|Year : 2020 | Volume
| Issue : 2 | Page : 203-209
The effect of nitric oxide to improve the ovulation and pregnancy rates in women with polycystic ovary syndrome treated with clomiphene citrate
Mai M Farrag1, Ayda A Hassan2, Mona A El Kafrawy2
1 BSc in 2011, in Medicine and General Surgery, Egypt
2 Department of Obstetrics and Gynecology, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
|Date of Submission||16-Feb-2020|
|Date of Decision||29-Feb-2020|
|Date of Acceptance||01-Mar-2020|
|Date of Web Publication||29-Jun-2020|
Mai M Farrag
Department of Obstetrics and Gynecology, Faculty of Medicine for Girls, Al-Azhar University, Cairo
Source of Support: None, Conflict of Interest: None
Background Polycystic ovary syndrome (PCOS), or also called anovulation, hyperandrogenic Stein–Leventhal syndrome, is one of the most common endocrinal disorders affecting ∼5–15% of women in the reproductive age.
Aim The aim was to monitor the effect of nitric oxide (NO) on patients with PCOS treated with clomiphen citrate (CC) and to find out the effect on pregnancy and ovulation rates.
Patients and methods The study was done on 90 patients divided into three groups: group A included 30 patients treated with CC only, group B included 30 patients treated with CC+10 mg NO, and group C included 30 patients treated with CC+20 mg NO.
Results The ovulation and pregnancy rates increased significantly in patients treated with CC+NO compared with patients treated with CC alone.
Conclusion The role of NO in induction of ovulation with CC in cases with PCOS increased the ovulation and pregnancy rates as a result of enhancement of follicular maturation and endometrial thickness and improvement of cervical mucus scoring.
Keywords: clomiphene citrate, nitric oxide donors, polycystic ovary syndrome
|How to cite this article:|
Farrag MM, Hassan AA, El Kafrawy MA. The effect of nitric oxide to improve the ovulation and pregnancy rates in women with polycystic ovary syndrome treated with clomiphene citrate. Sci J Al-Azhar Med Fac Girls 2020;4:203-9
|How to cite this URL:|
Farrag MM, Hassan AA, El Kafrawy MA. The effect of nitric oxide to improve the ovulation and pregnancy rates in women with polycystic ovary syndrome treated with clomiphene citrate. Sci J Al-Azhar Med Fac Girls [serial online] 2020 [cited 2020 Jul 11];4:203-9. Available from: http://www.sjamf.eg.net/text.asp?2020/4/2/203/288269
| Introduction|| |
Polycystic hyperandrogenic ovary syndrome (PCOS), or also called anovulation Stein–Leventhal syndrome, is one of the most common endocrinal disorders, affecting ∼5–15% of women in the reproductive age .
Clomiphene citrate has been the most widely used treatment for fertility enhancement for the past 40 years .
Clomiphene is an estrogen agonist, in the absence of estrogen, thereby enhancing follicle-stimulating hormone (FSH) stimulation of luteinizing hormone receptors in granulosa cells. Clomiphene acts primarily as an antiestrogen in the uterus, cervix, and vagina .
Pregnancy rates are lower among women who ovulate only after receiving higher doses of clomiphene. Failure to conceive despite ovulatory cycles, particularly at higher doses, may be owing to clomiphene’s antiestrogenic effects on the quantity and quality of cervical mucus and on the endometrium, impairing implantation .
Nitric oxide (NO) is a gaseous signaling molecule. It is a key vertebrate biological messenger, playing a role in a variety of biological processes ,.
NO plays an important role in female reproduction. It is believed to be involved in follicular development as its level increases during follicle growth and decreases immediately after ovulation .
It also regulates endometrial functions. It mediates spiral arterial changes in decidualization and promotes embryo implantation .
The aim of this study was to study the effect of NO on patients with PCOS treated with clomiphen citrate (CC) and its effect on ovulation and pregnancy rates.
| Patients and methods|| |
This randomized controlled trial was conducted on 90 patients in the infertility clinic, Department of Obstetrics and Gynecology, Al Zahraa University Hospital, during the period from March 1, 2016 to end of February 2017.
The study was done on a selected group of women with PCOS who were attending hospital service, according to inclusion and exclusion criteria.
The study included patients whose ages ranged from 25 to 35 years old; diagnosis of PCOS was based on the Rotterdam criteria ,.
Patients with uterine pathology such as fibroids or tubal factor of infertility (diagnosed by hysterosalpingography or laparoscopy) were excluded and also those withmale factor of infertility were excluded too.
