Take home message;- What are the good and bad effects of estrogens synthesized extra gonadaly from androgens by aromatase inhibitors

In conclusion, although estradiol is best recognized as sex hormone that regulates the development and function of reproductive hormone across the entire mammalian species, ever-growing evidence demonstrates its multi-faceted nature in exerting its role in non-reproductive organs and systems under normal as well as pathological conditions. It will be exciting to see what other functions estradiol may play in local tissues and from where the hormone is supplied to those sites.

Where are persons who was granted corers of money from difference banks of India and flew UK? Find out the estrogen receptor expression in the different human tissues so that the quantum of Extra-gonadal quantum of oestrogenes is assessed at Extra-gonadal sites. If too much oestrogen is synthesise at breast then there will be a risk of breast cancer. Conversely, if extragonadal estrogen production is less in the bones then there can be early osteoporosis of bones inspite of good serum calcium, PTH, Vit. D and normally acting oestoblast. I hope all of you knew this extragonadal production of oestrogens its advantages and disadvantages

Sites	Receptor subtypes
	ERα	ERβ	Other receptors
Brain	Cholinergic neuron  , GABAergic neuron  , Pro-opiomelanocortin neuron	GnRH neurons  , Subiculum neuron Ammon	GPER1 (glial cell, rat), GPER1 (GABAergic neuron,
Fat	Adipocyte	Adipocyte	GPER
Bone	Osteoblast  , Osteocyte  .
Liver	Hepatocyte
Blood vessel	Smooth muscle cell  , Vascular endothelial cell	Endothelial cell	GPR30 (endothelial cell, )
Intestine	Epithelial cell  , Parietal cell  , Myenteric neuron	Epithelial cell  , Parietal cell	GPER (colonic epithelia,
Skin	Keratinocyte  , Mast cell   Sebocyte	Keratinocyte  , Mast cell
Adrenal gland	Adrenal cortex	Adrenal cortex	GPER1
Muscle	Satellite cell	Satellite cell
Kidney	Mesangial cells	Mesangial cells
Pancreas	β-cell	β-cell

Adipose tissues, where estradiol stimulates the production of high density lipoprotein cholesterol (HDL) and triglycerides while decreasing LDL production and and fat deposition , are the most extensively studied sites of extra-gonadal estrogen synthesis. Both male and female aromatase-deficient (Cyp19KO) mice exhibit obesity and dyslipidemia , proving that estradiol plays a beneficial role in the lipogenesis. However, an adverse effect of adipose tissue-driven estradiol is also indicated in the pathogenesis of breast cancer. For instance, in a breast with a tumor, adipose tissues proximal to the tumor exhibit higher aromatase activity than those distal to the tumor 

What are the good effects and ill effects of extra gonadal  androgens on the Bone?

Aromatase expression in human bone has been demonstrated in osteoblasts, chondrocytes, and fibroblasts, where they convert circulating androgens into estrogens . In the bone of prepubertal children, the locally synthesized estradiol stimulates epiphyseal maturation during the growth phase. However, in both males and females, the massive pubertal increase of estradiol leads to increased apoptosis of chondrocytes in the epiphyseal plate, causing chondrocyte depletion and hence, ossification and growth slow-down. In adults, estradiol increases bone formation and mineralization and reduces bone resorption, thus reducing the risk of osteoporosis. Therefore, it is not surprising that the incidence of osteoporosis increases in postmenopausal women as their ovaries lose estradiol synthetic capacity.

What are the good effects and ill effects of extra gonadal  androgens on the Skin?

Aromatase expression in the skin occurs mainly in hair follicles and sebaceous glands. Glucocorticoids, cAMP analogs, growth factors, and cytokines modulate aromatase expression in these cells and therefore, local estrogene synthesis . Estradiol enhances collagen synthesis, increases skin thickness, and stimulates blood flow in the skin. Therefore, in situ estrogen synthesis in the skin is vital for maintaining healthy skin. Estradiol also prolongs the anagen phase of the hair cycle and therefore enhances hair growth by increasing the synthesis of essential growth factors stimulating the proliferation of hair follicle cells.

 What are the good effects and ill effects of extra gonadal  androgens on the Liver?

