ABSTRACT
Objective: To evaluate the value of ovarian suppression by administration of combined oral contraceptives for two months followed by ovulation induction using a minimal stimulation protocol in patients who failed to ovulate in response to clomiphene citrate treatment. Design: Prospective, randomized observational study. Setting: Infertility clinic, Woman's Health Center, Assiut University. Materials and methods: Sixty patients with evidence of anovulation documented by transvaginal ultrasonographic monitoring were included in the study. Baseline serum levels of Follicle stimulating hormone, luteinising hormone and estradiol were estimated in all patients at study entry. Patients were equally divided into two groups. The study group was given low dose combined oral contraceptive pills for two cycles to induce hypothalamo-pituitary–ovarian suppression. In the third cycle, patients were given 100 mg clomiphene citrate daily from day 3-7 and a single dose of 150 IU highly purified human follicle stimulating hormone at day 9. When one leading follicle attained a diameter ≥18 mm, human chorionic gonadotropin 10,000 IU was given to trigger ovulation and then timed intercourse was advised. The second (control) group was given the same treatment without previous ovarian suppression. Follicle stimulating hormone, luteinising hormone and estradiol levels were measured in the study group before and after combined oral contraceptive administration. Follicular growth, ovulation, occurrence of pregnancy and hyper-stimulation syndrome were looked for in both groups. Clinical pregnancy was defined as positive gestational sac with positive fetal heart beat viewed by transvaginal ultrasound. Results: Follicle stimulating hormone, luteinising hormone and estradiol levels were significantly lower in the study group after two months of combined oral contraceptive treatment compared to pretreatment levels. Mono-ovulatory cycles and pregnancy rates were significantly higher in the study group. Conclusion: The use of combined oral contraceptive pills to induce ovarian suppression followed by clomiphene citrate, highly purified human follicle stimulating hormone and human chorionic gonadotropin treatment can induce ovulation among cases with chronic anovulation resistant to clomiphene citrate treatment.