Human Reproduction, Vol.25, No.11 pp.

27832791, 2010
Advanced Access publication on September 21, 2010 doi:10.1093/humrep/deq254

ORIGINAL ARTICLE Infertility

Six weeks of structured exercise training

and hypocaloric diet increases the
probability of ovulation after clomiphene
citrate in overweight and obese patients
with polycystic ovary syndrome: a
randomized controlled trial
1
Unit of Reproductive Medicine and Surgery, Department of Obstetrics & Gynaecology, University Magna Graecia of Catanzaro, Viale
Europa 88100 Catanzaro, Italy 2Department of Clinical Medicine, Cardiovascular and Immunological Sciences, University Federico II of
Naples, Via Pansini 80131 Naples, Italy 3Department of Obstetrics & Gynaecology, University Federico II of Naples, Via Pansini 80131
Naples, Italy 4Endocrinology, University Parthenope of Naples, Via Ammiraglio Ferdinando Acton 80131 Naples, Italy

*Correspondence address. Tel: +39-3475880503; Fax: +390961961820; E-mail: stefanopalomba@tin.it

Submitted on February 28, 2010; resubmitted on August 20, 2010; accepted on August 24, 2010

background: Clomiphene citrate (CC) is the rst-line therapy for the induction of ovulation in infertile women with polycystic ovary
syndrome (PCOS), but 20% of patients are unresponsive. The aim of the current study was to test the hypothesis that a 6-week intervention that consisted of structured exercise training (SET) and hypocaloric diet increases the probability of ovulation after CC in overweight
and obese CC-resistant PCOS patients.
methods: A cohort of 96 overweight and obese CC-resistant PCOS patients was enrolled consecutively in a three-arm randomized,
parallel, controlled, assessor-blinded clinical trial. The three interventions were: SET plus hypocaloric diet for 6 weeks (Group A); 2
weeks of observation followed by one cycle of CC therapy (Group B); and SET plus hypocaloric diet for 6 weeks, with one cycle of CC
after the rst 2 weeks (Group C). The primary end-point was the ovulation rate. Other reproductive data, as well as anthropometric, hormonal and metabolic data, were also collected and considered as secondary end points.
results: After 6 weeks of SET plus hypocaloric diet, the ovulation rate was signicantly (P 0.008) higher in Group C [12/32 (37.5%)]
than in Groups A [4/32 (12.5%)] and B [3/32 (9.4%)] with relative risks of 3.9 [95% condence interval (CI) 1.1 8.3; P 0.035] and 4.0
(95% CI 1.2 12.8; P 0.020) compared with Groups A and B, respectively. Compared with baseline, in Groups A and C, a signicant
improvement in clinical and biochemical androgen and insulin sensitivity indexes was observed. In the same two groups, the insulin sensitivity
index was signicantly (P , 0.05) better than that in Group B.

conclusions: In overweight and obese CC-resistant PCOS patients, a 6-week intervention of SET and a hypocaloric diet was effective
in increasing the probability of ovulation under CC treatment.
The study was registered at Clinicaltrials.gov: NCT0100468.
Key words: clomiphene citrate / diet / exercise / infertility / polycystic ovary syndrome

Introduction
Clomiphene citrate (CC) was the rst agent used to induce ovulation
in oligomenorrheic women, and it is still considered the rst therapeutic option for the management of anovulatory infertility related
to polycystic ovary syndrome (PCOS; Palomba et al., 2004). In fact,

a recent meta-analysis (Brown et al., 2009) has demonstrated that

CC increases the pregnancy rate by .6-fold in comparison with
placebo or no treatment.
At present, the United Kingdom National Institute for Clinical Excellence (NICE, 2004) and World Health Organization (WHO, 2002)

& The Author 2010. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved.
For Permissions, please email: journals.permissions@oxfordjournals.org

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S. Palomba 1,*, A. Falbo 1, F. Giallauria 2, T. Russo 1, M. Rocca 1,

A. Tolino 3, F. Zullo 1, and F. Orio 4

2784

Materials and Methods

The procedures used during the study were in accordance with the principles laid down by the Declaration of Helsinki on human experimentation
and good clinical practice. The study protocol was approved by the Ethical
Committee of the Department of Gynecology & Obstetrics (University
Magna Graecia, Catanzaro, Italy). The purpose of the protocol was

explained carefully and detailed information was given to each patient

about the role of weight loss in reproductive disorders and the benets
of lifestyle modication, with particular regard to physical activity and
diet. Written informed consent was obtained from each patient.