In the liver, estradiol regulates protein synthesis, including lipoprotein and proteins responsible for blood clotting (factors II, VII, IX, X, plasminogen) . Estrogen signaling is also essential in regulating glucose homeostasis, thus improving glucose tolerance and insulin sensitivity. Recent research has explored the possibility that postmenopausal women with nonalcoholic fatty liver disease and with long durations of estrogen deficiency could have a higher risk of having severe fibrosis than premenopausal women . Estrogen receptor beta (ERβ) is implicated in mediating the protective role that estradiol plays under pathogenic condition in the liver as it shows potent anti-proliferative and anti-inflammatory properties. As such, chronic disease is linked to elevated ERβ expression in the liver. ERβ is also known to mediate the anti-tumor action of estrogens in intrahepatic cholangiocarcinoma.

What are the good effects and ill effects of extra gonadal  androgens on the Brain?

High levels of estrogen receptors are expressed during brain development. During this period, sex hormones determine apoptosis, neuronal migration, neurogenesis, axonal guidance, and synaptogenesis. Estradiol induces sexual differentiation in the developing brain. Aromatase mRNA expression in the hypothalamus of males peaks before and after birth, inducing sexual differentiation of the brain. In the brains of both males and females, estradiol provides a neuroprotective effect. Estradiol’s prevention of neurodegeneration in brain tissues is proven in both the Cyp19KO mouse model and the aromatase inhibitor-treated mouse  . Inhibition or null mutation of aromatase, a key enzyme for estradiol synthesis, results in accelerated neurodegeneration. Estradiol effects in the brain also include regulating mood, pain sensitivity, motor control, and cognitive behavior. Estradiol regulates neuronal metabolism by modulating the expression of metabolic enzymes such as GLUT (glucose-transporter), glycolytic enzyme hexokinase, pyruvate dehydrogenase (PDH), aconitase, and ATP synthase .

What are the good effects and ill effects of extra gonadal  androgens on the Adrenal gland?

Estrogens stimulate adrenal cortex growth during development by promoting cell proliferation and enhancing steroidogenic activity by increasing StAR and SF-1 expression in the adrenal gland. In the fetal adrenal gland, estradiol and ACTH form as a positive regulatory loop in which estradiol increases ACTH secretion from adrenal cortex while ACTH increase estradiol in the ovary.

What are the good effects and ill effects of extra gonadal  androgens on the Pancreas?

Estradiol increases insulin gene expression and insulin content in β-cells , increases β-cell proliferation during pancreatic development and recovery from injury, and prevents apoptosis of β-cells upon inflammatory insult  via ERα- and ERβ-mediated pathways.

What are the good effects and ill effects of extra gonadal  androgens  on Other female organs ?

In the blood vessel, estradiol positively impacts vascular function by preventing the oxidation of LDL cholesterol, stimulating nitric oxide synthesis and release, and inhibiting fibroblast transition to myofibroblast, preventing cardiac fibrosis  and atherosclerosis development. In the muscle, estradiol increases muscle mass and strength, alleviating disuse-induced muscle atrophy and promoting regrowth after reloading. It also stimulates muscle repair by stimulating satellite cell proliferation. Estradiol replacement on ovariectomized mice shows that estradiol can reduce stiffness in muscle as well as stimulate muscle regeneration. In the kidney, estradiol has a role of protecting kidney functions during progressive glomerulosclerosis in the female rat remnant kidney model. In the intestine, to maintain the intestinal epithelium, estrogens are necessary. Estrogens improve epithelial barriers and reduce intestinal permeability, preventing chronic mucosal inflammation in animals and humans 

What are the good and bad effects on inflammatory response in different areas on the body.

Estrogens play an important role in the inflammatory response by regulating development, proliferation, migration, and apoptosis of immune cells . Lymphocytes have been shown to express estrogen receptors (ERα and ERβ), but the expression levels of both receptors vary among cell types. CD4＋ T-lymphocytes express ERα whereas B-lymphocytes express ERβ. In contrast, CD8＋ T-lymphocytes express both receptors at low but equivalent levels. Regardless of subcellular differences, estrogens appear to exert a suppressive effect on both B- and T-lymphopoiesis. In support, B-lymphocyte formation is selectively reduced with estradiol treatment , and ovariectomy results in increased B-lymphopoiesis . In addition to the inhibitory effect on lymphopoiesis, estradiol has been shown to influence T helper (Th) responses; inhibit the production of Th1 cytokines such as IL-12, TNF-α, and IFN-γ; and stimulate Th2 anti-inflammatory cytokine production such as IL-10, IL-4, and TGF-β. Estradiol has also been shown to modulate the main activities (maturation, differentiation, and migration) of myeloid cells, including monocytes, macrophages, and dendritic cells. Thus, estradiol has an important impact on immune cells and affects both the innate and the adaptive immune systems, which may account for its contribution in diseases associated with immune disorder.

