1. OVULATION INDUCTION WITH CLOMIPHENE CITRATE IN PCOS Professor IOANNIS E. MESSINIS MD, PhD (Aberdeen, UK) Head of Department of Obs/Gynae University of Thessalia Larissa, Greece

2. . Li nk s Induction of ovulation with MRL/41. Preliminary report. JAMA. 1961, 178:101-4. Greenblatt RB, Barfield WE, Jungck EC, Ray AW

3. HYPOTHA LAMUS HYPOTHA LAMUS PITU ITA RY OVARY PITU ITA RY OVARY NORMALCLOMIPHENE (-) GnRH FSH LH FSH LH E2 ER

4. ClomidLH FSH Estradiol-17β Progesterone 15 14 28 Day of cycle EFFECT ON GONADOTROPHINS Adashi, 1984 Fertil. Steril. 42, 331-44

5. CC VS PLACEBO 4 studies (cross-over) - CC increased ovulation (OR: 6.8) (3 studies) and pregnancy rate (OR: 3.41) (2 studies) (Hughes et al., 2000 Cochrane Database Syst. Rev. (2): CD000056) 3 RCTs - CC increased pregnancy rate (OR 5.8, 95% CI 1.6 to 21.5) (Beck et al., 2005 Cochrane Database Syst. Rev. (1): CD002249)

6. CC ADMINISTRATION For 5 days Onset on days 2-5 No difference between different days of onset Starting dose 50 mg/day per os

7. CC: MONΙTORING OF TREATMENT No consensus Progesterone assay Ultrasound Estradiol assay Basal body temperature chart

8. 2 6 21 28 CC 50 mg/day P4 CYCLE DAYS PROTOCOL OF CLOMIPHENE CITRATE USE

9. RESULTS OF TREATMENT WITH CC 5 STUDIES (1968-1983): A total of 5878 cases - Ovulation rate:70-86% - Pregnancy rate:34-43% - Miscarriage rate:13-25% Messinis, 2002; Clomiphene citrate In: Ovulation induction, Elsevier, pp. 87-97

10. 100 50 0 2 4 6 8 10 Number of cycles Hammond et al., 1983; Obstet. Gynecol. 62, 196-202 (modified) OVULATION INDUCTION WITH CLOMIPHENE Diaphragm Clomiphene Cumulative pregnancy rate (%) 97%

11. 100 80 60 40 20 0 123456>6 23.2 32.6 39.0 42.5 51.5 61.3 67.3 17.7 26.6 32.7 36.0 45.2 51.4 56.6 % conceived CYCLE NUMBER CUMULATIVE CONCEPTION AFTER CC Kousta et al., 1997 Hum. Reprod. Update 3, 359-65 (n=128 women) All patients who responded Excluding other infertility factors

12. (n=55 women) 284 cycles Messinis & Milingos, 1997 Hum. Reprod. Update, 3, 235-253 12 3 4 5 6 7 8 9 10 11 12 Treatment cycle ClomipheneLow dose HMG 100 80 60 40 20 0 Cumulative pregnancy rate (%) OVULATION INDUCTION IN PCOS 63% 91%

13. A CONSECUTIVE SERIES OF 240 NORMOGONADOTROPHIC ANOVULATORY WOMEN (CC first, followed by FSH) 0 3 6 9 12 15 18 21 24 Follow-up (months) 1 0.8 0.6 0.4 0.2 0 50% 71% Eijkemans et al., 2003; Hum. Reprod. 18, 2357-2362 Ongoing Singleton Pregnancy Rate Resulting in Live Birth A

14. RECOMMENDATION In properly selected PCOS patients with no other causes of infertility, treatment with CC can be extended beyond the 6 cycles.

