy 203
flow 207 Chest
Bilateral polycystic ovaries 145f wall stimulation 171
Bleeding per vaginum 306 X-ray 289
Blood Choice and dose of
gases 289 gonadotropin 52t
tests 204 Chromohysteroscopy 245
Blunting of hepatic Chronic
gluconeogenesis 122 endometritis 242, 243, 243f
Body mass index 4 nonspecific endometritis 242
Bone mineral density 158 renal failure 172
Breast Cimetidine 172
cancer 62, 118
Cirrhosis 172
discomfort and bloating 23
Clomiphene 14, 20, 21, 27,
Bright echogenic stroma 115
128, 266
Bromocriptine 37, 128, 129,
and gonadotropin regime 41f
179, 183, 287
challenge test 208
Buserelin 72
Butyrophenones 172 citrate 9, 14, 127, 128, 271
challenge test 204
failure 31
C
in mild stimulation
Cabergoline 182, 183 protocol 60
Calcium channel blockers 172 resistance 31, 52
CAM therapy 217 therapy 16
Causes of with gonadotropins and
anovulation 282 GnRH antagonist 43f
suitable for ovulation with single dose FSH 60
induction treatment 2t Colony-stimulating factor 237
Index.indd 332 21-01-2014 12:19:56

Index 333
Color D
and pulsed Doppler
ultrasound 264 Danazol 9
Doppler imaging 312 D-chiroinositol 39, 126
Combined oral contraceptive Decidual prolactin
pills 225 measurement 263
Complications of ovulation Decreased
induction 276 renal function 279
Congenital SHBG 119
adrenal hyperplasia 2 Dehydroepiandrosterone 189
malformations 24 sulfate 135
uterine abnormalities 234 Dehydrogesterone 268
Constipation 180 Delayed puberty 173
Corpus luteal flow 316f Dendritic cells 239
Correction of circulatory volume Determination of ovarian
tissue 17
electrolyte imbalance 291
Development of GnRH
Correlation of number of
antibodies 165
oocytes recovered with
Dexamethasone suppression
pregnancy rate 95
test 159
Corticotropin
Diabetes
releasing hormone 238 insipidus 185
stimulation test 159 mellitus 118
Craniopharyngioma 2, 171 Diminished ovarian reserve
Creatinine 279 189, 190, 215
Cryopreservation 98 Dizziness 25, 180
of embryo 211, 226, 286 Dominant follicle ovary 319f
of oocyte 211, 226 Donor oocytes 217
Cumulative Dopamine 292
conception rate 20 agonists 37, 182, 287
pregnancy rate 98 receptor blockers 172
Cushing’s syndrome 135, 159 synthesis inhibitors 172
Cyproterone acetate 135 Dose of
Cystectomy 203 clomiphene 20
Cytokines 236 FSH 94
Index.indd 333 21-01-2014 12:19:56

Drainage of hydrosalpinx 252 Estrogen 249

Drug-induced deficiency 173
hypersecretion 172 replacement therapy 183
Dynamic tests 204 Evaluation of male partner 16
Dysgerminoma 171 Exogenous
Dyslipidemia 118 FSH ovarian reserve
Dysparenia 173 test 204, 209
gonadotropin stimulation 203
E hCG 9
Extended lithotomy position 145f
Early follicular phase
estradiol levels 205 F
inhibin B levels 205
Elevated circulating Failure of medical therapy for
androgens 262 ovulation induction 142
Fasting
Emotional stress 101
blood sugar 118
Empty sella syndrome 172
insulin levels 118
Endometrial
serum insulin 41
aspiration 246
Fatigue 180
biopsy 9, 126, 246, 263
Flexible antagonist protocol 109
carcinoma 118
Fluid in cul-de-sac 11
growth 22 Flutamide 136
hyperplasia 25 Focal or diffuse hyperemia 244
lymphocytes 242 Follicle
morphology 326, 327 aspiration 286
polyps 25 stimulating hormone 3, 51,
power 323 159, 188
thickness 27, 247, 323, 326 Free androgen index 119
vascularity 312f, 321 Functional hypothalamic
volume 324, 327 chronic anovulation 159
Endometriosis 234, 262
Endometritis 234 G
Endometrium 320, 328
Endothelial proliferation 322 Galactorrhea 173, 177, 181
Epidermal growth factor 236 Glucocorticoids 34, 128, 129,
Epileptic seizures 172 217, 224
Index.indd 334 21-01-2014 12:19:56