ESTROGEN AND ESTROGEN RECEPTORS IN THE GUT

In an effort to identify extra-gonadal sites of de novo estradiol synthesis, we generated a double transgenic mouse line in which a transgenic aromatase promoter induces the expression of a red fluorescent protein (RFP) (un-published). In this animal, RFP signal is strongly expressed in the Peyer's patch (Pp), a secondary lymphoid organ in the intestine. Pp have an organizational structure similar to lymph nodes consisting of multiple follicles and interfollicular areas. A follicle is made of a germinal center that is filled with proliferating B-lymphocytes, follicular dendritic cells, and macrophages; the interfollicular area is populated with T-lymphocytes as well as B-lymphocytes, macrophages, and dendritic cells. As part of the gut-associated lymphoid tissue, Pp are known as inductive sites of intestinal immune responses . The induction process in the Pp starts with sensing antigens or microbes in the gut lumen by M-cells located in a monolayer of specialized intestinal epithelial cells known as the follicle-associated epithelium. M-cells transport antigens to antigen-presenting cells, specifically dendritic cells (DCs), within the underlying sub-epithelial dome through transcytosis. Dendritic cells then further present antigens to T-and B-lymphocytes, triggering priming and proliferation of lymphocytes to complete the immune response. A well-known effect of the Pp’s induction function is generating antigen-specific intestinal IgA responses, which is critical for maintaining host-microbiota interaction, generating immune tolerance, and preventing infection  Interestingly, estrogens plays a significant role in the gastrointestinal tract. In this section, we will describe some of the lesser known roles for estrogen in the gastrointestinal system.

Napoleon Bonaparte was not aware of the true importance of his words when he said “An army marches on its stomach.” Technically, an army marches on its intestines. The gastrointestinal tract (GIT) is a unique environment colonized by a remarkable variety of bacteria as well as other organisms including fungi and viruses. This superorganism, the microbiome, is not a simple spectator in biological processes but is an active component of the biochemical and metabolic health of the host. The microbiome is capable of digesting large molecules into simpler ones that can be efficiently reabsorbed by the host. The importance of a healthy microbiome has been well published , and multiple pathologies have been correlated with poor diversity of the microbiome, including irritable bowel (IBS) , osteoporosis , and gluten intolerance. Therefore, controlling the microbiome is paramount to maintaining an optimally functioning GIT. The mucosal epithelium is perfectly adapted to monitor both microbial and nutrient composition. The release of antimicrobial peptides or anti-inflammatory molecules maintains the optimal microbial ecology depending on the current GIT contents.

What are the good effects and ill effects of extra gonadal  androgens on the Appetite?

Researchers have noted a correlation between estradiol levels and appetite. Food intake is significantly decreased during the preovulatory period when estradiol levels are increasing. These actions are attributed to estradiol inhibiting appetite indirectly through cannabinoid receptors. Further, blocking estrogen receptors with ICI182,270 ablates any action of estradiol on appetite . What is more interesting is that appetite is influenced by the microbiome present in the GIT. Bacterial peptides signal hunger or satiation; in essence, the bacteria control our desire to eat. Locally synthesized estrogen produced in response to microbiome composition in turn may influence immune responses, bringing us back to control of microbiome composition.

Immune function. Estrogenic compounds in the gut lumen suppress immune function through targeted apoptosis and inhibition of cell proliferation in the germinal centers of ileal Pp . The Pp are important in generating protective immune responses to pathogens through both innate and cell medicated responses  and are also key in tolerizing the host to food antigens. The mucosal surfaces of the gut must maintain homeostasis, allowing sufficient function of Pp to prevent immune responses to food antigens yet not responding prolifically to commensal bacteria in the gut. Abnormal Pp function through estrogenic compounds is responsible for initializing autoimmune responses and impaired innate responses. Again, we see the constituents of the gut signaling control of the microbiome composition. This leads into the next topic of estrogens and cancer.

What are the good effects and ill effects of extra gonadal  androgens on the formation of  Cancer?