15. OVULATION INDUCTION WITH CLOMIPHENE Response (ovulation – conception) Response (ovulation – no conception) CLOMIPHENE FAILURE No response (no ovulation) CLOMIPHENE RESISTANCE

16. CLOMIPHENE FAILURE (Ovulation but no conception) Anti-estrogenic effects on: - cervical mucus - endometrium - oocytes High LH

17. CC: EFFECTS ON CERVICAL MUCUS Meta-analysis 6 RCTs (1980-1996) Unfavorable effect: CC (100 mg/d) (OR 7.90, 95% CI 4.15 to 15.0) CC (150 mg/d) (OR 7.50, 95% CI 1.97 to 28.6) CC 50 mg: No adverse effect Roumen, 1997, Ned.Tijdschr. Geneeskd 141, 2401-5

18. Thickness  Number and diameter of glands  Number of vacuolated cells  β3 integrin expression (out-of-phase)  Failure in the down-regulation of PR Affected endometrial receptivity? CC: EFFECTS ON ENDOMETRIUM Nakamura et al., 1997 (Fertil. Steril.); Sereepapong et al., 2000 (Fertil. Steril.); Palomino et al., 2005 (Fertil. Steril.)

19. CC: EFFECTS ON THE OOCYTE CC in vivo did not affect cleavage in vitro CC adversely affects oocyte in vivo maturation Increased rate of immaturity with CC vs GnRH-a CC induces aneuploidy in mouse oocytes Messinis & Templeton, 1986; BJOG Seibel & Smith 1989; J. In Vitro Fert. Embryo Transfer Pieters et al., 1991; Fertil Steril. London et al., 2000; Fertil. Steril.

20. CC FAILURE Can we improve? Patients selection Combinations of clomiphene with other drugs Second line treatment

21. - Increase in: FAI BMI Mean ovarian volume Insulin, LH Age - Amenorrhea Imani et al., 1998 (JCEM), 1999 (JCEM), 2002a (Fertil. Steril.), 2002b (Fertil. Steril.), Van Santbrink et al., 2002 (Fertil. Steril.) CLOMIPHENE RESISTANCE (No ovulation)

22. FAIBMIAge Chance of ovulation (%) Chance of a live birth (%) (95% CI) Oligo- Ameno- Oligo- Ameno- A NOMOGRAM PREDICTING LIVE BIRTH (CC) Imani et al., 2002; Fertil. Steril. 77, 91-97 7 40 36 35 11 Chance of ovulation (%)

23. Higher doses (up to 250 mg) Extended treatment (~ 20 days) Combinations with other drugs CC RESISTANCE Is it possible to sensitize?

24. CC DOSE – PREGNANCY (PCOS) Treatment dose (mg) Women conceiving (n=35) % 50 100 150 18 11 6 51 32 17 Based on: Messinis & Milingos, 1997 Hum. Reprod. Update, 3, 235-253

25. Is clomiphene still the first line of infertility treatment in PCOS?

26. Alternatives as first line? Insulin sensitizers (Metformin) Aromatase inhibitors (Letrozole) Laparoscopic ovarian drilling (LOD) Low-dose FSH

27. METFORMIN vs CC First line 626 women with PCOS Live-birth rate CC39.5%47/209 (22.5%) CC + M46.0%56/209 (26.8%) M21.7%  5/208 (7.2%)   P<0.001  P=0.002 Conception rate Legro et al., 2007 N. Engl. J. Med. 356, 551-66

28. METFORMIN+CC First-line (Dutch study) CC+M vs CC+P (228 PCOS women) No difference in: Ovulations (64% vs 72%) Ongoing pregnancies (40% vs 46%) Miscarriages (12% vs 11%) Moll et al., 2006 BMJ 332, 1485 PRT

29. CC+M IN PCOS Systematic review CC is still first choice therapy In CC-resistant women, CC+M is the preferred treatment before moving to LOD or FSH Moll et al., 2007 Hum. Reprod. Update 13, 527-537

30. CC+M IN PCOS Meta-analysis 17 studies, 1639 women with PCOS CC+M vs CC (in CC resistance) (12 studies) –Ovulation (OR 4.39, 95% CI 1.94 to 9.96) –Pregnancy (OR 2.67, CI 1.45 to 4.94) Creanga et al., 2008 Obstet. Gynecol. 111, 959-68

31. Probability of Baseline estimate Range Live birth on CC0.210.15-0.22 Live birth on M0.150.07-0.52 Live birth on M+CC0.230.18-0.27 FERTILITY TREATMENT IN WOMEN WITH PCOS Jungheim and Obido, 2010 Fertil. Steril. May 6 (Epub)

