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An extended 10-day course of CC provides a simple, noninvasive, and inexpensive alternative for a subset of women with ovulatory disorders that are refractory to standard CC treatment.
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Three hundred sixty-three women undergoing 898 artificial inseminations with husband semen with a progressive motile sperm count of >20 million sperm per mL were randomly placed in the five treatment groups.
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Discussed are 41 pregnancies following a 6-months successful complex therapy of functional sterility. The patients were transmitted to the centers of prenatal care. The complex therapy enabled an increase in the present successful treatment with Clomiphen from 45 to 65 per cent of cases.
Sterility related to ovarian dystrophy is currently treated by means of standard inductors of ovulation such as Clomid and HMG. In case of failure, patients are recommended in vitro fertilization. In our study of 30 cases of ovarian dystrophy, 9 pregnancies occurred after in vitro fertilization. Slow injections of purified FSH appear to produce similar results but the method is still under evaluation. Our results suggest that after say, two years of failure with classical methods in patients with a long history of sterility, in vitro fertilization may be expected to give good results.
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Polycystic ovarian syndrome (PCOS) is the commonest endocrine disorder in women of a reproductive age, occurring in approximately one in seven women. Of these women approximately two-thirds will not ovulate on a regular basis and consequently may therefore seek treatment for ovulation induction. After exclusion of other significant causes of sub-fertility the pragmatic approach to ovulation induction is to commence with clomiphene citrate. The goal of ovulation induction is the development of a single ovulatory follicle and the avoidance of a multiple gestation. Second line therapies consist of gonadotrophin therapy and laparoscopic ovarian drilling, the place of metformin therapy is believed to lie in the management of woman with impaired glucose tolerance. It is imperative that all ovulation induction is performed with access to rapid serum estradiol monitoring and ultrasound facilities. The benefit of the use of aromatase inhibitors has not yet been proven in large studies. Women with PCOS undergoing in vitro fertilization (IVF) are at a substantial risk of ovarian hyperstimulation syndrome and this approach should be avoided if at all possible. If it is required these women may be suitable candidates for in vitro maturation of oocytes (IVM) so avoiding ovarian hyperstimulation. Women with PCOS are potentially at an increased risk of miscarriage and in pregnancy of they are at an increased risk of developing gestational diabetes, pregnancy-induced hypertension and pre-eclampsia. Furthermore the neonate has a significantly higher risk of admission to a neonatal intensive care unit and a higher perinatal mortality.
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The study took place in the IVF laboratory of an Infertility Department.
The aim of this study was to examine the effects of ovulation induction agents on the ovarian surface epithelium in rats. Sixty adult females were randomly divided into six groups, each containing 10 rats. In four of these groups ovulation induction was applied with six cycles of clomiphene citrate, human menopausal gonadotrophin (HMG), recombinant FSH (rFSH) or human chorionic gonadotrophin (HCG), respectively, followed by unilateral oophorectomy, and another six cycles of the same treatment. After a total of 12 cycles of ovulation induction, the remaining ovary was taken out and the alterations in ovarian surface epithelium were examined. No malignancies were observed on the ovarian surface epithelium of the rats that were given clomiphene citrate, rFSH or HMG as ovulation induction agents, while identification rates of histopathological parameters constituting epithelial dysplasia were found to be significant (P < 0.05). There was no significant dysplasia in the epithelium of the group which was given HCG only, relative to control groups. The findings suggest that the ovulation induction agents except for HCG bring about dysplasia in the ovarian surface epithelium. It is not clear whether these dysplasias are precursory lesions of ovarian malignancies.
Pregnancy occurred in 167/1,398 cycles (11.9%) in total without significant differences between groups. The total miscarriage rate was 16.1% (varied between 14.2% in CC group and 19.9% in anastrozole group) without difference between spontaneous and stimulated pregnancies. There were 129 deliveries in all groups. There were no significant differences between the stimulated and spontaneous pregnancies as regards mean gestational age, premature deliveries, birth weight, SGA<10th percentile or five minutes Apgar score. There was one case of complete cleft palate and one case of major congenital heart problem in the letrozole group. There were two cases of talipus equinovarus in the CC and spontaneous pregnancy group.
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The Cochrane Subfertility Review Group specialised register of controlled trials was searched.
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The cumulative delivery rate per patient after three fresh and/or frozen embryo transfers and time to pregnancy.
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In a nonhuman primate in vitro fertilization program clomiphene citrate was used to superovulate the chacma baboon Papio ursinus. The antiestrogenic effect of clomiphene citrate was demonstrated locally on the perineal tumescence. In comparing the result of 50 spontaneous cycles and 18 clomiphene citrate-stimulated cycles, there was a statistical significant influence on cycle length and duration and degree of perineal swelling. This inhibitory effect on perineal tumescence of the baboon is another example of a local antiestrogenic effect of this drug. Furthermore, it nullified an important clinical parameter of ensuing ovulation.
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Octreotide was no more effective than placebo for clomiphene citrate resistance in patients with PCOS, but it did reduce E2 levels and follicle numbers when combined with urinary FSH. Thus, octreotide may reduce the incidence of OHSS in patients with PCOS.