The small intestine is the main absorptive area of the gastrointestinal tract. To maximize absorption, the epithelial layer is covered with invaginations or crypts of Lieberkühn and exists as a sheet of single cells. These cells are prone to injury and are therefore replaced every 3-5 days. To facilitate this replacement, the base of the crypts is populated with stem cells that differentiate into the mature epithelium as they migrate towards the crest of the crypt. ERα and ERβ are both expressed in the crypt cells. However, they are distributed such that ERα is predominantly expressed in the cells at the base of crypts and ERβ is expressed in the cells towards the crest. ERα signaling stimulates proliferation and ERβ signaling opposes this action, and the net signaling from the two receptors controls proliferation. To further support the role of estrogen receptors in tumor development, ERβ-deficient mice demonstrate a hyper-proliferation of the colonic epithelium with progression to colon carcinoma . More than 30 years ago, it was established that there is an associative risk between reduced estrogen levels and colorectal cancer in menopausal women and that hormone (estrogen) replacement therapy reduces the incidence of colorectal cancer . Recent literature on estrogen and colorectal cancer confirms an anti-tumorigenic role for estrogen signaling in the gut due to preferential ERβ signaling .

However, estrogen in the gut is not always good. A recent review by Kwa et al.  associated the “estrobolome”, bacteria with the capacity to metabolize estrogens, with level of risk for breast cancer. A phylogenetic diverse microbiome favors metabolism of conjugated estrogens. Once metabolized, the free estrogens are more easily reabsorbed increasing systemic estrogen levels. Increased circulating estrogens levels increases relative risk for hormone dependent malignancies such as breast cancer. As described above, our recent unpublished work has demonstrated that not only are Pp able to respond to estrogens, but they are also a significant site of estradiol synthesis. Thus, Pp are able to monitor the bacterial diversity of the gut lumen and secrete estradiol. This estradiol then regulates immune responses locally and ultimately alters the diversity of the microbiome.

What are the benefits of oestrogens in Males??

estradiol plays a beneficial role in the lipogenesis Both male and female aromatase-deficient (Cyp19KO) persons exhibit obesity and dyslipidemia , proving that estradiol plays a beneficial role in the lipogenesis. However, an adverse effect of adipose tissue-driven estradiol is also indicated in the pathogenesis of breast cancer. For instance, in a breast with a tumor, adipose tissues proximal to the tumor exhibit higher aromatase activity than those distal to the tumor 

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Estrogens are a class of steroid hormones that regulate the development and function of male and female reproductive organs. In the ovary, estrogen synthesis begins in theca cells with androgen synthesis and ends with conversion of androgens to estrogens in granulosa cells by the enzyme aromatase.

In the male gonad, estrogens are synthesized in the Leydig cells, Sertoli cells, and mature spermatocytes.

Like other steroid hormones, estrogens enter passively into the cells and bind to the estrogen receptors, which then regulate the transcription of downstream estrogen-responsive genes. Among the number of different forms of estrogens, 17β-estradiol (estradiol) is the most common and potent form of estrogen in mammals.

 Extragonadal organs sourcesa;-Estradiol is also produced in a number of extragonadal organs, including the adrenal glands, brain, adipose tissue, skin, pancreas , and other sites yet to be identified. The discoveries of extra-gonadal sites of estradiol synthesis greatly expands our knowledge of the novel roles of estrogens beyond the reproductive system.

EXTRA-GONADAL SITES OF ESTROGEN SYNTHESIS AND ITS LOCAL ROLES

The first discovery of extra-gonadal estrogen synthesis was made in 1974 by Hemsell and his colleagues when they made an unexpected observation that androgens were converted to estrogens in adipose tissue . Since then, a number of other extra-gonadal sites of estrogen synthesis have been discovered. Adipose tissues are considered to be the major source of circulating estrogen after the gonads in both men and women, and the contribution made by the adipose tissues to the total circulating estrogens increases with advancing age .

 The chemical structure and biological activity of the estrogens synthesized in the extra-gonadal sites are not different from those that are produced by the gonads. However, there are unique features that make the extra-gonadal estrogen synthesis differ from the gonadal synthesis. A major difference is in the biochemical pathway of estrogen synthesis. The tissues and cells of the extra-gonadal sites of estrogen synthesis are unable to synthesize C19 steroids, the precursors of estrogen synthesis, but are able to convert C19 steroids to estrogens, a critical and rate-limiting step mediated by Cyp19 aromatase.