After fulfilling the inclusion and exclusion criteria, the studied patients were divided into three groups. The first group (group A) or the control group consisted of 30 women who were treated with clomiphene citrate 100 mg for 5 days from the fifth day of the cycle for induction of ovulation. The second group (group B) consisted of 30 women treated with clomiphene citrate 100 mg for 5 days from fifth day of the cycle, in addition to 10 mg isosorbide mononitrate (ISMN) tablets (Effox; Mina Pharm, Heliopolis, Cairo, Egypt, under license of Shwarz Pharma, Germany) applied vaginally in the first half of the cycle from the second day and continued till the day 15±2 of the cycle (diagnosis of ovulation). The third group (group C) consisted of 30 women treated with clomiphene citrate 100 mg for 5 days starting from fifth day of cycle in addition to 20 mg ISMN tablets applied vaginally in the first half of the cycle from second day till day 15±2 of the cycle.
Follow-up by monitoring of the patients was continued for three successive cycles, and if pregnancy occurs at any cycle, the patients were sent to the antenatal care clinic, and we continued with other patients.
This study was done after approval of the Ethical Committee of the Department of Obstetrics and Gynecology, Faculty of Medicine, Al Zahraa University hospital. Informed consent was taken from all participants and their husbands.
All patients underwent the following:
Every patient in this study had full history taking regarding medical, menstrual, and obstetric, and specifically the infertility histories. Routine general examinations were done. Local examinations including abdominal examination and vaginal examination were done.
Then laboratory testing was done: for male, semen analysis to exclude male factor of infertility, and for female, serum FSH, luteinizing hormone, E2, total testosterone, and serum prolactin were done (in second to fifth day of the cycle), and also, serum blood sugar was estimated. Ultrasound examination focusing on transvaginal ultrasound was performed.
Then patients were given the treatment according to the aforementioned groups if they had spontaneous cycle, but if they were amenorrheic, progesterone withdrawal was done, induction of ovulation was taken then folliculometry was done from day 12th of the cycle by transvaginal us (using LOGIQ v5 ultrasound scanner, USA) every other day till the follicle reaches greater than or equal to 18 mm, then human chorionic gonadotropin injection (10 000 IU) was administered by intramuscular injection, then follow-up after 48 h to be sure that the follicle was ruptured, so it is considered as an evidence of ovulation.
Measurement of endometrial thickness at the thickest point between the two basal layers on the anterior and posterior uterine walls was done.
On the day of ovulation, cervical mucus was assessed by a scoring system  using five parameters: quantity, viscosity, spinnbarkeit, ferning, and degree of external os opening.
Then the patients were advised to have intercourse every other day when a leading follicle reached 16 mm. Then diagnosis of pregnancy by serum β-hCG was performed 14 days after the expected time of ovulation. Treatment was continued for three cycles and discontinued earlier when pregnancy was achieved. Moreover, patients were asked to record any adverse effects during the treatment cycles and also any adverse effects discovered by ultrasound, such as ovarian cyst or ovarian hyperstimulation syndrome, which were recorded, and discontinuation of treatment was done.
Data was analyzed by Microsoft Office 2010 (excel) and Statistical Package for the Social Sciences (SPSS) version 20, taking P value less than 0.05 as significant.
| Results|| |
The results of the current study showed no significant difference in the demographic and hormonal profile among the three groups ([Table 1]).
On the contrary, it showed that there were no statistically significant differences among the three groups regarding ovarian volume and antral follicular count ([Figure 1] and [Table 1]). However, there was a statistically significant difference regarding increase in the number of mature follicle, endometrial thickness, and cervical mucus score between groups A and B and between groups A and C, with P value less than 0.05, whereas there was a slight increase in group C compared with group B, but without a statistically significant difference (P>0.05) ([Table 2]).
|Figure 1 (a) Flow diagram showing the ovulation and pregnancy rates per treatment cycles; (b) flow diagram showing the ovulation and pregnancy rates per treatment cycles.|
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|Table 2 Ultrasound findings and cervical mucus score of the studied groups per treatment cycles.|
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Moreover, there was a significant increase in ovulation and pregnancy rates per treatment cycles in group B compared with group A (P1), in group C compared with group A (P2), and in P3 group C compared with group B (P3), with P value less than 0.05 ([Table 3]).
|Table 3 Comparison among the three groups regarding outcome in ovulation and pregnancy rate after 3 successive cycles (N=30)|
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Moreover, the result of this study shows that there was a significant increase in the adverse effects, especially headache, dizziness, flushing, and palpitation, in group B compared with group A, with P value 0.000, 0.003, 0.003, and 0.000, respectively, and that there was a significant difference in development of ovarian cyst in group A compared with group B, with P value 0.0578. On the contrary, there was a significant increase in the adverse effects, especially headache, dizziness, flushing, palpitation, and hypotension, in group C compared with group A, with P values of 0.000, 0.043, 0.033, 0.043, and 0.051, respectively, and that there was a significant difference in development of ovarian cyst in group A compared with group C, with P value of 0.032, whereas there was no significant difference between groups B and C ([Table 4]).
|Table 4 Adverse effects recorded during treatment in the three groups per treatment cycle|
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| Discussion|| |
Polycystic ovarian syndrome (PCOS) is one of the most common endocrine disorders that affect ∼5–10% of the women in the fertility age ,.
