IVF & Genetic Center Jabalpur Madhya Pradesh, India

Dear Colleagues

Hello

In this month we have our journal club and a young gynecologist of the city Dr.Anupama Solonki presented her topic on “ steroid synthesis and Two cell-two gonadotropin theory” . It was very basic in reproductive endocrinology and with new facts of paracrine and autocrine actions of various cytokines.In the same context I presented one topic on clinical correlation of this theory in ovulation induction and ovarian stimulation. Various facts of different drugs were discussed.
In this news letter I took two drugs ,which I found of interest ,one is clomiphene citrate and the other is GnRh antagonist. I am really touched by the response I am getting for this news letter, I request you all to contribute in this endeavor to bring new clinical facts to our colleagues.

Thanks once again
Sincerely yours
Dr.D’Pankar Banerji 

1.Clomiphene citrate: Some useful points

Clomiphene acts as a competitive antagonist of 17beta estradiol at the level of the cytoplasmic nuclear receptor complexes in the hypothalamus, pituitary and elsewhere. Blockade of E2 receptor at eh level of hypothalamus leads to increase in gonadotropin –releasing hormone (GnRh) and to an increase in LH and presumably FSH.
FSH and LH rise is increased to 3-4 fold.
It requires an intact hypothalamus-pituitary-ovarian axis an destrogen
Due to its site of action the dose should be taken in one time to optimize its entry into hypothalamus.

After administration : A stedt state approximately 25%,of peak concentration is reached at 48 hrs. and remains constant fprthe next 14 days
Dose of clomiphene necessary to induce ovulation or increase luteal phase progesterone os proportional to body weight
The effect of repeated administration of a single 50mg tablet at 28 days interval is cumulative,wit basal level of zu-clomiphene omcreasing by 50% per month. Owing to the accumulation of zuclomiphene, clomiphene may be more effective in inducing ovulation during the second and later cycles of treatnment, even though the dose administered remains the same.
After ovulation induction with clomiphene, serum progesterone and estradiol serum levels are increasd during the luteal ppase of the cycle in a direct dose –response relationship.
Clomiphene citrate I given for 5 days,beginning from day 3- day5
Clomiphene is ineffective if started too soon,before estradiol level are 45-60 pg/ml. Follicles are 6 mm or greater when estradiol is in this range.
Starting dose should not be greater than 50 mg when weight is around 50 kg and should not be more than 100mg when around 75 kg.

Test required before starting clomiphene :
Ultrasound: Clomiphene should not be sarted if the endometrial lining is more than 6 mm,follicular response will be poor. It should be done to rule out any persistand corpus luteum,ovarian neoplasm,endometriosis and antral follicle count.
Ovarian cysts: cysts larger than 4 cm should be explored surgically,not drained. Smaller cyst without cancer chareacteristics of wall thickness 3 mm or greater or inclusions may either be followed until they resolve or suppressed with oral contraceptives.Progesterone alone is ineffective, and GnRh agonists may cause functional cysts to grow larger.
E2 and Progesterone : E2 > 45-60 pg/ml ,clomiphene will be effective. Raised progesterone will tell whether retension cyst is active or not. Before deciding that a patient is clomiphene resistant,E2 level should me measured on the customary start day to determine if clomiphene has been started too soon.
Monitoring :
Follicular development : In clomiphene cycle, the lead follicle is usually 20-24 mm the day ovulation and 18-20 mm the day of spontaneous LH surge.highest pregnancy rates occur when there are four follicles 15 mm or larger ad are not increased when five or more follicles.when HCG is used to trigger ovulation, highest pregnancy rates are achieved when the lead follicle is 16 mm.
Endometrial thickness : It should be at least 6 mm and preferably 9 mm or greater on preovulatory ultrasound. Endometrial thickness increases at a faster rate in clomiphene cycles than in spontaneous cycles durig the late proliferative phase as it escapes from antiestrogen effect of clomiphene.
Serum or urine LH : an increase in serum LH twice Vaseline level predicts ovulation within 24 hrs and urine LH predicts ovulation within 12 hrs.
Progesterone : It is used to confirm ovulation to determine if the dose of clomiphene is sufficient. It should be measured in midluteal phase5-7 days after ovulation,to conside with the day embryo inplantation. Progesterone levels in th midluteal phase of clomiphene cycles that result in term pregnancies average 37 pg/ml,compared to 22 pg/ml in spontaneous cycles. If it is found less in luteal phase then additional progesterone should be given to increase it above 20 pg/ml.
Intra-uterine insemination : IUI should be considered fpr women whose partner’s sperm only meets minimal standards for normal as well as women who have mucus abnormalities.
Unexplained infertility : use of clomiphene to increase pre-ovulation estrogen level and post ovulation progesterone levels, alone or combined with IUI has been shown to be an effective first-line treatment for “unexplained infertility”. Diagnosis of luteal insufficiency can be missed if it is assumed that a progesterone level of 5 pg/ml is normal. In fact it should be more than 15 pg/ml.
How many cycles of clomiphene should be performed: cumulative pregnancy rates after six cycles of clomiphene IUI reached 75% in women receiving donor semen and 65% in women treated with clomiphene for ovulatory dysfunction if they ere younger than forty two yrs, used sperm of satisfactory quality and did not have endometriosis or tubal factor