Hence, extra-gonadal estrogen synthesis is dependent on an external source of C19 precursors and the level of aromatase expression. Because C19 steroids can be supplied to a local tissue via circulation and are converted to estrogens in any tissue where aromatase is expressed, the presence of aromatase expression in a local tissue confirms extra-gonadal estrogen synthesis. . lists the peripheral tissues that express aromatase and are therefore able to convert C19 precursors to estrogens.

These extra-gonadally synthesized estrogens are thought to act and be metabolized locally, which limits their systemic effects .. Another unique feature of extra-gonadal estrogen synthesis is that while the total amount of estrogen synthesized in each tissue may be small, the local tissue concentrations of estrogens could be high enough to exert biological impact locally. The functional roles of estrogens are mediated mostly by estrogen receptors that are nuclear receptor transcription factors. Therefore, a tissue that expresses one or more estrogen receptors is considered to be a target of estrogenic regulation lists key organs and tissues that express estrogen receptors.

Extra-gonadal sites of estrogen synthesis

Sites	Evidence of 17β-estradiol synthesis
	Cyp19 mRNA	Cyp19 protein	17β-estradiol
Brain	Astrocyte Hippocampus and hypothalamus	Astrocyte  , GnRH  , Dentate gyrus/ pyramidal cell Interneurons  , Granular cell Purkinje cell Ependymal andsubependymal cell  .	Astrocyte .
Fat	Stromal cell  , Adipocyte	Stromal cell  , Adipocyte, mesenchymal cell
Bone	Osteoblast	Osteoblast	Osteoblast
Liver	HepG2 hepatoma andhepatocellular carcinoma  , Hepatocyte	HepG2 hepatoma and hepatocellular carcinoma	HepG2 hepatoma and hepatocellular carcinoma
Adrenal gland	Adrenocortical cell	Adrenocortical cell	Adrenocortical cell
Intestine	Parietal cell	Parietal cell	Parietal cell
Skin	Fibroblast  . Keratinocyte  .	Fibroblast	Fibroblast
Blood vessel	Smooth muscle cell	Smooth muscle cell
Spleen	T cell	T cell

Part 1:-Let us start with the benefits of oestrogens in Males?

Estradiol plays a beneficial role in the lipogenesis in both male and females , But those who are aromatase-deficient (Cyp19KO) persons exhibit obesity and dyslipidemia , proving that estradiol plays a beneficial role in the lipogenesis.(more fat deposition). In the male gonad, estrogens are synthesized in the Leydig cells, Sertoli cells, and mature spermatocytes.

Part : 2  ABC of Extra-gonadal synthesis of Oestrogens in Females and their role in women??
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Can extragonadal synthesis of oestrogens from androgens promote Cancer in females. However, adverse effect of adipose tissue-driven estradiol is also indicated in the pathogenesis of breast cancer. For instance, in a breast with a tumor, adipose tissues proximal to the tumor exhibit higher aromatase activity than those distal to the tumor .(See Fibroadenoma) What are then the Extragonadal organs sourcesa;-Estradiol is also produced in a number of extragonadal organs, including the adrenal glands, brain, adipose tissue, skin, pancreas , and other sites yet to be identified. The discoveries of extra-gonadal sites of estradiol synthesis greatly expands our knowledge of the novel roles of estrogens beyond the reproductive system.

 Q.3:-Know your Friend and Foe(at Breast/Endo ) Estrogens are a class of steroid hormones that regulate the development and function of male and female reproductive organs. In the ovary, estrogen synthesis begins in theca cells with androgen synthesis and ends with conversion of androgens to estrogens in granulosa cells by the enzyme aromatase.

How Oestrgen enters ATM Booth?? What does it do corruption / deposit cash money at ATM_how does E2 acts in nucleus:-Like other steroid hormones, estrogens enter passively into the cells and bind to the estrogen receptors, which then regulate the transcription of downstream estrogen-responsive genes. Among the number of different forms of estrogens, 17β-estradiol (estradiol) is the most common and potent form of estrogen in mammals.

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The first discovery of extra-gonadal estrogen synthesis was made in 1974 by Hemsell and his colleagues when they made an unexpected observation that androgens were converted to estrogens in adipose tissue . Since then, a number of other extra-gonadal sites of estrogen synthesis have been discovered. Adipose tissues are considered to be the major source of circulating estrogen after the gonads in both men and women, and the contribution made by the adipose tissues to the total circulating estrogens increases with advancing age .

