FERTILITY AND STERILITY

VOL. 80, NO. 5, NOVEMBER 2003

Copyright 2003 American Society for Reproductive Medicine
Published by Elsevier Inc.
Printed on acid-free paper in U.S.A.

IN VITRO FERTILIZATION

A double-blind, randomized, placebocontrolled study to assess the efficacy of

ketoconazole for reducing the risk of
ovarian hyperstimulation syndrome
Mohammad Ebrahim Parsanezhad, M.D.,a Saeed Alborzi, M.D.,a Mahnaz Pakniat, M.D.,a
and Ernst Heinrich Schmidt, M.D.b
Shiraz University of Medical Sciences, Shiraz, Iran, and Evang. Diakonie Teaching Hospital of Gottingen
University, Bremen, Germany

Objective: To evaluate the role of ketoconazole in prevention of ovarian hyperstimulation syndrome (OHSS)
in women with the polycystic ovary syndrome (PCOS) undergoing ovarian stimulation with gonadotropins.
Design: Prospective, randomized, double-blind, placebo-controlled study.
Setting: University hospitals.
Patient(s): One hundred nine women with PCOS who were referred for treatment with gonadotropins.
Intervention(s): Fifty patients were randomly assigned to receive two ampoules of hMG beginning on day
2 or 3 of the cycle and ketoconazole (50 mg every 48 hours) starting on the first day of hMG treatment.
Fifty-one patients received the same amount of hMG plus one tablet of placebo every 48 hours.
Main Outcome Measure(s): Follicular development, E2 level, and pregnancy rate.
Result(s): The total number of hMG ampoules and duration of treatment to attain ovarian stimulation were
higher among ketoconazole recipients. The serum E2 level and number of patients with dominant follicles on
day 9 of the cycle were greater in placebo recipients. Serum E2 level and total number of follicles at the time
of hCG administration did not differ between the two groups. The cancellation rate and OHSS rate were
similar in the two groups.
Conclusion(s): Ketoconazole does not prevent OHSS in patients with PCOS who are undergoing ovarian
stimulation. It may reduce the rate of folliculogenesis and steroidogenesis. (Fertil Steril 2003;80:
11515. 2003 by American Society for Reproductive Medicine.)
Key Words: Polycystic ovary, gonadotropins, hyperstimulation, ketoconazole

Received December 5,
2002; revised and
accepted April 2, 2003.
Reprint requests:
Mohammad Ebrahim
Parsanezhad, M.D., P.O.
Box 71345-1657, Shiraz,
Iran (FAX: 98-711229-6486; E-mail:
parsame@sums.ac.ir).
a
Department of Obstetrics
and Gynecology, School of
Medicine, Shiraz University
of Medical Sciences.
b
Department of Obstetrics
and Gynecology, Evang.
Diakonie Teaching Hospital
of Gottingen University.
0015-0282/03/$30.00
doi:10.1016/S0015-0282(03)
01177-4

Ovarian hyperstimulation syndrome (OHSS)

is a relatively common and potentially life-threatening complication of ovarian stimulation with
gonadotropins (1). In its severe form, the syndrome is characterized by extreme ovarian
multifollicular enlargement, ascites, hydrothorax, hypovolemia, and hemoconcentration (2).
The underlying mechanisms leading to
OHSS remain to be elucidated, but excessive
quantities of peptides regulating the growth
and permeability of blood vessels are likely to
be involved (3). Some authors have suggested
that augmentation of steroids and peptide production from the multifollicular hyperstimulated ovaries may be responsible for several
features of the OHSS (4).

Vascular endothelial growth factor has been

shown to exert a twofold effect: It serves as a
potent promoter of neovasculogenesis and increases vascular permeability (57).
Early identification of patients at risk and
prevention of OHSS is clinically important.
Several methods have been recommended for
minimizing the probability of OHSS in highrisk patients, including canceling the cycle before administration of hCG or reducing the
ovulatory hCG dose (8), withholding luteal
support with hCG (9), cryopreserving all embryos for further use in a nonstimulated cycle
(10), repeating aspiration of ovarian follicles
and early corpus luteum cysts (11), administering human albumin at the time of hCG injec1151

tion (12), using GnRH analogue to trigger ovulation (13),

and performing vaginal aspiration of ascites (14).

their allocated intervention from the first menstrual cycle

after randomization.

