To assess the effectiveness of ovulation induction in patients with normogonadotropic form of autoimmune oophoritis, two groups of patients were formed; the first group (19 patients) received clomiphene citrate (clostilbegit) from day 5 to day 9 of the menstrual cycle at a dose of 50-150 mg per day for three cycles. The second group (20 patients) received the same treatment regimen in combination with taking 15 dragees of Wobenzym per day from 5 to 25th day of the menstrual cycle. A significantly (p <0.01) higher efficiency of the combination of clomiphene citrate with wobenzym was shown, leading to the onset of ovulation in 70 ± 10.2% of these patients.
Key words: clomiphene, clomid, treatment, autoimmune oophoritis; induction of ovulation; antiovarian antibodies
In the structure of etiological factors in the development of primary ovarian insufficiency, an essential role belongs to the autoimmune process in the ovaries. According to the literature and the results of our own studies, it is the cause of the development of hypergonadotropic ovarian insufficiency in 43-69% of cases. At the same time, it was shown that autoimmune oophoritis can be the cause of the development of normogonadotropic primary ovarian insufficiency in 19.2-31.5% of cases. The most common treatment for patients with chronic normogonadotropic anovulation is clomiphene citrate ovulation stimulation. This drug has been used in clinical practice for more than three decades and is still considered one of the main methods of treatment, since it ensures the achievement of ovulation in 65-80% of patients with normogonadotropic anovulation. In addition, the positive effect of systemic enzyme therapy on the course of systemic and organ autoimmune diseases is known. Own experience of the use of systemic enzyme therapy in patients with autoimmune oophoritis showed a significant improvement in the indicators of steroidogenesis and folliculogenesis in the ovaries of these patients.
The aim of this study was to study the effectiveness of clomiphene citrate and its combination with systemic enzyme therapy in normogonadotropic anovulation caused by autoimmune ovarian damage.
Material and research methods
Autoimmune oophoritis was diagnosed by determining antiovarian autoantibodies in the blood of patients with normogonadotropic ovarian insufficiency by the method of enzyme-linked immunosorbent assay using antigens of the microsomal fraction of ovarian granulosa cells according to the author's method. The threshold diagnostic level of antiovarian autoantibodies was established according to the “two sigma (o)” rule and amounted to 350 U / ml.
We used the following patient management regimen: clomiphene citrate (clostilbegit manufactured by Egis Pharmaceuticals Ltd, Hungary) was administered from days 5 to 9 of the menstrual cycle, starting with a minimum dose of 50 mg / day. The management of the patient in the ovulation stimulation cycle included monitoring of the development of the dominant follicle and the thickness of the endometrium. Three days after ovulation, established by ultrasound and hormonal signs, in the absence of signs of hyperstimulation, 3000 IU of human chorionic gonadotropin (rotten, prophasi) was injected intramuscularly. The injection was repeated one week later. If there are more than three follicles with a diameter of more than 3.0 cm and free fluids in the pelvic cavity more than 50 ml were abstained from the use of chorionic gonadotropin. Two groups of patients were formed according to the principle of randomization. Patients of the first group, which consisted of 19 people, underwent ovulation stimulation according to the described method. Patients of the second group, which consisted of 20 people, along with the induction of ovulation with clomiphene citrate according to the indicated scheme, received systemic enzyme therapy with Wobenzym (Mucos Pharma Gmbh & Co, Germany). One Wobenzym dragee contains: 100 mg of pancreatin, 60 mg of papain, 45 mg of bromelain, 24 mg of trypsin, 1 mg of chymotrypsin, 10 mg of amylase, 10 mg of lipase and 50 mg of rutin. He was prescribed in the amount of 15 pills per day (5 pills three times a day) from the second to the 25th day of the menstrual cycle. In the absence of pregnancy, the treatment cycle in both groups of patients was repeated up to 3 times with an increasing dose of clostilbegit (up to 150 mg / day). The clinical effect of the therapy was assessed as "positive" at the onset of ovulation or pregnancy. If after three cycles of stimulation it was not possible to achieve ovulation, the result of the treatment was assessed as the absence of a clinical effect. Statistical processing analyzed the data obtained in the best clinical effect of the ovulation stimulation cycle.