 The chemical structure and biological activity of the estrogens synthesized in the extra-gonadal sites are not different from those that are produced by the gonads. However, there are unique features that make the extra-gonadal estrogen synthesis differ from the gonadal synthesis. A major difference is in the biochemical pathway of estrogen synthesis. The tissues and cells of the extra-gonadal sites of estrogen synthesis are unable to synthesize C19 steroids, the precursors of estrogen synthesis, but are able to convert C19 steroids to estrogens, a critical and rate-limiting step mediated by Cyp19 aromatase.

Hence, extra-gonadal estrogen synthesis is dependent on an external source of C19 precursors and the level of aromatase expression. Because C19 steroids can be supplied to a local tissue via circulation and are converted to estrogens in any tissue where aromatase is expressed, the presence of aromatase expression in a local tissue confirms extra-gonadal estrogen synthesis. . lists the peripheral tissues that express aromatase and are therefore able to convert C19 precursors to estrogens.

These extra-gonadally synthesized estrogens are thought to act and be metabolized locally, which limits their systemic effects .. Another unique feature of extra-gonadal estrogen synthesis is that while the total amount of estrogen synthesized in each tissue may be small, the local tissue concentrations of estrogens could be high enough to exert biological impact locally. The functional roles of estrogens are mediated mostly by estrogen receptors that are nuclear receptor transcription factors. Therefore, a tissue that expresses one or more estrogen receptors is considered to be a target of estrogenic regulation lists key organs and tissues that express estrogen receptors. 

Let us not watch TV for election result Better listen to Grand—pa This will bring name and fame of you

Clomiphene Citrate.-

Selection of cases: - Anovulatory PCOS with normal oestradiol levels who clinically exhibit irregular periods or absent periods (anovulation). The commonest cause i s HP dysfunction-i.e. WHO Group II anovulatory disorders. Absent or irregular periods with normal serum oestradiol. Majority are of course PCOS women. This resets the ovulation in order. It acts primarily on hypothalamusàthereby changes the pattern of pulsatile gonadotrophin-RH in order. CC Resistant cases: - What other instigations? Primary infertility with pcod. Did not respond to 100mg of clomiphene. Don't forget to get 1) AMH 2) What is her age, 3) baseline FSH, 4) LH 5) e2? 6) What’s the tubal status?

Before going for hmg is there any other protocol. She is also taking tab. Metformin, & Myoinositol, N- Acetylcysteine combination for 2-3 months and then tries induction with 200mg of cc.Top of Form

 For PCOS FSH is better than hmg..; Cc+metformin or cc+ steroids:  As she is already taking cc+metformin, one may start with cc+inj r-FSH ,to do follicular monitoring and accordingly add r-FSH/HMG

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Initial Dose: Treatment with CC is effective only in patients with sufficient serum estradiol levels After correction of underlying problems, including those related to stress, exercise and eating disorders, treatment with gonadotropins is effective in patients with low FSH levels, but it must be started at a low dose because of the possibility that ovaries unaccustomed to FSH will be hyperstimulated It does not matter whether one initiates on day 2/3/4 or day 5 of cycle. Most favour   50/100 mg dosage. The advantage of initiating 100 mg dosage is that by initiating with 100 mg one can diagnose which cases are CC resistant by 3 cycles and thereby minimize the superfluous cycles.

When to move o to other modality of treatment? One should wait at least for six ovulatory cycles before switching over to complex modality of treatment e.g.  Gonadotrophins/ IVF. By allowing six chances of six ovulatory cycles-when one can almost be certain that CC will not work. As a matter of fact as many as 75% of CC induced successful pregnancies occur by third cycles. There are only few records where pregnancy has occurred after seven ovulatory cycles. But if after one / two cycles repeatedly ET become thin ie < 8 mm –it will be better to move on to gonadotrophins.

Results & outcome: -   In as many as 80% of cases there will be ovulation and pregnancy will occur in 35-40% of women. Why so discrepancy between ovulation rate and pregnancy rate? This is explained by the fact that 1) Thinning of endometrium 2) Thickening of cervical mucus in 15% of casesà may proceed for IUI. The chance of conception is poor if ET s < 8 mm. Why there is thinning of ET is not clearly known but appears to be unrelated to dosage & duration of Ry. Maybe it is idiosyncratic in nature.