Population
From February 2008 to August 2009, 96 overweight and/or obese PCOS
patients with anovulatory infertility and known CC resistance were
enrolled in a randomized, parallel, controlled assessor-blinded clinical
trial (registration number NCT01004068 at www.clinicaltrial.gov).
Diagnosis of PCOS was based on the presence of chronic anovulation,
conrmed by serum progesterone (P) levels ,2 ng/ml randomly assessed
for at least the two consecutive months prior to the study start, and of
clinical and/or biochemical hyperandrogenism [Ferriman Gallwey score
8 (Ferriman and Gallwey, 1961) and elevated serum androstenedione
and/or dehydroepiandrosterone sulphate (DHEA-S) and/or total testosterone concentrations according to normal reference values].
The diagnosis of anovulatory infertility was made on the basis of regular
sexual intercourse for at least 1 year and a history of irregular periods
(cycle length .35 days), as well as normal serum FSH and estradiol (E2)
levels (The ESHRE Capri Workshop Group, 1995).
Patients were dened as CC-resistant if they had failed to ovulate after
treatment under an incremental regimen with a maximum dose of 150 mg
CC/day. Under this regimen, CC was administered for 5 days beginning at
Day 3 following a P-induced withdrawal bleeding with a starting dose of
50 mg daily. If ovulation did not occur, this dose was increased by increments of 50 mg in successive cycles, until ovulation was achieved or a
maximal dose of 150 mg daily was reached.
Subjects were considered to be overweight or obese if their body mass
index (BMI) was 25 30 or .30, respectively (National Heart, Lung, and
Blood Institute/National Institutes of Diabetes and Digestive and Kidney
Diseases, 1998).
The exclusion criteria included: age ,18 or .35 years; BMI , 25 and
35; major medical disorders or other concurrent medical illnesses; and
current or previous use of hormonal, anti-diabetic or anti-obesity drugs,
or other drugs that affect hormone levels, carbohydrate metabolism or
appetite.

Protocol and interventions

After careful selection according to the above inclusion and exclusion criteria, all eligible subjects were enrolled and randomly allocated into three
treatment arms of 32 women each (Groups A, B and C). The study was
single blind, i.e. assessors were masked to the treatment assignment,
whereas those giving the interventions and the enrolled patients were
aware of the assigned treatment because the interventions differed. The
random allocation sequence was made in single blocks, i.e. by using a
single sequence of random and obtained with the use of a computergenerated randomization list. The sequence was concealed from all investigators until the interventions were assigned using sequentially numbered
opaque sealed envelopes that were prepared distant from the study site.
At the start of the study, 100 mg natural P was administered to each
woman intramuscularly.
During the rst 2 weeks, Groups A and C underwent SET and were
given a hypocaloric diet, whereas Group B underwent observation
alone. During the following 4 weeks, Groups A and C continued with
SET and the hypocaloric diet, and Groups B and C received one cycle
of CC therapy.
The interventions and the timing of follow-ups for each arm are summarized in Fig. 1.
The SET consisted of three training sessions per week, during which
the subjects exercised for 30 min on a bicycle ergometer and the