32. CC vs METFORMIN Clinical pregnancy rate Live birth rate CC39% (14/36)36% (13/36) M40% (14/35)29% (10/35) CC+M54% (19/35)43% (15/35) Johnson et al., 2010 Hum. Reprod. Apr 30 (Epub) BMI  32 Kg/m2

33. METFORMIN vs CC Metformin improves clinical pregnancy and ovulation rates. There is no evidence that metformin improves live birth rates whether it is used alone or in combination with CC, or when compared with CC. Tang et al., 2010 Cochrane Database Syst. Rev. Jan 20; (1): CD 003053

34. Letrozole 5 mg/d (n=218) Clomiphene 100 mg/d (n=220) P No. of follicles 4.4  0.4 6.8  0.3 0.042 Endom. Thick. (mm) 8.1±0.2 9.2±0.7 0.021 Serum E2 (pg/ml) 255.1±64.2 384.0±91.3 0.022 Serum P4 (ng/ml) 7.1±0.9 11.1±1.2 0.024 Days of stimulation 12.1±1.38 8.0±2.9 0.036 Preg./cycle 82/540 (15.1%) 94/523 (17.9%) Miscarriage/patient 4 (12.1%) 4 (9.7%) LETROZOLE vs CLOMIPHENE (First-line) Badawy et al., 2007 Fertil. Steril. doi:10.1016/j.fertnstert.2007.02.062.

35. LETROZOLE IN PCOS Meta-analysis 4 RCTs Letrozole vs CC –Ovulation (OR 1.17, 95% CI 0.66 to 2.09) –Pregnancy/cycle (OR 1.47, CI 0.73 to 2.96) –Pregnancy/patient (OR 1.37, CI 0.70 to 2.71) Requena et al., 2008 Hum. Reprod. Update 14, 571-82

36. 123456789101112 70 60 50 40 30 20 10 0 CCLOD OVULATION INDUCTION IN PCOS CC vs LOD as first line Amer et al., 2009; Hum. Reprod. 24, 219-225 Time (months) Cumulative pregnancy rate %

37. OI IN PCOS CC vs rFSH (first line) CCrFSH Women/cycles38/10438/91 Ovulation53%74% Preg./cycle 9%18% Preg./ov. Cycle16%29% Preg./woman24%42% Live births/woman16%29% Twins 019% Lopez et al., 2004 RBMOnline 9, 382-390 3 months treatment

38. CC: SIDE EFFECTS Hot flushes (10%) Nausea, vomiting, breast tenderness, dizzines, mild skin reactions (2%) Visual disturbanses (blurred vision) (1.6%) Multiple follicles – OHSS (rare) Multiple pregnancies (2-17%)

39. CC: ADVANTAGES Low cost Oral administration Reasonably efficacious Few side effects Safe for offspring

40. Consensus on infertility treatment related to polycystic ovary syndrome. The Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group et al. Hum. Reprod. 23, 462-77, 2008 Fertil. Steril. 89, 505-22, 2008 WHO GROUP II PCOS

41. Obese Diet-Life style No compliance changes Ov (+) Ov (-) Pregnancy (-) Lean CC (6 m) Ov (-) Ov (+) M+CC (?) (6 m) Ov (-) Ov (+) Pregnancy (-) FSH (6 m) (LOD?) Ov (-) Ov (+)Pregnancy (-) IVF OVULATION INDUCTION ALGORITHM IN WHO GROUP II (PCOS) ? M: Metformin CC: Clomiphene citrate Ov: Ovulation LOD:Laparoscopic ovarian drilling 1st line 2nd line 3rd line

42. SUMMARY I A high ovulation rate is achieved with CC Conception rate can be also high in properly selected patients Consecutive treatments with CC and low-dose FSH result in high cumulative conception and singleton live birth rates

43. In CC failure, it is recommended to proceed with the next step, i.e. low- dose FSH In CC resistance, combinations of CC with metformin may be efficacious before the use of second line therapeutic regimens SUMMARY II

44. CONCLUSIONS CC effectively induces ovulation in PCOS patients Conception and singleton live birth rates are reasonable Side effects and complications are rare CC remains the first choice for infertility treatment in PCOS