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Arias-Stella reaction commonly is seen in gestational endometrium, but rarely is described outside the endometrium, particularly in nonpregnant women. Although the cytological diagnoses of Arias-Stella reaction by cervical Papanicolaou (Pap) smears in pregnant, postpartum, and postabortal women are documented, to our knowledge, this is the first report of Arias-Stella reaction in a cervicovaginal smear of a nonpregnant woman undergoing infertility treatment with clomiphene and beta-human chorionic gonadotropin (beta-HCG). The cytological features observed in this case were characteristic of Arias-Stella reaction but mimic malignancy leading to initial misinterpretation. It is of paramount importance to recognize this phenomenon in cervical Pap smears, especially in women receiving ovulation-inducing agents and exogenous hormonal treatment to avoid this potential cytological pitfall.
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Randomized controlled trial.
Endometrial thickness, echogenic pattern of the endometrium, serum E2 content, and E2 and P receptor contents in the endometrium.
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Ovulation induction by metformin alone or in combination with clomiphene
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Thirty one pregnancies (7% per cycle, 15% per patient) occurred. One pregnancy occurred (pregnancy per cycle was 2% and per patient was 12%) in 8 patients undergoing 37 cycles of IUI with natural ovulation. The result with CC in 27 patients undergoing 41 cycles IUI was 2 pregnancies (4% per cycle, 7% per patient). In 129 patients receiving 283 cycles of IUI with CC+HMG 21 pregnancies occurred (7% per cycle, 16% per patient). In 35 patients receiving 80 cycles of IUI with HMG 8 pregnancies occurred (9% per cycle, 23% per patient).
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Although many assisted reproductive technology (ART) programs no longer perform postcoital tests, many perform intrauterine insemination (IUI), often with gonadotropins or clomiphene citrate, in their subfertile patients. Therefore, this review article will be of value to our readers who treat subfertile patients with IUI, whether or not they perform postcoital tests. For additional explanations of the statistical tests employed in this review, see D. Grimes, KF Schulz, Obstetrical and Gynecologic Survey, 57; Supplement 3: S35, September 2002; and D. Grimes, KF Schulz, Obstetrical and Gynecologic Survey, Supplement 2, S53-S69, September 2005.-RBJ.
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Double IUI increases the pregnancy rate significantly in patients with male factor infertility, and single IUI acts as efficient as double IUI in patients with idiopathic infertility.
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Gamete intra-Fallopian transfer (GIFT) was combined with a diagnostic laparoscopy on a routine operating list in a district general hospital. The equipment used was entirely portable. Operations were programmed 6-12 weeks in advance using a fixed ovarian stimulation regimen. Of 47 patients treated, 38 (81%) responded appropriately to stimulation. Of these, 23 had partners with normal semen parameters and 5 of 21 (24%) who had GIFT conceived. Two others were found to have tubal damage. Their eggs were transported to an in-vitro fertilization unit at another hospital. Both conceived after embryo transfer. In 15 couples, the semen was found to be sub-optimal and none of these became pregnant. GIFT can be performed in a district hospital, on a fixed schedule in conjunction with a diagnostic laparoscopy. The technique appears unsuitable for patients with suboptimal semen and the backing of an in-vitro fertilization unit increases pregnancy rates.
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The widespread use of clomiphene citrate and exogenous gonadotrophins for in vitro fertilization (IVF) in human frequently results in the production of multiple embryos. Replacement of more than two embryos increases pregnancy rate but may result in multiple pregnancies with increased pre- and post-natal abnormality. Preservation of embryos for a limited time allows fewer embryos to be replaced on several different occasions and thus the problems of multiple pregnancy can be minimized, the effectiveness of a single IVF procedure increased and embryo replacement in adverse maternal conditions avoided. Preimplantation embryos have been successfully cryopreserved in many animal species. The sensitivity of embryos to cooling and freezing varies between species and stages of embryo development. We report here the cryopreservation procedures that allow a high survival rate of four- and eight-cell human embryos and the establishment of a pregnancy following the freezing and storage of an eight-cell embryo for 4 months in liquid nitrogen. The pregnancy terminated at 24 weeks' gestation due to development of a septic Streptomyces agalactiae chorion amnionitis after premature membrane rupture.
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The pregnancy in polycystic ovary syndrome (PPCOS) study was a prospective, multi-center, randomized clinical trial comparing three ovulation induction regimens: clomiphene citrate (CC), metformin and the combination of the two. There were 446 women who ovulated in response to the treatments among the entire 626 participants. In this report, we focus on the 418 women who received CC (alone or combined with metformin) to determine if readily available baseline physical characteristics and/or easily obtainable baseline measures could be used to distinguish treatment effectiveness in stimulating ovulation. We used a recursive partitioning technique and developed a node-splitting rule to build decision tree models that reflected within-node and within-treatment responses.
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Thirty women from the University of Vermont Reproductive Endocrinology Service with unexplained, male, or cervical factor infertility.
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The plum-blossom needle therapy based on regulating Thoroughfare, Conception, Governor and Belt Vessel could improve the ovarian blood perfusion, promote the follicular growth, increase the ovulation rate of mature follicle and avoid the out-of-sync between growth of follicle and endometrium during the treatment of western medication.