Advertisement

Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

Evidence-based reproductive medicine in clinical practice: the case of clomiphene-resistant PCOS

Abstract

Evidence-based medicine (EBM) tries to integrate best research evidence with clinical expertise and patient values. Clinicians can use this method to provide their counseled patients with the best available evidence. The aim of the present article is to demonstrate the application of EBM in everyday practice. We present a case of a woman with subfertility due to polycystic ovary syndrome (PCOS) who was not responding to treatment with clomiphene citrate. Herein a search of the literature is discussed, and a randomised clinical trial assessing the effectiveness of a strategy starting with laparoscopic electrocoagulation (LEO) and gonadotrophins is scrutinised with regard to internal validity. Studies on treatment should be appraised regarding method randomisation, concealment of allocation, blinding or masking, comparability of the groups, completeness of follow-up, analysis according to the intention-to-treat principle, equality of treatment of both groups, and adequate sample size. The study reports both treatments to be equally effective with respect to ongoing pregnancy, which is the primary outcome. A strategy starting with LEO seems to be more cost-effective and reduces the number of multiple pregnancies, which are arguments in favour of it. These arguments should be weighed against individual characteristics such as the risk of laparoscopic surgery and individual patient preferences.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2

References

  1. 1.

    Davidoff F, Haynes B, Sackett D, Smith R (1995) Evidence based medicine: a new journal to help doctors identify the information they need. BMJ 310:1085–1086

  2. 2.

    Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS (1996) Evidence based medicine, what it is and what it isn’t. BMJ 312:71–72

  3. 3.

    Guyatt G, Drummond R (2002) Users’ guides to the medical literature: a manual for evidence-based clinical practice. AMA Press, Chicago

  4. 4.

    Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB (2000) Evidence-based medicine: how to practice and teach EBM. Churchill Livingstone, New York

  5. 5.

    Coomarasamy A, Khan KS (2004) What is the evidence that postgraduate teaching in EBM changes anything? A systematic review. BMJ 329:1017

  6. 6.

    Stein IF, Leventhal ML (1935) Amenorrhea associated with bilateral polycystic ovaries. Am J Obstet Gynecol 29:181–191

  7. 7.

    Hull MG, Glazener CM, Kelly NJ, Conway DI, Foster PA, Hinton RA, Coulson C, Lambert PA, Watt EM, Desai KM (1985) Population study of causes, treatment, and outcome of infertility. BMJ 291:1693–1697

  8. 8.

    Rowe PJ, Comhaire FH, Hargreave TB, Mellows HJ (1993) WHO manual for the standardized investigation and diagnosis of the infertile couple. Cambridge University Press, Cambridge

  9. 9.

    Imani B, Eijkemans MJ, te Velde ER, Habbema JD, Fauser BC (1998) Predictors of patients remaining anovulatory during clomiphene citrate induction of ovulation in normogonadotropic oligoamenorrheic infertility. J Clin Endocrinol Metab 83:2361–2365

  10. 10.

    Imani B, Eijkemans MJ, te Velde ER, Habbema JD, Fauser BC (1999) Predictors of chances to conceive in ovulatory patients during clomiphene citrate induction of ovulation in normogonadotropic oligoamenorrheic infertility. J Clin Endocrinol Metab 84:1617–1622

  11. 11.

    Gjonnaess H (1984) Polycystic ovarian syndrome treated by ovarian electrocautery through the laparoscope. Fertil Steril 41:20–25

  12. 12.

    Khan JD, Kunz R, Antes G, Kleijnen J (2003) Framing questions for a review. In: Systematic reviews to support evidence-based medicine. How to review and apply findings of healthcare literature. Royal Society of Medicine Press, London

  13. 13.

    Palomba S, Orio F Jr, Nardo LG, Falbo A, Russo T, Corea D, Doldo P, Lombardi G, Tolino A, Colao A, Zullo F (2004) Metformin administration versus laparoscopic ovarian diathermy in clomiphene citrate-resistant women with polycystic ovary syndrome: a prospective parallel randomised double-blind placebo-controlled trial. J Clin Endocrinol Metab 89:4801–4809

  14. 14.

    Bayram N, van Wely M, Kaaijk EM, Bossuyt PM, van der Veen F (2004) Using an electrocautery strategy or recombinant follicle stimulating hormone to induce ovulation in polycystic ovary syndrome: randomised controlled trial. BMJ 328:192

  15. 15.

    Schulz KF, Chalmers I, Hayes RJ, Altman DG (1995) Empirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA 273:408–412

  16. 16.

    Moher D, Pham B, Jones A et al (1998) Does quality of reports of randomised trials affect estimates of intervention efficacy reported in meta-analyses? Lancet 352:609–613

  17. 17.

    Grimes DA, Schulz KF (1996) Determining sample size and power in clinical trials: the forgotten essential. Semin Reprod Endocrinol 14:125–131

  18. 18.

    van Wely M, Bayram N, van der Veen F, Bossuyt PM (2004) Laparoscopic electrocautery of the ovaries versus recombinant FSH in clomiphene citrate-resistant polycystic ovary syndrome. Impact on women’s health-related quality of life. Hum Reprod 19:2244–2250

  19. 19.

    van Wely M, Bayram N, van der Veen F, Bossuyt PM (2004) An economic comparison of a laparoscopic electrocautery strategy and ovulation induction with recombinant FSH in women with clomiphene citrate-resistant polycystic ovary syndrome. Hum Reprod 19:1741–1745

Download references

Author information

Correspondence to Elisabeth A. A. van Tetering.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

van Tetering, E.A.A., van Dessel, H.J.H.M. & Mol, B.W.J. Evidence-based reproductive medicine in clinical practice: the case of clomiphene-resistant PCOS. Eur Clinics Obstet Gynaecol 1, 89–94 (2005). https://doi.org/10.1007/s11296-005-0014-5

Download citation

Keywords

  • Laparoscopic electrocoagulation
  • Evidence-based medicine
  • Gonadotrophins
  • PCOS
  • PICO