Ketoconazole interferes with cytochrome P450 enzyme

systems in testis, ovary, adrenal gland, and liver. Steroidogenesis is inhibited by its action on the C17-20 lyase, the
cholesterol side-chain cleavage enzyme, and the 17-hydroxylase. In gonads, it inhibits aromatase, and adrenocortical steroid biosynthesis is inhibited at the 11-hydroxylation and 18-hydroxylation steps.

Serum concentrations of liver aminotransferase and bilirubin were measured by using kinetic and colour anylin
methods, respectively. E2 was assayed by using the Coat-aCount recombinant immunoassay (Diagnostics Products Co.,
Los Angeles, CA) 2 to 3 days after the start of menstrual
bleeding or progesterone-induced bleeding between days 1
and 3 of menstrual cycle. During this time, transvaginal
ultrasonography was performed by using a 5-MHz transvaginal transducer (Medison 600, Korea).

The antiandrogenic effect of ketoconazole may be useful

in the management of metastatic prostate carcinoma and
hirsutism. Its anticortisolic effect may be useful in the treatment of most patients with Cushings syndrome (1517).
Ketoconazole, a broad-spectrum imidazole antimycotic
agent, was recently reported to reduce the incidence of
OHSS in women with PCOS undergoing superovulation
with gonadotropins (18). Because this study was not placebo
controlled, however, a placebo effect could not be ruled out.
We performed a double-blind, placebo-controlled study
to assess the role of ketoconazole in prevention of multifollicular development, excess ovarian steroidogenesis, and
moderate and severe OHSS in patients with PCOS undergoing superovulation with gonadotropins.

MATERIALS AND METHODS

The study was performed at Shiraz University of Medical
Sciences, Shiraz, Iran. From September 2000 to November
2002, we enrolled 637 women with PCOS from our infertility division into this prospective, randomized, doubleblind, placebo-controlled study.
Patients were interviewed, the study protocol was described
to them, and patients charts were carefully reviewed. Patients
had undergone a complete infertility evaluation that included
hormonal assay, hysterosalpingography, postcoital testing, semen analysis, and endometrial biopsy. Inclusion criteria were
infertility, an elevated serum LH level, a normal or elevated
FSH level, an LH-to-FSH ratio greater than 2, elevated testosterone and DHEAS levels, oligomenorrhea or amenorrhea, and
at least 10 follicles smaller than 8 mm in diameter in the
subcapsular region around the hyperechogenic central stroma
on ultrasonography.
Except for PCOS-related anovulatory infertility, women
with other infertility factors were excluded. A total of 528
patients were excluded (217 women did not fulfill the inclusion criteria and 311 women declined to participate). Thus,
109 women were randomly allocated after giving informed
consent. The ethics review committee for human research of
the university approved the study.
Women had been unsuccessfully treated with clomiphene
citrate at daily doses of up to 200 mg for 5 days. All were
being considered for treatment with hMG. They received
1152 Parsanezhad et al.

Ketoconazole in prevention of OHSS

All patients had sonographic characteristics of PCOS.

Liver aminotransferase and bilirubin levels were normal in
all patients. The serum E2 level was normal for the early
follicular phase.
Before receiving the allocated intervention and undergoing work-up, all patients were randomized by using a random table. A pharmacist who did not take part in this study
administered medication and placebo. Neither the patients
nor the physician and laboratory staff knew the treatment
protocol.
The ketoconazole administration protocol was similar to
that used as alternate protocol by Gal et al. (18). Fifty
patients received two ampoules of hMG (75 IU of FSH and
75 IU of LH per ampoule) (Organon, Oss, The Netherlands)
i.m. beginning on day 2 or 3 of the cycle and the minimal
dose of ketoconazole (50 mg) starting on the first day of
hMG treatment. Ketoconazole was given at a dose of 50 mg
every 48 hours, and its administration was limited up to the
last day of hMG stimulation. Fifty-one patients received the
same hMG protocol but received one placebo tablet every 48
hours.
Ovarian stimulation was monitored by ultrasonographic
assessment of total number of growing follicles, mean diameter of the follicles, and the full endometrial thickness and
measurement of E2 every 2 days.
Ovulation was triggered by i.m. injection of 10,000 IU of
hCG (Organon) when the leading follicle reached a diameter
greater than 16 mm and the E2 concentration was greater
than 300 pg/mL for each main follicle (16 mm in diameter). Liver aminotransferase and bilirubin measurement was
repeated on the last day of ketoconazole and hMG administration.
Ovarian hyperstimulation syndrome was predicted by using the criteria described by Rabe et al. (19). The syndrome
was graded by using established criteria (20). If a patient was
at risk of OHSS, the hCG dose was reduced to 5,000 IU or
her cycle was cancelled (i.e., administration of hCG was
withheld). Patients were monitored during the luteal phase 6
2 days and 12 1 days after injection of hCG. They were
asked about symptoms of OHSS (abdominal pain, nausea,
vomiting, diarrhea, and weight gain).
Vol. 80, No. 5, November 2003

