Role of Low-Dose Human Chorionic Gonadotropin Following Clomiphene Citrate in Folliculogenesis and Ovulation in Infertile Women


Background:Ovulation disorders, usually presents as menstrual disturbance, arethe cause of infertility in around 25% of couples who have difficulty to conceive.The drug most commonly prescribed for the induction of ovulation is clomiphenecitrate (CC). If the patient does not ovulate after the use of CC, the choice wasto add gonadotropins. Gonadotropin therapy is very expensive with significantrisks of high order multiple gestations and ovarian hyperstimulation syndrome.Human chorionic gonadotropin hCG can function as a surrogate for LH and occupiesLH receptors for more than 24 hours allowing prolonged stimulation alsoit has longer half-life and greater affinity for the LH receptor.Objective: The purpose of this study was to compare the effectiveness of lowdosehuman chorionic gonadotropin (hCG) in the late follicular phase to induceovulation in clomifene citrate resistant patients who had previously failed toovulate on clomiphene citrate (CC) alone.Subjects,Materials and Methods: A total of 71 patients who attend infertilityclinic in the High Institute of Infertility Diagnosis and Assisted ReproductiveTechnologies, Al-Nahrain University, where prospectively randomly assignedinto two groups. hCG Group received 100 mg dose of CC from day 5 of menstrualcycle for 5 days, then each patient received 200 IU hCG (DICLAIR®)subcutaneous injection daily when the largest follicle mean diameter was 12 mmor larger starting on day twelve of menstrual cycle. Non-hCG group received 150mg dose of CC from day 5 of menstrual cycle for 5 days, and both groups weremonitored with transvaginal ultrasound. Ultrasound measurements of folliclenumber and growth, ovulation, endometrial thickness and pattern were recordedand compared between the two groups. Student t test and fisher exact test wereused for statistical comparison between the two groups.Results: The low-dose hCG group had significantly higher percentage of ovulatorycycles (80% vs 44.4% P value 0.006). There was no significant difference inthe endometrial thickness between the groups but it appears higher in hCG group(10.55±1.82 vs. 9.62 ± 1.87 in non-hCG group, p value 0.056). Non significantbut higher incidence of echogenic (luteinized) endometrium 48 hour post ovulationin hCG group (36/40 (90%) vs. 20/25 (80%) for non-hCG group p-value =0.288).Conclusions: The use of low-dose hCG after CC in the late follicular phase resultsin continued follicle growth, higher ovulation rate. This treatment offers anefficient and cost-effective alternative before gonadotropin therapy for this typeof patients.