What to do if in first cycle there is thinning of ET < 8 mm? It is unlikely that in next cycles there will be improvement of ET. It is better to switch over to gonadotrophins in second cycle (see Roy Homburg –p. 76).

Prevalence of Cyst formation? In most cases the cyst formation after CC is due to hyper response has to be halved. In such cases of extreme sensitivity àthe dosage may have to be halved.

Prevalence of CC Resistance? As many as 20-25% of women with normal FSH (No DOR) - will be eventually CC Resistant. CC resistance is more commonly seen in women with 1)   IR, (metformin) 2) Obese women, 3) hyperandrogenic (Dexa). Those with 4) high LH (pretreatment with Progesterone) also respond poorly to CC. Therefore one can add Metformin to lower the hyperinsulinaemia / add Dexamethasone to curtail adrenal androgens where hyperandrogenism is the cause / choose for pretreatment   with micronised Progesterone if LH is very high.

Multifollicular growth of Follicles in CC induced cycles? : - As many as 60% do exhibit multifollicular growth as hypothalamus is blocked by CC. Therefore rise of E2 in midfollice do not block the release of GNRH fro hypo-. As such pulses will be there and FSH level will not be stopped as usually is the cases in natural cycles where rising Serum E2 inhibits GNRH receptors.

When to ask for refraining from intercourse? If two follicles are above 14 mm then asking them to use condom-otherwise multiple gestation will follow.

Prevalence of OHSS: _ never occurs with CC. But slight enlargement of ovaries may ensue...

How to know that ovulation is occurring? –By simply performing day 21 (supposed midluteal phase) serum progesterone assay.  But serial USG is better because if there are multiple follicles are coming up then multiple pregnancy    can be avoided by refraining from intercourse.

Is USG necessary? Yes. The benefit of serial USG is that those who were duly monitored and concerned doctor reacted according to variations in follicular  growth   pattern, scheduling intercourse/IUI/ Inj HCG-  and poor  ET-in  such cases the preg rate was slightly higher e.g. 48% rather than 35% who  were not monitored. The most important benefit of USG monitoring that by careful monitoring one can quickly move on to other modalities of Ry. This will reduce the total cos of infertility Ry.

What about triggering with HCG? Roy Homburg considers that it is beneficial even in CC cycles as it ensures definite LH surrogate surge if administered after the follicle attains the size of 19-24 mm. What can be done that one can proceed for LH surge is delayed, protracted or even absent in some cases even when the Follicle is ready.  LH urine test may replace HCG in such cases.

What pretreatment can be done?   What are the ill effects of CC?   CC forces hypothalamus to release the GnRH pulse frequency from hypothalamus. This action on hypothalamus and pituitary not only increase the FSH but LH too which is already raised. To curtail the raised basal LH one can prescribe micronised progesterone as pretreatment.

What about Metformin pretreatment? Though theoretically seems to be sound combination but in practice it has been evidenced that addition / pretreatment with metformin do not increase the ovulation rate or preg rate too much. But may be tried in CC resistant women. Some believe metformin should be given a fair trial along with CC before we proceed for more costly HMG therapy in CC resistant women.

How metformin does exert its action in PCOS women? It is needless to mention that most women who are selected for CC are cases of anovulatory PCOS with some degree of IR. Metformin lowers the serum insulin levels. Metformin also causes decrease of serum Testosterone, LH, & increase in SHBG...l

What is the prevalence of absent LH surge despite presence of good follicle? Not known.

What about adding Dexamethasone 0.5 mg at bedtime? It may be used when there is evidence if hyperandorgenism or proven raised value of serum DHEASO4. But many believe that it should only be reserved for proven CAH cases.  As it causes weight gain and increase in appetite it should better be reserved for CC resistant women.

Is there any rationality of prescribing CC in unexplained subfertity: In cases of unexplained infertility IVF is better option? If CC is used then per cycle the preg rate is only 5.6% (slightly superior to TI) but increase slightly to 8.3% f IU is added in combination. Nowadays nobody treats such unexplained infertility women with CC.

What should be ideal flow chart for anovulatory PCOS women?  1) Weight reduction & Metformin 2) CC 4-6 ovulatory cycles 3) Clomiphen e Failure: Add metformin if not added. à Low dose FSH alone for 4-6 ovulatory cycles: Thereafter either advises for IVF or LOD if age is < 30yrs. (see Roy Homburg-pp. 80).