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guidelines state that rst-line treatment for anovulatory patients should

be CC for up to 12 months. Similarly, the European Society of Human
Reproduction and Embryology (ESHRE) and the American Society for
Reproductive Medicine (ASRM) recommend induction of ovulation
with CC for up to six ovulatory cycles as the rst-line drug treatment
for PCOS-related infertility (The Thessaloniki ESHRE/ASRMSponsored PCOS Consensus Workshop Group, 2008).
Notwithstanding the efcacy of CC, ovulation is not achieved in a
proportion of patients, although a maximum dosage is used. These
patients are dened generally as CC-resistant (Kousta et al., 1997).
Traditionally, CC is administered up to a maximum dose of 250 mg
daily to obtain an optimal clinical response (Gysler et al., 1982).
However, in more than 75% of cases, ovulation occurs with a dose
of 150 mg/day, and increasing the dose confers no signicant reproductive benets in terms of ovulation (Imani et al., 1998, 1999) but
only peripheral adverse effects (Palomba et al., 2006a,b). Therefore,
150 mg/day CC is considered the highest dose that should be administered (NICE, 2004). In this regard, the United States (US) Food and
Drug Administration (FDA) has suggested that doses of CC should not
exceed 750 mg per cycle (Dickey and Holtkamp, 1996).
CC resistance represents an important clinical problem that affects
up to 25% of infertile women with PCOS. In these patients, several
combined or alternative treatments have been proposed for inducing
ovulation (Palomba et al., 2009). Second-line strategies to induce ovulation in CC-resistant PCOS patients are based on treatments with
mechanisms of action that are different from those of CC, such as
aromatase inhibitors, or treatments that sensitize the ovary to subsequent or concomitant administration of CC, such as ovarian drilling
and metformin (Palomba et al., 2009). The re-administration of CC
using luteal-phase CC treatment and a stair-step CC protocol has
been also proposed (Palomba et al., 2009).
To date, the administration of metformin in parallel with CC is
probably the most common second-line treatment for PCOS-related
anovulation. Metformin seems to sensitize the ovary to CC via mechanisms that are probably related to its insulin-sensitizing action, when
it is administered in pretreatment protocols (Palomba et al., 2009).
Lifestyle modication programmes are considered unanimously to
be a valid alternative to drug therapy for obese women with anovulatory infertility (Cussons et al., 2005; Pasquali et al., 2006; Palomba
et al., 2008), and many clinicians and recent guidelines regard lifestyle
management as the primary therapy in overweight and obese women
with PCOS (The Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group, 2008; Moran et al., 2009). Surprisingly, no
data are available in the literature regarding the specic clinical efcacy
of physical exercise and/or diet in CC-resistant PCOS.
The aim of the present study was to test the hypothesis that a
6-week intervention that consisted of structured exercise training
(SET) and a hypocaloric diet could increase the ovulation rate after
CC administration in PCOS patients with known CC resistance.

Palomba et al.

Lifestyle modications and CC-resistance

2785

exercise workload was increased gradually until a target of 60 70% of

maximal oxygen consumption was achieved, according to an initial
cardiopulmonary exercise test (Vigorito et al., 2007; Palomba et al.,
2008). Each session was preceded by a 5-min warm-up and followed
by a 5-min cool down. The training sessions were performed under
continuous electrocardiographic monitoring and supervised by a
cardiologist.
The hypocaloric diet was characterized by a high protein composition
(35% protein, 45% carbohydrate and 20% fat), and energy inputs were
adjusted to create a 1000-kcal decit per day on the basis of the
normal daily caloric input previously calculated for each patient.
After a 2-week period of observation (Group B) or SET and hypocaloric
diet (Group C), and in the absence of any ovarian response at ultrasound
evaluation, CC was given at a xed dose of 150 mg/day for 5 days. In the
case of follicular development, no agent to induce ovulation was administered, patients carried on with their original treatment, and were excluded
from the nal analysis.
At entry into the study and at 2 weeks follow-up, clinical, biochemical
and ultrasonographic assessments were performed. At the end of the
study, anthropometric data were evaluated, and reproductive outcomes
were noted as described below. In addition, compliance to the interventions was evaluated in all cases.
Ovulation was monitored by serial transvaginal ultrasonographic scans
performed by the same experienced operator (T.R.) at baseline, every 4
days, and successively daily until ovulation in case of a dominant follicle
with a mean diameter of 12 mm. Ovulation was identied retrospectively by observation of a decrease in follicular dimensions and liquid in
the cul-de-sac, and was conrmed by plasma P assay (.10 ng/ml)
assessed 7 days before the expected menses on the basis of ultrasonographic ndings.
In the absence of menstrual bleeding, a pregnancy test was performed in
all patients in whom ovulation had occurred. If pregnancy was achieved,
patients stopped the assigned treatments, i.e. SET and hypocaloric diet
or CC, and were followed in our institution; otherwise, withdrawal

