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Medication with Clomiphene Citrate and its effects on the quality of cervical mucus and the addition of exogenous estrogens in order to suppress abnormal mucus secretion are controversial issues. We have prospectively studied a group of 19 anovulatory women who were treated with clomiphene citrate in order to characterize those patients most likely to respond to the addition of exogenous estrogens. On day 14 of the cycle, 17 beta estradiol and cervical score were measured and 1 mg estradiol benzoate was injected intramuscularly. Cervical scores were below 7 in 12 out of the 19 patients before estradiol benzoate administration. In these patients, 17 beta estradiol rose from 751 +/- 541 to 1321 +/- 648 pg/ml (p less than 0.03), and cervical scores rose from 3.75 +/- 2.1 to 7.1 +/- 3.7 (p less than 0.01), after estradiol benzoate administration. Patients with cervical scores of 8-12 did not improve significantly. In the 12 patients with cervical scores below 7, those (n = 6) with 17 beta estradiol below 600 pg/ml experienced a significant improvement in cervical score, in contrast to those (n = 6) with 17 beta estradiol above 600 pg/ml who had no improvement. The reduction in cervical mucus accomplished with clomiphene citrate can be further improved by adding exogenous estrogens, mainly in patients who have low 17 beta estradiol levels concomitant with low cervical score.

The study was designed to evaluate if ovarian hyporesponsiveness, which is associated with combined gonadotropin-releasing hormone agonist (GnRH-a) and human menopausal gonadotropin (hMG) therapy is because of suboptimal serum follicle-stimulating hormone (FSH) levels. Two groups of 12 patients each were suppressed with GnRH-a and stimulation with a fixed dose of hMG. The control group (n = 10) received equal doses of hMG only. The follicular phase and the number of hMG ampules was significantly higher in the study group. Basal FSH levels and FSH levels during hMG treatment were significantly lower in patients treated with GnRH-a. Peak estradiol levels and the outcome of in vitro fertilization treatment were similar in the three groups. We suggest that the delay in ovarian response in patients treated with a combination of GnRH-a and hMG is because of lack of endogenous contribution of FSH, resulting in low circulating levels of FSH. An increase of serum FSH levels by administration of higher doses of hMG can reverse this effect.

The effect of dexamethasone (DEX) (9 alpha-Fluro-16 alpha-methyl prednisolone) on secretion of steroids by human granulosa luteinized cells was studied by culturing cells from mature follicles of women with polycystic ovarian disease and treated for infertility in the in vitro fertilization program. Patients were treated with DEX 0.5 mg/d until the day of human chorionic gonadotropin administration. The cells were cultured for 24 hours in the presence of androstenedione (10(-7)M). After incubating for 24 hours, the medium was replaced and the cells were incubated for an additional 24 hours. The medium was then harvested and assayed for estradiol (E2) and progesterone (P). Results were compared with those of a control group who was not treated with DEX. Estradiol production by cells was significantly lower in the study group treated with DEX. Progesterone production was not influenced by DEX. Follicular fluid levels, E2, and androgens did not vary with DEX treatment, whereas cortisol levels markedly decreased and P levels increased with the treatment. These findings suggest that glucocorticosteroids can directly influence granulosa luteinized cell function.

During the last decade, 154 patients treated with human menopausal gonadotropin human chorionic gonadotropin developed hyperstimulation necessitating hospitalization in 201 cycles. Moderate ovarian hyperstimulation occurred in 116 of the patients and severe ovarian hyperstimulation in 34. Sixteen patients underwent operative procedures. Twelve patients underwent puncture of the pleura or abdomen to drain symptomatic hydrothorax or ascites, with clinical improvement of the symptoms in all of them. Three patients had coagulation abnormalities, and 1 patient had thromboembolic phenomena. Hyperstimulation seems to be associated with an increased pregnancy rate, since seventy-five pregnancies (35%) occurred in the study group. Appropriate monitoring can reduce the rate of OHSS but it should be kept in mind that death due to OHSS may occur.

Six women who became pregnant after human menopausal gonadotrophin/human chorionic gonadotrophin (hMG/hCG) treatment regimens were operated on between 6 and 21 weeks gestation with an intra-operative diagnosis of twisted ischaemic-haemorrhagic adnexa. During operation unwinding of the adnexa was performed in all patients. Monitoring of the pregnancy before and after operation by ultrasonography was normal. The postoperative period and the rest of the pregnancy were uneventful. Three women were delivered normally at term. One patient was delivered by caesarean section because of twin pregnancy with malpresentation, and two pregnancies are still ongoing beyond the first trimester. This preliminary study suggests that detorsion of ischaemic-haemorrhagic adnexa during pregnancy is an option that is not associated with subsequent complications. This approach might be adopted relatively safely when preservation of future fertility is a goal.