Statistical processing was carried out using the methods of parametric and nonparametric statistics using the statistical software packages EXCEL for WinXP, STATISTICA 6.0, SPSS V.13, Manugistic Statgraphics v.5.0. The hypothesis that the sample belongs to a normal distribution was tested using the Kolmogorov-Smirnov test. Depending on the test results, the samples were compared using:
- Student's t-test (applying the correction Welch in the case of unequal variances);
- nonparametric analysis for two groups (Mann-Whitney method);
- nonparametric analysis of variance for multiple comparisons (criterion Kruskell-Wallis).
For the "before-after" situation, the paired Student's t-test or the paired Wilcoxon test was used. Correlation analysis was performed using the Spearman and Kendall methods. We used stepwise logistic regression analysis to assess the multifactorial impact on the clinical effect of the therapy.
In the first group of patients, ovarian failure was manifested by chronic anovulation in 18 patients, in one patient there was an insufficiency of the luteal phase of the cycle. In the second group of patients, chronic anovulation took place in 19 patients, of which three had luteinization of the non-ovulated follicle and one patient had a deficiency of the luteal phase of the cycle. The characteristic of the menstrual cycle in groups of patients is shown in Figure 1. Correlation analysis according to Kendall did not reveal a significant (t = 0.12; p = 0.29) relationship between the characteristics of the menstrual cycle, depending on the patients belonging to the first or second group. Primary infertility was the reason for going to the polyclinic department of the Research Institute of Obstetrics and Gynecology. DO Ott RAMS in 17 patients of the first group. In the second group of patients, primary infertility was in 17 and secondary in two patients. Other clinical, laboratory and echographic indicators are presented in Table 1. These data show that the patients of the two groups were comparable in age, disease duration, time of menarche onset, height and weight indicators. There was also no statistically significant difference when comparing hormonal parameters. The level of antiovarian autoantibodies in the blood also did not differ in the two groups. The only significantly different echographic indicator was the volume of the right ovary, but this difference has no significant clinical significance. The protocol of ovulation induction in groups of patients with normogonadotropic form of autoimmune oophoritis is presented in Table 2. Based on the examination results, at the first visit, the question of including the patient in one of the ovulation induction protocols was decided, guided by the principle of randomization. On the 3-5th day of the menstrual cycle, before the start of stimulation, the state of the endometrium was assessed and follicular apparatus of the ovaries. In the absence of contraindications to the appointment of clostilbegit, the drug was prescribed at a dose of 50 mg / day. At the next intermediate visits, all patients noted the normal tolerance of the drug. During the entire period of ovulation induction, no serious adverse events were detected. Wobenzym was well tolerated by all patients of the second group. Four patients of the first group had nagging pains in the lower abdomen after the end of the drug intake; 6 patients of the second group had similar complaints. There were no obvious signs of ovarian hyperstimulation in any patient. After a single injection of pregnil at a dose of 3000 IU, ultrasound examination revealed a luteal cyst 5.4 cm in diameter and 80 ml of free fluid in the pelvic cavity in one patient of the first group. Subsequently, a spontaneous reduction of the cyst occurred. Luteal cysts were also detected in six patients of the second group with a diameter of 4.0 cm to 6.4 cm. In the cavity of the small pelvis, these patients also revealed free fluid in a volume of 50-120 ml. These conditions did not require additional medical interventions and resolved spontaneously. On the 20-23rd day of the menstrual cycle, estradiol and progesterone in the blood were determined. Figure 2 shows the change in the content of estradiol and progesterone in the blood of patients as a result of stimulation of ovulation. In both groups of patients, there was a significant (p <0.001) increase in the levels of estradiol and progesterone in the blood after ovulation stimulation. It should be noted that in the absence of significant differences in the initial levels of estradiol and progesterone in the blood, as a result of treatment in patients of the second group, both the average content of estradiol (p = 0.001) and the average content of progesterone (p = 0.009) in the blood were significantly higher. At the final visit, the level of circulating antiovarian antibodies in the blood was determined.