Index 335
Glucose tolerance test 118 Hashimoto’s thyroiditis 234
GnRH Headache 23, 25, 180
agonist 36, 42, 71, 80, 128, Hematoma 165
131, 133, 136, 221 Hepatic dysfunction 81
for ovulation trigger 79 High dose of
in luteal phase 270 gonadotropins 210, 218
pulsatile therapy 164f Highly purified human
therapy 163 menopausal
GnRHa stimulation test 208 gonadotropin 53
Golan’s classification 277 Hormonal
of OHSS 278t control of endometrial
Goldmann’s perimetry 176 preparation 234
evaluation 246
Gonadotropin 41, 50, 130,
Hormones 172
217, 250
Hot flushes 23, 25
releasing hormone 86
Human
analog 76
chorionic gonadotropin 35,
challenge test 158
51, 66, 268
stimulation 288 menopausal gonadotropin
therapy 128, 159 219, 50, 266, 272
Grades of severity of pituitary gonadotropin 50
hypothalamic Hydrothorax 289
amenorrhea 157t Hydroxyethyl starch
Granulomas 172 administration 286
Granulosa cells 215 Hypergonadotropic
of primordial follicles and hypogonadism 1
follicles 188 Hyperinsulinemia 133
Grasping of ovarian in polycystic ovarian
ligament 146f syndrome 117f
Growth hormone 223 Hyperplasia of lactotrophs 172
replacement 163 Hyperprolactinemia 2, 170,
173, 174f, 177, 262
H Hyperstimulation syndrome 62
Hypertension and
Hair loss and dryness 23 cardiovascular disease 118
Hallucinations 180 Hypoglycemia 123
Index.indd 335 21-01-2014 12:19:56

Hypogonadotropic Intravenous
hypogonadism 1, 2, 52, immunoglobulins 251
53, 155, 156, 158, 159t, Invasive hemodynamic
161, 166 monitoring 289
and ovulation Irregularity of follicle 11
induction 155
Hypophysectomy 2 K
Hypotension 291
Hypothalamic pituitary Kallmann syndrome 2
dysfunction 1 Ketoconazole 136
failure 1, 16 Kidney function tests 289
stalk damage 171
Hypothalmic disorders 155 L
Hypothyroidism 2, 159, 172
Hysteroscopy 246, 249 Laparoscopic
evaluation of pelvis 142
I ovarian drilling 42, 128, 131
Laparotomy 293
Idiopathic hyperprolactinemia 173 Large granular lymphocytes 239
Imipramines 172 L-arginine 251
Induction of ovulation 177 Late
Infertility 118 follicular phase index
Injection of intrathoracic values 313
potassium chloride 306f luteal phase index values 313
Insertion of needle 305f Leaking per vaginum 306
Insulin Letrozole 25, 27, 34, 217,
resistance 115 226, 250
sensitizers 38, 121, 128 Leukemia inhibitory factor 237
sensitizing drugs 128 Leukocyte immunotherapy 251
Intolerable nausea and Leuprolide 72
vomiting 291 Liver
Intracranial injection of disease 16
potassium chloride 302 dysfunction 281
Intramuscular depot enzymes 279
injections 73 function tests 17, 289
Intranasal route 73 toxicity 25
Intrathoracic injection of Loading of syringe 305f
potassium chloride Long-acting depot intramuscular
300, 301 injection 179
Index.indd 336 21-01-2014 12:19:56

