Obstetric implications for and identification of women with a normal clomiphene citrate challenge test result who have a poor response to gonadotropins
Received 3 March 2003; received in revised form 17 May 2004; accepted 17 May 2004.
Objective
To determine the incidence and obstetric implications and to identify prospectively women with a poor response to hMG with a normal clomiphene citrate challenge test (CCCT) result.
Design
Retrospective chart review.
Setting
Tertiary fertility center.
Patient(s)
One hundred sixty-three women who underwent ovulation induction with hMG for IUI, and 266 women who underwent ovulation induction with GnRH analogue and hMG for IVF. All had a CCCT before stimulation. Seventy-five percent of IUI patients (123 of 163) and 89% of IVF patients (238 of 266) had normal CCCT results. A poor response to hMG was defined as a response less than the 90th percentile of women with an abnormal CCCT result (peak E2 [pg/mL] level per ampule hMG used: 90th percentile ≤30).
Intervention(s)
Clomiphene citrate challenge test and ovulation induction for IUI or IVF.
Main outcome measure(s)
Response to gonadotropins and pregnancy outcome after treatment.
Result(s)
Thirty-five percent of IUI patients (43 of 123) and 52% of IVF patients (123 of 238) with a normal CCCT result had a poor response to hMG. Intrauterine insemination patients with a poor response to hMG had significantly lower delivery rates than IUI patients with a normal response (19% vs. 39%). In vitro fertilization patients with a poor response to hMG had similar delivery rates compared with IVF patients with a normal response (32% vs. 35%). For both groups of patients, an FSH >12 mIU/mL (IMx assay) on either day 3 or day 10 (normal ≤14.5 IMx) was highly predictive of a poor response to hMG, the elevated FSH level being a much better predictor than the woman's age.
Conclusion(s)
A poor response to hMG with a normal CCCT result (false negative) is a common event. A day-3 or day-10 FSH >12 mIU/mL (IMx assay) or 20 mIU/mL (converted to the original RIA) will identify approximately 80% (IUI) and approximately 94% (IVF) of the women who will experience a poor response to hMG. When identified, the data suggest that these patients will benefit significantly from the more aggressive IVF.
aBethesda Center for Reproductive Health and Infertility, Bethesda Hospital, Cincinnati, Ohio, USA
bDepartment of Environmental Health, Division of Biostatistics and Epidemiology, University of Cincinnati, Cincinnati, Ohio, USA
Reprint requests: Glen E. Hofmann, M.D., Ph.D., Bethesda Center for Reproductive Health and Infertility, Bethesda Hospital, 10506 Montgomery Road, Cincinnati, Ohio 45242 (FAX: 513-745-1676
Presented in part at the annual District V meeting of the American College of Obstetrics and Gynecology, Palm Beach, Florida, October 22–23, 2001.
ABSTRACT