CC is the first-line agent used for ovulation induction in patients with PCOS. It achieves an ovulation rate of 75–80% . However, the conception rate is up to 22% per cycle in those ovulating with CC .
NO is a free radical gas whose effect does not last long and is synthesized from l-arginine and is believed to be the main intervention in most of the natural functions of the cardiovascular organs, reproductive organs, immune system, and digestion .
The study showed no statistically significance difference among the three groups regarding the general demographic data, hormonal profile, and ultrasound features concerning ovarian volume and antral follicular count ([Table 1] and [Table 2]).
In addition, there was a significant increase in the number of mature follicles (n), endometrial thickness (mm), and cervical mucus score in group B compared with group A and in group C compared with group A, with P value less than 0.05 ([Table 2]).
On the contrary, the number of mature follicles, endometrial thickness, and cervical score were increased but not significantly between groups B and C, with P value greater than 0.05.
Moreover, there was a significant increase in ovulation and pregnancy rates, each group per treatment cycles, in group B compared with group A (P1), in group C compared with group A (P2), and in group C compared with group B (P3), with P value less than 0.05.
These results are in line with the results obtained by Mahran et al.  who found that concomitant use of NO with CC seems to improve the ovulation and pregnancy rates in the patients with PCOS with no significant increase in adverse effects as compared with CC alone. A total of 90 patients with PCOS were randomly allocated into three groups. Patients in group A were treated with 100 mg CC for 5 days starting from the fifth day of the cycle. Patients in groups B and C received 10 mg and 20 mg of ISMN, respectively, in addition to CC, applied vaginally till the diagnosis of ovulation. There was a significant increase in the ovulation and pregnancy rates in the patients treated with CC+ISMN as compared with patients treated with CC alone (P<0.001).
Moreover, Ajam et al.  corresponded with the current study regarding the ovulation rate and endometrial thickness but disagreed with this study regarding pregnancy rate and number of mature follicle as there was no significant increase in their study. This difference may be owing to that in their study, both groups of patients received exogenous gonadotropins, which might have a confounding effect on their results.
El-Berry and Abdel Razik  agree with these results and stated that the novel treatment of infertile patients with PCO with combination of CC and NO donors is simple and promising. The ovulation rate was increased owing to improvement of follicular maturation, cervical mucus quality, and endometrial receptivity in the CC+ISMN group compared with CC group only.
Moreover, another study by Bassil et al.  agreed with this study regarding increase in follicular maturation, as it showed that an enhanced vascularization by NO seems to be responsible for the selection and maturation of follicles in both spontaneous and stimulated in-vitro fertilization cycles, on these bases, Battaglia et al.  speculated that NO acts as a vasodilator, increasing the permeability of follicular epithelium to plasma proteins. As the follicles mature, they become more permeable and more susceptible to circulating FSH and growth hormone action; both hormones promote and increase production of insulin growth factor-1, which plays a critical role in follicular maturation and differentiation of granulose cell.
Previous studies such as Ramsay et al.  correspond with this study in that NO can increase the endometrial thickness. The study showed that human uterine blood flow and endometrial vessels perfusion can be increased by administration of NO donor.
Morlin and Hammarstrom  agree with this study as their study shows that there was a statistically significant difference in cervical mucus scoring in group taking NO than other group during induction of ovulation.
Moreover, the study by Balen et al.  found that NO increases cervical secretion at ovulation, and this is in line with the current result.
Gutarra‐Vilchez et al.  concluded in their study that the vasodilator agents improve pregnancy rates in women undergoing fertility treatment.
Moreover, Battaglia et al.  stated that NO can counteract the adverse effect of CC on uterine artery blood flow and improves endometrial vascularity and receptivity leading to improvement of pregnancy rate.
The most common adverse effects were headache, dizziness, flushing, and palpitation ([Table 4]). Moreover, this study showed that there was a significant difference regarding adverse effect of treatment in patient who received NO compared with CC group and that there was a slight increase in the adverse effect in group C that received higher dose of NO than group B which received lesser dose, but without clear significance. Moreover, there was a significant increase in ovarian cyst formation in CC group compared with NO group intake.
Gutarra‐Vilchez et al.  agreed with the current study in that vasodilators increase overall rates of adverse effects including headache and tachycardia. This study included 15 studies with a total of 1326 women. All included studies compared a vasodilator versus placebo or no treatment.
This result disagreed with the study of Mahran et al.  who stated that concomitant use of NO with CC seems to improve the ovulation and pregnancy rates in the patients with PCOS with no significant increase in adverse effects as compared with CC alone.
| Conclusion|| |
The role of NO in induction of ovulation with CC in cases with PCOS increased the ovulation and pregnancy rates as a result of enhancement of follicular maturation and endometrial thickness and improvement in cervical mucus scoring.
Financial support and sponsorship
Conflicts of interest
There was some conflicts as there was some patients didnot continue the induction cycles but this didnot affect the paper as there were another group of patients taken to continue the study.
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[Table 1], [Table 2], [Table 3], [Table 4]