Antihormonal substance used to induce ovulation :
Ans. is b i.e. Clomiphene citrate 1. Clomiphene citrate is the initial treatment for most anovulatory infeile women. It is chemically similar to tamoxifen Clomiphene is a non steroidal triphenylethylene derivative which demonstrates both estrogen agonist and antagonist propeies (predominant). It is the agent of choice for women with oligomenorrhea or amenorrhea having sufficient ovarian function to maintain estrogen at a serum level of 40pg/ml. Patient selection : Normal gonadotropicdeg normoprolactinemicdeg patients with normal cycle with absent or infrequent ovulation.deg PCOSdeg Post pill amenorrhea.deg Dose : Initial dose of 25 to 50mgdeg is given daily from D2 - D 5. Ovulation is expected to occur about 5 - 7 days after the last day of therapy. If ovulation doesnot occur, dose is increased in 50mg steps to a maximum of 250mg daily. (Although doses > 100 mg /day are not approved by FDA). Therapy is in given for 4-6 cycles. Clomiphene will be successful in inducing ovulation in about 70% of women, with ovaries producing estrogen Switch over from clomiphene to more aggressive therapy is done when : There is no response to clomiphenedeg (even with 100 mg / day dosing). There is ovulatory response to clomiphene but no pregnancydeg (following 3 to 6 months of ovulatory response to clomiphene). Patients with pituitary insufficiencydeg These patients usually respond to Gonadotropins. Note : Letrozole - 2.5mg (non steroidal aromatase inhibitor) is found superior to clomiphene. 2. Gonadotropin therapy : Prerequisite for Gonadotropin therapy : Ovarian reserve must be present. The Gonadotropins used are Human menopausal Gonodotropin : -- It is a formulation containing equal amounts of FSH and LH (751U each). -- It is prepared from hormones obtained from urine of postmenopausal women. HCG is required as an ovulatory trigger. FSH : purified urinary FSH and Recombinant FSH are also available. 3. Gonadotropin releasing hormone : Pulsatile GnRH : If other methods have failed then pulsatile GnRH is needed in patients with anovulation and hypothalamic insufficiency. Other drugs which can be used to for ovulation : Bromocriptine/Cabergoline : Are used to to treat anovulation caused by increase in serum prolactin level. Coicosteroids : Use to treat anovulation due to congenital adrenal hyperplasia. Also know : Mangement of unilateral proximal tubal block : Hysteroscopic cannulation or microsurgical tubo cornual anastomosis (if any periadenaxal adhesions are also present). Management of distal tubal block : Best is IVF. Surgical procedures like fimbrioplasty (lysis of fimbrial adhesions or dilatation of fimbrial stenosis) or neosalpingostomy may be done. Management of distal tubal block by hydrosalperix First laparoscopic salpingectomy followed by IVF Management of Bipolar tubal obstruction i.e. both proximal and distal tubal obstruction. Best is IVF Extra Edge : Lets quickly revise the tests for tubal patency. Tests for tubal patency : Rubins test : Outdateddeg Hysterosalpingography : screening procedure.deg Hystero contrastosonography Laparoscopy : Best technique for diagnosis of tubal and peritoneal pathology.deg Selective salpingography and falloscopy For evaluation of proximal tube obstruction. By falloscopy : tubal ostia and intra tubal architecture can also be seen. Time for performing tubal patency tests : D6-D 11 of the cycle.
Mifepristone
Clomiphene citrate
Tamoxifen
Raloxifen