Index 337
Loss of remaining fetuses 306Management of
Low ascitis 292
dose clomiphene
of gonadotropin 59 failure 32
oral contraceptive pills 133
resistance 44f
estradiol levels 157 hyperprolactinemia 177, 178f
gonadotropins 157 luteal phase defect 265f
ovarian stimulation OHSS 282
protocols 288 PCOS 134f
progesterone levels in luteal
Mechanism of hyperinsulinemia
phase 264 and hyperandrogenemia
resistance pattern 313f 116f
Lubeck protocol 81, 81f Medical treatment of
Lupus erythematosis 234 endometritis 253
Luteal Meningioma 171
estradiol 217, 225 Menstrual
initiation of FSH 219 disturbance 118
phase irregularities 173
defect 16, 260 Metalloproteases 236
support 252, 286 Metformin 38, 121, 124, 128,
serum progesterone levels 6 133, 136, 287
supplementation 282 Methods of
support 85, 283 endometrial evaluation 246t
Lutein cyst formation 263 multifetal pregnancy
Luteinized unruptured reduction 300
follicle 12, 263 Metoclopromide 172
Luteinizing hormone 3, 41, 106
Micro-adenoma 172
Lymphocytic hypophysitis 172 Micronized progesterone 266
Micropolyps 244
M Mifepristone 110
Mild ovarian stimulation 92, 97
Macro-adenoma 172 Mild stimulation protocol 58, 222
Macroprolactin 175 Miscarriage 62
Maintaining normal Modes of ovulation induction in
endometrium 119 PCOS 127f
Maintenance of Monitoring of thyroid activity 166
intravascular volume and Mucosal edema 244
electrolyte imbalance 291 Mullarian inhibiting
renal function 291 substance 204
Index.indd 337 21-01-2014 12:19:56

Multiple perifollicular flow 317t

endocrinopathies 185 stromal artery flow 317t
pregnancy 61, 98, 276, 293 uterine artery RI score 320t
Oral contraceptive 36, 76, 83,
N 210, 217
pill 9, 135, 172
N-acetyl cysteine 39 Orthostatic hypotension 180
Naltrexone 40, 128 Osteopontin 233
Nasal Osteoporosis 173
congestion 180 Ovarian
spray 73 artery 310f
Natural cancer 62, 276
cycle 217 and ovulation
killer cells 239 induction 294
Nausea 23, 25, 180 cyst 16
Navot’s classification 278 drilling 203
Nitric oxide 251 enlargement 279
Nitroglycerin 250 failure 1, 16, 151
Nonapeptide agonists 72 hyperstimulation syndrome
Nonspecific chronic 53, 92, 100, 276, 277
endometritis 241 reserve tests 203, 204t
Number of sensitivity index 206
follicles 282, 284 size 289
mature follicles 27 stimulation 83
stroma 188
O stromal
arteries 328
Obesity 118 peak systolic velocity 204
Oligomenorrhea 4, 173 suppressive agents 262
Oligo-ovulation 262 transplant 211
Oocyte volume 204, 207, 216
donation 211, 226 Ovaries 201, 310
pick-up 254 irrigated with normal
Optic nerve 185 saline 147f
Optimal Overnight dexamethasone
endometrial score 324f, 324t suppression test 135
and vascularity Ovulation 27, 152
quantification 323t documentation 4
Index.indd 338 21-01-2014 12:19:56