Comparison of their average values with the initial data showed that as a result of the induction of ovulation in both groups of patients, there was a significant decrease in the level of circulating antiovarian autoantibodies. Despite the general trend, in two patients of the first group, as a result of the induction of ovulation, an increase in the level of antiovarian autoantibodies in the blood was revealed. In the second group of patients, there was no such response to treatment. It was. However, the average ratio of antiovarian autoantibodies to their initial level, reflecting the degree of change in this indicator as a result of treatment, also did not differ significantly in the groups of patients. The main echographic characteristics reflecting the efficiency of ovulation induction are considered to be the diameter of the maximum follicle and the thickness of the endometrium (Fig. 4). In the first group of patients receiving ovulation induction by Clostilbegit, there was a significant (p = 0.00013) increase in the diameter of the maximal follicle, which averaged 2.2 ± 0.1 cm. The thickness of the endometrium in this group of patients was also significant (p = 0, 02) increased and averaged 0.9 ± 0.03 cm. In the group of patients who received clostilbegit in combination with wobenzym, the diameter of the maximal follicle became significantly (p <0.0001) larger. There was also a significant (p <0.0001) increase in endometrial thickness. At the same time, comparison of the two groups by these parameters showed that in the second group of patients the diameter of the maximum follicle significantly (p = 0.013) exceeded the corresponding indicator in the first group, the thickness of the endometrium was also significantly (p = 0.007) more in the second group of patients.
The ratio of the clinical effect of ovulation stimulation in the groups of examined patients is shown in Figure 5. In the first group of patients, ovulation was achieved in three patients. Two of them ovulated after the second cycle of ovulation induction at a dose of 100 mg of clos-tilbegit per day. One patient was ovulating during the third cycle of treatment (150 mg of clostilbegit per day). Pregnancy occurred in two patients of this group: in one patient in the first cycle of treatment when taking 50 mg of clostilbegit, in the second patient in the third cycle of stimulating ovulation with a dose of 100 mg of clostilbegit. Both pregnancies proceeded with signs of threatened termination at an early stage. The first patient underwent urgent labor without complications. The second patient underwent operative delivery by caesarean section according to indications from the fetus at 37 weeks gestation. The child was born with a score of 7 points on the Apgar scale. The remaining 14 patients in this group achieved ovulation in three stimulation cycles with the use of increasing doses of clomiphene citrate failed. In the second group of patients, ovulation was achieved in 10 patients. In eight of them, ovulation occurred after the second cycle of stimulation with the use of 100-150 mg of Clostilbegit per day, in two patients, ovulation occurred in the first cycle of stimulation while taking 50 mg of Clostilbegit per day. Pregnancy occurred in four patients in this group. In three patients, the first trimester of pregnancy proceeded with signs of threatened termination. In two patients, the second half of pregnancy was complicated by gestosis. Two pregnancies ended in urgent labor without complications. One patient had labor induction for a period of 36-37 weeks due to with no effect of conservative therapy of late gestosis. The child was born with a score of 7 points on the Apgar scale. One pregnancy is currently progressing. Comparison of the frequency of the onset of a positive effect in the two groups of patients showed significantly (p = 0.0097) greater effectiveness of treatment in the second group of patients. The use of Kendall's correlation method with a high probability (r = 0.39; p = 0.0005) revealed the dependence of the severity of the clinical effect on the method of stimulating ovulation. The use of stepwise logistic regression analysis with high reliability (p <0.00001) for the model as a whole revealed the contingency of the onset of a positive clinical effect from the ratio of the estradiol content as a result of treatment to its baseline level in the blood of patients, the initial diameter of the maximal follicle, endometrial thickness and the level of antiovarian autoantibodies in the blood as a result of the treatment.
Thus, the induction of ovulation by clomiphene citrate in combination with systemic enzyme therapy is an effective method of stimulating ovulation, ensuring ovulation is achieved in 70 ± 10.2% of patients with normogonadotropic form of autoimmune oophoritis. The isolated use of clomiphene citrate to stimulate ovulation in this category of patients gives a positive result only in 26.3 ± 10.1% of patients.