Clomiphene Stair-Step Protocol for Women With Polycystic Ovary Syndrome

Jones, T.L.; Ho, Jocelyn; Gualtieri, M.; Bruno-Gaston, Janet; Chung, Karine; Paulson, Richard J.; Bendikson, Kristin

doi:10.1097/aog.0000000000002418

Cited by 22 publications

(22 citation statements)

References 20 publications

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“…Standard treatment for ovulation induction with CC in women with PCOS has been doses of 50‐150 mg per day for 5 days starting on day 3‐5 after the onset of a withdrawal bleeding. With increasing dose of CC, the probability of ovulation rises from approximately 45% to 90%, therefore a stair‐step protocol to rapidly increase probability of ovulation has been suggested . The multiple pregnancy rate is almost 10 times higher than in spontaneous conceptions, therefore monitoring with ultrasound to detect multifollicular development and to advise the couple when to have intercourse should be performed .…”

Section: Resultsmentioning

confidence: 99%

Ovulation induction in polycystic ovary syndrome

Tanbo

Mellembakken

Bjercke

et al. 2018

Acta Obstet Gynecol Scand

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The objective of this narrative review was to suggest a rational order of treatment choices in anovulatory women with polycystic ovary syndrome (PCOS), for whom a multitude of treatment options exist. In obese/overweight women with PCOS the importance of weight reduction should be stressed. Inositol, a dietary supplement with a documented effect on ovulation and without adverse effects in the doses recommended, may be suggested. Additional first-line medical alternatives include insulin sensitizers, selective estrogen receptor modulators, and aromatase inhibitors. Of these, the aromatase inhibitor letrozole and the combination of clomiphene citrate and metformin have the highest rates of ovulation and live birth. Second-line treatments are ovarian electrocautery and low-dose follicle-stimulating hormone stimulation. Controlled ovarian stimulation with in vitro fertilization, should be considered the last option as it carries a significant risk of ovarian hyperstimulation syndrome in patients with PCOS.

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Section: Resultsmentioning

confidence: 99%

Ovulation induction in polycystic ovary syndrome

Tanbo

Mellembakken

Bjercke

et al. 2018

Acta Obstet Gynecol Scand

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“…Other important risk factors for EP include a history of EP, damage to the fallopian tubes, pelvic infection, pelvic or fallopian tube surgery, and infertility. Other less significant risk factors include cigarette smoking and patients older than 35 years ( 11 ) . But one half of all the women who were diagnosed with EP do not present any known risk factors like the presented case ( 12 ) .…”

Section: Discussionmentioning

confidence: 99%

“…The management of an EP depends on the hemodynamic status of the patient, the location, gestational age, the activity of the trophoblast human chorionic gonadotropin-beta, as well as the presence of a concomitant pregnancy (heterotopic pregnancy) and obstetric history of the patient. Methotrexate treatment can be considered for women with a confirmed diagnosis of EP who are hemodynamically stable, who have an unruptured mass, and who do not have absolute contraindications for methotrexate ( 11 ) . The decision for the surgical management or medical management of EP should be guided by the initial clinical, laboratory, and radiologic data as well as patient-informed choice based on a discussion of the benefits and risks of each approach.…”

Section: Discussionmentioning

confidence: 99%

Spontaneous unilateral quadruplet tubal ectopic pregnancy

Karadağ¹,

Yüksel²,

Gürses³

et al. 2020

tjod

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Ectopic pregnancy (EP) is defined as the implantation of the fertilized ovum outside the uterine cavity. Importantly, the implantation site is tubal in 95% of the cases. Multiple EPs are extremely rare. We present a case of a 25-year-old patient, gravida 2 para 1, with amenorrhea accompanied by the complaints of vaginal bleeding and abdominal pain. She was admitted to the emergency department. Trans-vaginal ultrasound revealed a left ovarian anechoic cyst of 30 mm and four embryos in the right tube with positive cardiac activities. An emergency laparotomy found the rupture of tubal pregnancy on the right side, which ultimately led to hemo-peritoneum. Therefore, we performed right salpingectomy. This is the first well-documented case of a patient with spontaneous unilateral quadruplet tubal EP.