Index 339
induction 126 ovaries 2, 114
protocol 282 syndrome 31, 40
treatment 2t Poor
with clomiphene 19f hormonal environment 232
ovarian reserve and mild
P ovarian stimulation 99
uterine artery blood flow 234
Panhypopituitarism 159, 185 Post-oocyte retrieval
Paracentesis of hydrothorax 292 albumin 286
Pathophysiology of Postpartum hemorrhage 166
luteal phase defect 261f Postprandial insulin 118
ovarian hyperstimulation Pouch of Douglas 151
syndrome 279, 280f Pregnancy 27, 283, 289
Peak systolic velocity 317 and lactation 171
Perifollicular circumfrential complications 166
vascularity 328 monitoring 166
Perivascular fibrosis 182 rate 109, 152
Persistent Premature
hypersecretion of LH 142 luteinization 106
perifollicular reaction 263 menopause 4
Phenothiazines 172 ovarian aging 190
Pioglitazone 39 Prevention of
Piroxicam 252 endometrial hyperplasia 133
Pituitary thrombosis 291, 292
capacity test 158 Previous ovarian surgery 203
dynamic testing 158 Primary amenorrhea 4
failure 2 Principle of ELISA test 7
function assessment 17 Procedure of multifetal
gland 164f pregnancy reduction 300
hypersecretion 172 Progesterone 3
stimulation test 159 supplementation 264, 266
tumor 181 Prolactin
Plenty of fluids 290 and ovarian function 171
Polycystic secreting adenoma 159
ovarian Prolactinoma 172
disease 141 Proliferation of spiral
syndrome 42, 114 arteries 318
Index.indd 339 21-01-2014 12:19:56

Protocol of ovarian Role of

stimulation 283 androgens in ovulation
Pulmonary compromise 292 induction 188
Pulsatility index 204, 317, 312 chronic endometritis in
Pulse frequency and dose 163 endometrial
Purified urinary FSH 50 receptivity 241
GnRH agonists 290
Q and antagonists in
assisted reproductive
Quantify blood flow 312 technology 71
Quinagolide 182, 287 GnRH antagonist 290
in mild stimulation 59, 93
R LH supplementation 159
metformin after
Radioimaging of sella conception 124
turcica 176 natural killer cells 239
Ranitidine 172 oral contraceptive pill 83
Raynaud’s phenomenon 180 Rosiglitazone 39
Recombinant
FSH 50, 62, 63, 219 S
hCG 51
LH 50, 65 Scanning electron
Recurrent abortion 262 microscopy 246
Reducing uterine Selective multifetal pregnancy
contractility 252 reduction 299
Regularization of cycles 133 Sella turcica 176
Renal Serum
dysfunction 81 estradiol 283
failure 279, 292 levels 61
Resistance ovarian waveform prolactin
pattern 313f estimation 175
Resistive index 312, 317 measurement 263
Results of Severe OHSS 291
gonadotropin therapy 162 Sex hormone-binding
laparoscopic treatment 152 globulin 33
Rheumatoid arthritis 234 Sheehan’s syndrome 2
Ritodrine 252 Sibutramine 120
Index.indd 340 21-01-2014 12:19:56

Index 341
Side effect of T
bromocriptine 180t
Signs of ovulation on T regulatory cells 240
ultrasonography 11t Tamoxifen 24, 33, 250
Sildenafil 250 Termination of pregnancy 293
Simple Testosterone 3
needle puncture 149 Tests for ovulation 4
office procedure 11 Thiazolidinediones 125
Slide test 7 Thioxanthenes 172
Small for gestational age 166 Thyroid stimulating
Spindle damage 234 hormone 3, 119
Spiral arteries 311 Transabdominal procedure of
Spironolactone 136 fetal reduction 303
Standard flare protocol 220 Transcervical aspiration 301
Steroid 287 of gestational sac 300
Transdermal testosterone
hormone receptor
gel 190, 194, 223
analysis 263
Transient
Stimulation of
hyperprolactinemia 173
folliculogenesis 271
Transvaginal
Storage of steroid hormones 33
procedure of fetal
Strenuous exercise 262 reduction 303
Stress 2, 171 puncture and embryo
Strict intake output chart 289 aspiration 300, 301
Study of pinopodes 246 sonography 115
Subcutaneous injections 72 ultrasound scan 4
Sub-endometrial blood Treating anovulation 119
flow 326, 327 Treatment of
Suppressive therapy 36 hyperprolactinemia 177
Supraseller pituitary mass luteal phase defect 264
extension 171 poor uterine receptivity 249
Surgical ovulation prolactin secreting
induction 42, 128, macroadenomas 177
131, 141 Triple layer endometrial
Systemic disorders 172 thickness 321f
Index.indd 341 21-01-2014 12:19:56