TABLE 1
Effects of ketoconazole and placebo in patients undergoing hMG superovulation.
Variable
No. of cycles
Duration of hMG therapy
Total no. of hMG ampoules/patient
E2 level on day 9 of the cycle
No. of patients with dominant follicles on day 9 (%)
E2 level before hCG injection (pg/ml)
Endometrial thickness before hCG administration (mm)
No. of patients with E2 level 1,500 pg/mL at hCG injection
(%)
No. of patients who received 5,000 IU of hCGa
No. of patients with 13 lead follicles (%)
No. of successful stimulation cycles (%)
a

Ketoconazole group

Placebo group

P value

50
13.5 0.98
19.44 1.5
465.27 134.24
13 (25.6%)
1349.58 381.71
10.7 1.45
36 (72.1%)

51
9.6 1.9
15.18 1.9
1001.54 552.28
30 (59.1%)
1288.65 473.64
10.4 1.4
38 (75%)

.0001
.0001
.0001
.0001
.05
.05
.05

5 (10%)
43 (86%)
36 (72.1%)

.05
.05
.05

7 (13%)
45 (88.6%)
38 (75%)

Because of the risk of ovarian hyperstimulation syndrome.

Parsanezhad. Ketoconazole in prevention of OHSS. Fertil Steril 2003.

Transvaginal ultrasonography was performed to measure

peritoneal fluid, ovarian size, total number of cysts, and
maximum cyst diameter. Blood samples were obtained for
measurement of E2, -hCG, plasma proteins, and electrolytes and for a blood count. If any evidence of moderate
OHSS was present, the patient was hospitalized for further
management.
Clinical and laboratory variables were compared between
the treatment and placebo groups. Statistical analysis was
performed by using the Student t-test and 2 test. Correlations were calculated at a 95% level of confidence. P.05
was considered significant.

RESULTS
One hundred one women completed the study protocol.
Three ketoconazole recipients and five placebo recipients
were lost to follow-up.
Ketoconazole and placebo recipients did not statistically
differ in mean (SD) age (26.3 3.1 years vs. 28.33 4.0),
body mass index (27.12 2.1 kg/m2 vs. 28.62 4.8 kg/m2),
duration of infertility (3.7 1.8 years vs. 3.8 1.4 years), and
percentage of participants with primary infertility (81.4% vs.
75%). Ketoconazole had no side effects with the treatment
protocol.
The duration of treatment with hMG was significantly
longer in ketoconazole recipients than placebo recipients
(P.0001). Although the total numbers of follicles on day 9
of the cycle were similar in ketoconazole and placebo recipients (11.13 3.37 and 10.6 3.63, respectively), the
number of the patients with dominant follicles (mean diameter 14 mm) was significantly higher among placebo recipients (P.0001). Serum E2 concentrations on day 9 of the
cycle were significantly higher among placebo recipients
FERTILITY & STERILITY

(1001.54 552.28 pg/mL vs. 465.27 134.24 pg/mL

among ketoconazole recipients; P.0001).
The number of hMG ampoules that was needed to attain
superovulation was significantly higher among ketoconazole
recipients (P.0001) (Table 1). Serum E2 level, endometrial
thickness at the time of hCG administration, and number of
patients who received 5,000 IU of hCG were similar in the
two groups (Table 1).
Table 1 shows the number of patients with an E2 value
less than the critical level of 1,500 pg/mL and the number
of lead follicles at the time of hCG administration. The E2
level and number of lead follicles were similar in the two
groups. The number of pregnancies, cases of OHSS, and
number of cancelled cycles did not differ between the ketoconazole and placebo group (Table 2).