Letrozole vs Clomiphene: - Pregnancy rate was 27.5% vs only 25% by CC alone. But twining rate was 7.4% but in letrozole group it was 3.2% with no added risk of c m.

Salient Features of FM.

1)      Per follicle E2 level should be about 150-300pg/ml. per follicle.

2)      Dipstick urine test(home monitoring)- second morning sample is best,  7 am to 10 am  best

3)      FM- when? - Better to commence on day 9.

4)      Doppler Velocimetry- Perifollicular blood flow- 50-75%  wit RI of 0.4 – 0.48

5)      Midluteal P- 1) above 3ng/ml= evidence of Ovulation. B) IF ABOVE 10NG/ML= ADEQUATE P= Expected to be adequate luteal LENGTH.

6)       What is clomiphene check+-- t means after each cycle of failed CC- on subsequent Day 3 USG is done to note Evidence of Cyst. (Residual cyst).

7)      If no conception after 30-4 cycles ten one may proceed for MG.

8)      If recurrently serum P on Day 21 is < 10 ng.

9)      /ml ten= Vag P must.

10)   Poor ET- Go for MG/Letroz.

. Pharmacology:-CC was synthesized in 1956 but therapeutic use in 19961 by Greenblatt. FDA approval in 1967.Trade ratio between En and Zu are 62% and 38%.Chemically CC is drug with contains both estrogen agonist and antagonist activity. But its main action is estrogen antagonist. But Zuclomiphene is absorbed slowly and is retained in body for prolonged timeout 85% is excreted in stool. After administration the enclomiphene is absorbed first and disappears more rapidly.

A)     Mode of Action:-Structural similarity with estrogens molecule cause competitive occupation of nuclear receptors naturally designed for estrogens- present in the hypothalamusàCC binds with the nuclear receptorsàultimately depletes causes “interference with development/ synthesis of new nuclear receptorsà depletion of ERà The very process of ER replenishment is interfered with”.

B)      Action at Hypothalamus: - More pulsatile rise of LHRH from Hypothalamusàmore release of gonadotrophins from Pituitary. Therefore, in summary, GNRH pulsality is increased after admistration of CC. The point is this in cases of PCOS the pulse frequency is already highàAfter CC administration the pulse amplitude is increased, not the frequency. After CC administration both LH and FSH amplitude rise, but this raised secretion of LH & FSH fall son after discontinuation of CC. The rise of LH causes more rise of P in the CC-induced cycle-as such the drug may be used in cases of diagnosed LPD as an initial Ry.

C)      Clinical Indications of CC: - 1) WHO type II anovulation: - PCOS type. 2) LPD as P levels are typically higher in CC induced cycles ->which raises improved preovulatory follicle and good functioning CL development.3) Unexplained infertility.

D)      Side effects (K. Rao-pp 530). Vasomotor, Visual disturbances, Breast discomfort,

E)      Adverse effects of CC on reproductive tract: _ 1) it has some toxicity on ovum, embryo, ovaries, and ET, Cx mucus that is not clinical significance. In most cases ET is satisfactory and so also Cx mucus production.

F)      What about level of LH level after CC administration? There is marked increase of LH in proportion to FSH may occasionally occur. This temporary change in FSH: LH ratio may alter proper growth of Follicle. ( Source :Balasch J et al Hum Reprod 1995;10:1678-83.Administarion of Cc for more than 5 days resulted in an initial rise of FSH  levels, despite continuation of CC beyond 5 days, whereas LH level remained high throughout the entire treatment period(Source: Soham Z. “The clinical therapeutic window for LH in COH” Ferti Steril 2002;77:1170-7.

G)     Questionable Indications: - 1) LPD, 2) Unexplained infertility.

I) Contraindications: - Ovarian Cysts, Liver diseases.

J)       CC insensitive women-What to do?

1)      Add the followings 1) metformin 2) Glucocorticosteroids 3) Gonadotrophins as an added agent 5) Anti-oxidants/ ovum nutrients.

2)      Other alternatives modes of OI: - AI/ Gonadotrophins and sometime ovarian drilling.

3)      The prevalence of multiple pregnancy:-8%

4)      OHSS:-

5)      Spont. Abortions:-

6)      CM:-