Triptorelin 71, 236 LH 217

Tube 202 recombinant FSH 219
Tubercular Uterine
endometritis 241, 242 artery 318, 328
Tuberculosis and chronic dysfunction 166
nonspecific Uterus 201, 311
endometritis 241
Tumor 171
V
necrosis factor alpha 237
Turner’s syndrome 2 Vaginal
Typical triple layer dehydroepiandrosterone 195
endometrium 311f
dryness 173
Visual disturbances 23
U
Visualization of needle tip 306f
Ultrasonographic scoring of Vomiting 23, 25, 180
uterine receptivity 325
Ultrasonography of ovary 282 W
Ultrasound machine 303f
Unexplained Wall thickening and coiling 322
infertility 16, 52, 203 WBC count 279
Unilateral oophorectomy 203 Weight
Use of charts 289
general anesthesia 301 loss 32, 120, 127, 128
Index.indd 342 21-01-2014 12:19:56

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Step by Step®

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

Jaypee Medical Inc Jaypee Brothers Medical Publishers (P) Ltd

Jaypee Brothers Medical Publishers (P) Ltd

© 2014, Jaypee Brothers Medical Publishers

Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com

Step by Step® Ovulation Induction

First Edition: 2006

Abha Majumdar MD Neerja Goel MD

Shweta Mittal Surveen Ghumman

In the recent years, the subject of infertility has changed

dilemmas in management of infertile couples bringing the

In the recent years, there has been a revolution in the field

ovulation induction. This is becoming an important option

I thank all the contributors, for their well-researched chapters

1. Anovulation and Tests for Ovulation 1

3. Clomiphene Resistance—What Next? 31

5. Role of GnRH Agonists and Antagonists in

6. Mild Ovarian Stimulation 92

• Clomiphene, Gonadotropins and

7. Premature Luteinization 106

8. Polycystic Ovarian Syndrome and

9. Surgical Ovulation Induction 141

10. Hypogonadotropic Hypogonadism and

12. Role of Androgens in Ovulation Induction 188

13. Ovarian Reserve and Fertility in

14. Ovarian Stimulation for the

15. Endometrial Receptivity—A Vital Role 231

• Current Strategies to Assess Endometrial

16. Luteal Phase Defect 260

17. Complications of Ovulation Induction 276

18. Selective Multifetal Pregnancy Reduction 299

19. Ultrasonography and Color Doppler

Disorders of ovulation account for approximately 30–40%

Ch-01.indd 1 18-01-2014 12:01:54

Table 1.1: Causes of anovulation suitable for ovulation

Table 1.2: Causes of anovulation not suitable for ovulation induction

Ch-01.indd 2 18-01-2014 12:01:55

Table 1.3: Investigations for anovulation1

Ch-01.indd 3 18-01-2014 12:01:55

Tests for Ovulation

Basal Body Temperature (BBT)

Ch-01.indd 4 18-01-2014 12:01:55

Ch-01.indd 5 18-01-2014 12:01:55

Luteal Serum Progesterone Levels

Ch-01.indd 6 18-01-2014 12:01:55

Principle of ELISA Test

Ch-01.indd 7 18-01-2014 12:01:55

begin in the early morning hours and are not detected in

Ch-01.indd 8 18-01-2014 12:01:55

Ch-01.indd 9 18-01-2014 12:01:55

An­ovulatory women are always in the follicular phase and have

Ch-01.indd 10 18-01-2014 12:01:55

Table 1.4: Signs of ovulation on ultrasonography

Ch-01.indd 11 18-01-2014 12:01:55

also be observed. The follicle may grow at an abnormal pace,

Ch-01.indd 12 18-01-2014 12:01:55

Ch-01.indd 13 18-01-2014 12:01:55

Anovulatory women are always in the follicular phase and have