DISCUSSION
Gal et al. (18) first attempted use of ketoconazole to treat
OHSS. They administered 50 mg of ketoconazole every 24
to 48 hours beginning on the first day of hMG administration

TABLE 2
Outcome of treatment in patients receiving ketoconazole
or placebo.
Variable
No.
No.
No.
No.

of
of
of
of

pregnancies (%)
multifetal pregnancies
cancelled cycles (%)
patients with OHSS (%)

Ketoconazole
group

Placebo
group

9 (18)
0
14 (27.9)
4 (7)

11 (21.5)
0
16 (31)
5 (9)

P value
.05
.05
.05

Parsanezhad. Ketoconazole in prevention of OHSS. Fertil Steril 2003.

1153

and reported a significant reduction in OHSS after treatment

with ketoconazole.
The regimen that we used does not differ from that used
as alternate protocol by Gal et al. (18) in terms of drug,
dosage, and follow-up. We found a slow rate of E2 production during the follicular phase (on day 9 of the cycle) in the
ketoconazole group compared with placebo recipients. Similar results were reported when a different dose of ketoconazole was given (21).
On the 9th day of the cycle, equal numbers of follicles
were growing in the two groups. However, significantly
more placebo recipients had dominant follicles. This finding
suggests that the drug did not affect the total number of
growing follicles, but the rate of follicular growth was reduced. Ketoconazole was expected to prevent multiple follicular growth and excess steroidogenesis despite continuing
gonadotropin administration to attain acceptable numbers of
dominant follicles, an appropriate serum E2 level, and a
successful stimulation cycle.
When administration of gonadotropins was continued to
reach an acceptable number of dominant follicles to trigger
ovulation by hCG, some patients developed hyperstimulated
ovaries. Zelinski-Wooten et al. (22) and Moudgal et al. (23)
also reported a similar finding. They discovered that
trilostane, a 3-hydroxysteroid dehydrogenase inhibitor, and
fadrozole, a nonsteroidal aromatase inhibitor, administered
throughout the follicular phase to rhesus monkeys undergoing ovarian stimulation with human gonadotropins had no
effect on the total number of antral follicles and their distribution, the number of retrieved oocytes, and ovulation, despite a profound reduction in E2 levels. In contrast, Gal et al.
(18) found a substantial reduction in the number of mediumsized follicles and reported a reduction in cancellation rate
from 37% to 7%.
In our study, the incidence of OHSS in both groups was
similar to that reported by Gal et al. (18) in their untreated
cycles. We also found no significant difference in the rates of
cycle cancellation and hyperstimulated cycles between ketoconazole and placebo recipients. The numbers of successful stimulation cycles were also similar in the two groups.
Our results suggest that during ovulation induction with
gonadotropins, ketoconazole may decrease the rate of folliculogenesis and steroidogenesis.
The total number of follicles, including small, mediumsized, and leading follicles, and serum E2 levels were similar
in the ketoconazole and placebo groups at the time of hCG
administration. These findings may explain why ketoconazole does not prevent OHSS.
Gal et al. (18) reported that low-dose ketoconazole did
not affect progesterone production. Because progesterone
does not play a critical role in our results, we did not
consider these values in our analysis.
1154 Parsanezhad et al.

Ketoconazole in prevention of OHSS

Zelinski-Wooten et al. (22) reported a reduced fertilization rate among trilostane-treated monkeys. Similar results
were reported by Moudgal et al. (23) when aromatase inhibitor was administered. Although we did not evaluate the
fertilization process, the similar pregnancy rate per ovulatory
cycle in our two groups may support the idea that low-dose
ketoconazole does not adversely affect fertilization.
In conclusion, low-dose ketoconazole during stimulation cycles with gonadotropins may reduce the rate of
folliculogenesis and steroidogenesis. Ketoconazole has no
beneficial effect on the development of multiple follicles,
final serum levels of E2 at the time of HCG administration, OHSS development, and cycle cancellation. Further
study to evaluate the effects of various protocols of ketoconazole on vasoactive agents affecting OHSS may be
helpful.

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