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“…Ectopic pregnancies can be treated with various medical and surgical interventions, including expectant management, methotrexate, salpingostomy, and salpingectomy. Management decision should be guided by patient-informed preference, clinical evaluation, and laboratory and radiological information [4]. Surgical management is necessary if patients have an absolute contraindication to methotrexate use, are hemodynamically unstable, have symptoms of a ruptured ectopic pregnancy, or have signs of intraperitoneal bleeding [4].…”

Section: Introductionmentioning

confidence: 99%

“…Management decision should be guided by patient-informed preference, clinical evaluation, and laboratory and radiological information [4]. Surgical management is necessary if patients have an absolute contraindication to methotrexate use, are hemodynamically unstable, have symptoms of a ruptured ectopic pregnancy, or have signs of intraperitoneal bleeding [4]. According to randomized control trials, there is no fertility advantage of salpingostomy versus salpingectomy in the management of tubal ectopic pregnancy with a healthy contralateral tube [5].…”

Section: Introductionmentioning

confidence: 99%

Simulation-based Training in Ectopic Pregnancy and Salpingostomy

Sabatina

Shah

Gothard

et al. 2019

Cureus

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ObjectiveEctopic pregnancy leads to approximately 3% of deaths in pregnancy. Surgical management is indicated when patients are hemodynamically unstable or have signs of a ruptured ectopic pregnancy. Salpingectomy is more commonly performed, but salpingostomy is preferred in a patient with prior salpingectomy with a desire for future pregnancy. Due to the lack of exposure, salpingostomy is not frequently performed and most residents do not feel adequately trained. Our goal was to provide a hands-on simulation about ectopic pregnancy and salpingostomy in hopes that the simulation will improve the resident’s confidence and knowledge in recognizing an ectopic pregnancy, identifying an appropriate candidate for surgical management, and performing a salpingostomy.MethodsThe educational initiative was aimed towards postgraduate year (PGY) 1-4 OB/GYN residents (n=11). Knowledge and confidence questionnaires were given to participants prior to and post-simulation. A gynecologic mannequin was modified by taking the existing pelvic organs and creating a tubal pregnancy. In the first part of the simulation, a hemodynamically unstable patient presented with lab and imaging findings consistent with an ectopic pregnancy. Once recognized and the decision made for surgical intervention, participants were transferred to a simulated operating room where they performed salpingostomy or salpingectomy on the mannequin. The simulation was followed by a debriefing session to discuss the actions and thought processes of participants, provide reflection, and incorporate improvement opportunities for future cases. Finally, participants engaged in a didactic lecture where they were educated about the incidence, presentation, and management of tubal ectopic pregnancy.ResultsAnalysis of the knowledge questionnaires showed the median score pre- and post-intervention was 9 and 12, respectively, with a median change of 3 (p=0.001). The median confidence value pre- and post-intervention were 28 and 42, respectively, with a median value change of 12 (p<0.001).ConclusionOur intervention improved residents' confidence and knowledge in recognizing an ectopic pregnancy, identifying an appropriate candidate for surgical management, and performing a salpingostomy.

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Clomiphene Stair-Step Protocol for Women With Polycystic Ovary Syndrome

Abstract: For women with PCOS, the stair-step clomiphene protocol is associated with decreased time to ovulation and increased ovulation rates at higher doses when compared with the traditional protocol.

Cited by 22 publications

References 20 publications

Ovulation induction in polycystic ovary syndrome

Ovulation induction in polycystic ovary syndrome

Spontaneous unilateral quadruplet tubal ectopic pregnancy

Simulation-based Training in Ectopic Pregnancy and Salpingostomy

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