2.GnRh antagonist regimen in IUI and IVF
New GnRh antagonists (cetrorelix and ganirelix) have been developed and approved for use in assisted reproduction technology like IUI and IVF.
Its invention becomes a great help in preventing premature LH surge during ovarian stimulation. During ovarian stimulation FSH and/or hMG or drugs like clomiphene citrate or letrozole are used to select more eggs to maturation. But because of rise of estradiol more than the threshold level in the early pre-ovulatory phase, it leads to premature LH surge (or attenuated LH surge) before the eggs are mature enough to get fertilized.
These agents compete with natural GnRh for binding to membrane receptors on pituitary cells and thus control the release LH and FSH in a dose dependent manner. The onset of LH suppression is approximately 1-2 hours post-administration depending on the dosage used. This suppression is maintained by continuous treatment, and there is a more pronounced effect on LH than on FSH. An initial release of endogenous gonadortropin has not been detected with the use of GnRh antagonists. Because they avoid the flare effect associated with the use of GnRh agonists, they can be started concurrently with gonadotropins and do not require additional time for down regulation. Typically, the antagonist is administered by daily subcutaneous injection, beginning on cycle day 7 or more commonly, when the lead follicle reaches 14 mm in diameter. Alternately, the medication may be administered as single bolus dose on approximately cycle day 8.
A recent review shows that both the GnRh analogue protocol and GnRh antagonist protocol are equally effective in preventing premature LH surge.
One of the factors with antagonist ,is that it has significantly less pregnancy rate compared to GnRh agonist ,but the advantage is that it has less chances of ovarian hyperstimulation syndrome and it can be effectively used in IUI protocols. It helps to make the treatment cheaper and more user friendly.
3.Fellowship course in Reproductive endocrinology and Infertility

Program
Day 1 :Theory : Basic reproductive endocrinology of female, Understanding of Hypothalamo-pituitary-gonadal axis
Practical : Microscopy, stereozoom, trinocular, micro-photography and documentation ,inverted microscope and micromanipulator introduction
Day 2:Theory : Introduction to cell biology and cell division and cell culture, Meiosis and Gametogenesis, Culture media preparation
Practical : Tissue culture media preparation for IUI
Day 3:Theory : Basic endocrinology of Male, Hormonal control of Spermatogenesis
Practical : Routine semen analysis, sperm preparation methods for IUI, hands on
Day 4 :Theory : Anovulation and Polycystic ovaries ,Hirsutism
Practical : Preparation of culture dishes and droplet making under oil
Day5 :Theory : Amenorrhoea ,How to deal with it.
Practical : Hands-on retrieval of mammalian eggs and their in vitro maturation
Day6 :Theory : Induction of Ovulation for IUI and IVF
Practical : Observation and demonstration of Cryo preservation techniques

• Theory classes will be from 9.30am to 11.00am.
• Candidates can repeat their practical, if they wish
• Candidates will be involved in daily OPD infertility counseling and treatment approach from 11-4 . They will see and do transvaginal sonography (as patients allow).
• They will be allowed to observe IVF and ICSI procedures done during their stay. They will have access in embryology laboratory to see the lab set up and equipments and exposure to embryology ( observation), fertilization to blastocyst stage and embryo transfer.*
• Fees : Rs .25,000 per candidate. Students** : Rs.15,000
• One or Two candidates are allowed in one batch
• Course will be from Monday to Saturday of a week.
• Certificate of attendance will be given at the end of the course
• Prior registration is must with full payment( demand draft in the name of Dr.D'Pankar Banerji,payable at Jabalpur)
• Stay and food is extra. Stay @ Rs. 500-1500/day can be arranged in nearby hotels within one kilometer of the venue

Faculty :
1. Dr.D'Pankar Banerji, Consulting Gynecologist and Infertility specialist
2. Dr. Mrs. Rinku Banerji ,Consulting Pathologist and Embryologist

Venue :

Ideal Fertility, ICSI,IVF and Genetic center, Jabalpur
*Depending on the availability of cases.
**Student, applies to undergraduate medical students and residents. A letter from the Head of the Department proving the participant’s student status must accompany each student registration