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    Is menses induction necessary before ovulation induction?

    New evidence suggests that progestin withdrawal may adversely affect outcomes of ovulation induction with clomiphene.



    As noted previously, the traditional practice of administering progestin to provoke a withdrawal bleed has no foundation in evidence-based practice. In addition, recent data raise important questions regarding the conventional wisdom that induction of a withdrawal bleed in anovulatory women prepares the endometrium for pregnancy initiation in a subsequent cycle. In fact, results suggest that there may be an advantage in avoiding initiation of progestin withdrawal. Because this discovery presents important implications in the practice of ovulation induction, the findings need to be definitively confirmed by appropriately designed and conducted clinical trials.  Although multiple mechanisms have been proposed to account for this observation, suggested molecular events at the endometrial level require further elucidation and experimental confirmation, which is likely to reveal involvement of more than one mechanism.  If in fact progestin-induced withdrawal bleeds in anovulatory/oligo-ovulatory women had a detrimental effect on pregnancy outcome following clomiphene ovarian stimulation, further studies will also be needed with other ovulation induction agents, as well as in regularly ovulating women.  Furthermore, the effect of progestin administration in frozen embryo transfer cycles in ovulatory or anovulatory women represents another clinical paradigm with a potential impact on pregnancy outcome.


    Dr Diamond reports that this paper was supported in part by HD 39005 to him.


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    Soumia Brakta, MD
    Dr. Brakta is a reproductive endocrine and infertility fellow at Medical College of Georgia at Augusta University, Augusta, GA.
    Michael P. Diamond, MD
    Dr. Diamond is William H. Brooks, MD, Distinguished Chair, Professor and Chair, Department of Obstetrics and Gynecology, Associate Dean ...


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