الفهرس 
Aim of workOnly 14 pages are availabe for public view
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Abstract
Clomiphene resistance defined as failure to ovulate after receiving 150 mg of CC daily for 5 days per cycle, for at least three cycles, is common and occurs in approximately 15 to 40% in women with PCOS.
Failure of CC to induce ovulation or CC resistance is unpredictableed. This Result showed and foremost unexplainable event. Some studies showed that it is more likely in patients who are obese, insulin resistant and hyperandrogenic a genetic predisposition was suggested. Nevertheless, it is virtually impossible to predict who will respond to which dose of CC, if at all. So far, there is no general agreement on a standard management of CC resistant PCOS patients. Some alternatives to CC include aromatase inhibitors, gonadotropins and laparoscopic ovarian drilling. However, these alternatives may be costly and sometimes risky. Addition of adjuvants to CC such as Nacetyl cysteine, metformin and glucocorticoids may give a hope for better ovarian response.
The economic aspects of therapy are important in developing communities and different protocols for clomiphene citrate are being tried, such as starting clomiphene citrate in the late-luteal phase to optimize its performance. This trial involved testing the effect of extended clomiphene citrate treatment in comparison with gonadotrophin therapy in clomiphene-resistant women with PCOS.
The aim of our study to evaluate the effect of extended clomiphene citrate treatment on the ovulation rate, pregnancy rate, and hormonal profile of clomiphene resistant PCOS.
A prospective study conducted on 60 PCO patients with Clomiphene Citrate resistant as diagnosed according Rotterdam criteria 2003, they were received CC maximum dose (150 mg) for 5 day starting in second day of the cycle with no evidence of ovulation in the next 3 months preceding recruitment. Patients were received (150 mg) of clomiphene citrate for 10 days starting from second day of the spontaneous or progesterone withdrawn cycles for (3) cycles.
All patients attended the Obstetrics and Gynecology outpatient clinic at Menoufia teaching hospital, and Al-Bagour General Hospital, Menoufia governorate, Egypt, during the period from April 2019 to February 2019.
Inclusion Criteria:
− Infertility due to PCOS.
− Documented history of clomiphene resistant cases diagnosed AS failure to ovulate after receiving 150 mg of CC daily for 5 days per cycle, for at least three cycles.
Exclusion criteria:
− Non-ovarian causes of infertility, or combined factors of infertility.
− Ovarian cysts or ovarian masses.
All patients included in the study were subjected to the following:
Complete history:
− Personal history: Including name, age, education, occupation, residence, parity, and special habits.
− Present history: Including symptoms which are usually associated with PCOS such
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as: infertility either primary or secondary and menstrual irregularities such as oligomenorrhea menorrhagia or amenorrhea.
− Obstetric history: (number of prior pregnancies, deliveries and abortions).
Physical examination:
− Anthropometric parameters (height, weight and body mass index.
− Measurement of BP, pulse and temperature.
− Chest and heart examination
− Measurement of endometrial thickness
− Vaginal sonographic examination
Laboratory Investigations:
− Day 3 serum FSH, LH
− Duration of fertility
− Number of cases growing follicles 18 mm or more
− Serum oestradiol (pg/ml)
− Serum progesterone (ng/ml)
− Serum hCG
Main outcome measures:
− The primary outcome measures: were changes in hormonal profile, the number of growing and mature follicles growth up to 18 mm size and day 21 progesterone more than 12 ng/m., serum oestradiol (pg/ml), and endometrial thickness (mm).
− Secondary outcome measures: were the occurrence of biochemical pregnancy defined by presence of gestational sac with or without pulsating fetal pole.
Results of the current study could be summarized as follow:
• Age of the studied PCO patients with Clomiphene Citrate resistant ranged from 25 to 35 years with mean 29.07±6.20 years, while, 58.33% of women had secondary and 41.67% had primary of infertility. Also, Body mass index was ranged from 28-36 kg/m2with mean 33.45±7.94 kg/m2.
• Duration of infertility/year of the studied patients ranged from 2 to 5 years with mean 3.18±0.92 years, while, FSH level ranged from 4.5 to 6.5 IU/L with mean of 5.41±0.77 IU/L and LH level ranged from 8.5 to 11.11 IU/L with man 10.03±2.91 IU/L. While, LH/FSH was ranged from 1.89 to 1.71with mean 1.85±3.78.
• Serum progesterone level among the studied patients ranged from 0 to 5 ng/mL with mean 3.60±2.70 ng/mL, while, mean number of primordial follicles of them was 3.85±0.95. Regarding Estradiol was ranged from 810-30 with mean of 19.56±7.84.
• most of PCO patients with Clomiphene Citrate resistant had regular cycles (18.75%), amenorrhea (25%) and 56.25% had oligomenorrhea.
• There was statistically highly significant difference in FSH, LH and FSH/LH after extended clomiphene citrate treatment (p<0.001). FSH level and FSH/LH
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ratio were compared before and after treatment showing increased significantly after extended clomiphene citrate treatment.
• There was statistically significant difference in serum progesterone and number of mature follicles that were compared before and after extended clomiphene citrate treatment showing that serum progesterone and number of mature follicles were increased significantly after treatment. Also, 3(6.25%) of women had pregnancy rate and 2(4.17%) had multiple pregnancy. Regarding ovarian hyper stimulation, there were 3(6.25%) of women had mild hyperstimulation and 2(4.17%) had moderate Hyper stimulation.