To the Editor:
It was an interesting article by Badawy et al. on luteal-phase clomiphene citrate (1). There were two points on which I would like to request clarification.
1. In the early clomiphene citrate (CC) group, patients received 100 mg CC daily, starting the day after finishing medroxyprogesterone acetate (MPA) before withdrawal bleeding.
It is a well known fact that polycystic ovary syndrome (PCOS) patients have oligo-/anovulation. Occasional spontaneous ovulations and pregnancies do occur in these cases, and starting CC after finishing MPA may cause damage to a few cases of PCOS who may have conceived spontaneously.
I would suggest that before starting CC on last day of MPA, pregnancy must be ruled out by serum β-hCG estimation or by transvaginal sonography. If corpus luteum is seen, CC should not be started.
Alternatively, instead of giving MPA for withdrawal and starting CC, one should wait for withdrawal bleeding to occur and the patient should be put on oral contraceptive pills in the next cycle. Clomiphene citrate should be started after finishing oral contraceptive pills and before withdrawal bleeding, in the so-called luteal phase.
2. In materials and methods, withdrawal bleeding was achieved using 10 mg tablets of MPA for 10 days before stimulation. Patients were then randomly allocated using a computer-generated random table into two treatment groups: early CC and late CC.
My concern is that if patients were randomly allocated after withdrawal, CC cannot be started in the early group, as luteal phase is already over. Random allocation will have to be done much earlier before starting MPA.
Dhiraj Gada, M.D.
1. Badawy A, Inany H, Mosbah A, Abulatta, M. Luteal phase clomiphene citrate for ovulation induction in women with polycystic ovary syndrome: a novel protocol. Fertil Steril 2009; 92:538-41.
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2009.07.1003
The Authors Respond:
I would like to thank Dr. Dhiraj Gada for his comments.
1. We always started medroxyprogesterone acetate (MPA) on day 16 of the cycle, i.e., after menstruation, whether this menstruation occurred naturally or was expressed by medications. We already performed serum hCG on the last day of MPA to rule out pregnancy before starting clomiphene citrate (CC).
2. Randomization of the patients was performed while they were on MPA and not after the occurrence of the withdrawal bleeding.
Ahmed Badawy, M.Sc., M.D., Ph.D.
Faculty of Medicine
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2009.07.1004