bleeding was induced by medroxyprogesterone acetate (10 mg/day for

10 days).
To evaluate adherence to the SET intervention, the number of SET
sessions missed per week was recorded. We considered no sessions
missed per week as high adherence, one session missed per week as
moderate adherence, and more than one session missed per week as
low adherence. The lack of adherence to the dietary programme was
dened as the inability to tolerate the caloric restriction or composition
of the diet, and was calculated according to the degree of change with
respect to caloric intake and dietary composition. In particular, adherence
was dened as high with a mean caloric decit .4900 kcal/week and/
or with a dietary composition of 30 35% protein and 45 50% carbohydrate; moderate with a mean caloric decit of 3500 4900 kcal/
week and/or with a dietary composition of 25 30% protein and 50
55% carbohydrate; and low with a mean caloric decit ,3500 kcal/
week and/or with a dietary composition of ,25% protein and .55%
carbohydrate.
Interactive group educational meetings were organized to improve the
adherence rate. Conversely, in order to eliminate bias due to arbitrary
changes in diet and physical activity, daily diet and physical activity were
monitored in all patients using two well-validated questionnaires
(Roeykens et al., 1998; Willett, 1998). In particular, daily dietary monitoring consisted of compiling personal charts and sending them weekly to the
investigators, and food consumption was assessed using a selfadministered, semi-quantitative, well-validated food-frequency questionnaire (Willett, 1998), which was used to cross-check the dietary history.
Daily diet was evaluated with the aid of software that is specic for the
analysis of food habits and for the estimation of nutrient and caloric
intake (WinFood version 1.5; Medimatica, Martinsicuro, Italy). The monitoring of daily physical activity consisted of a leisure-time physical activity
(LTPA) questionnaire and calculation of a weekly energy expenditure
score (total LTPA level) in metabolic equivalents per hour/week, by
using a standardized classication of the energy expenditure associated
with particular physical activities (Ainsworth et al., 2000).

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Figure 1 Interventions and timing of follow-up visits.

2786

Clinical and biochemical assessments

Statistical analysis
The primary end-point of the study was the ovulation rate, dened as the
number of women who ovulated divided by the total number of women
studied. Secondary end points were other reproductive outcomes,
changes in anthropometric, hormonal and metabolic parameters, as well
as compliance with the interventions.
On the basis of previous data (Branigan and Estes, 2003),
re-administration of CC in resistant PCOS patients is associated with an
ovulation rate of 10%. To detect an increase of 30% in the ovulation
rate, which was dened as clinically signicant, with 80% power and a twosided type I error of 5%, we calculated that 31 subjects were required

for each group. To allow for an unpredictable number of withdrawals,

we decided to enrol a total of 96 patients in the expectation that at
least 31 would remain in each group.
Data were analysed by using the per-protocol and intention-to-treat
(ITT) analyses on the basis of treatment receipt and assignment,
respectively.
The Kolmogorov Smirnov test with a Lilliefors signicance level was
used to test normality. Our data were normally distributed and expressed
as mean + standard deviation (SD). Continuous variables were analysed
by one-way analysis of variance (ANOVA), and ANOVA for repeated
measures with the Bonferroni correction for the post hoc analysis. Differences in dichotomous outcomes among the three study groups were analysed with the use of the x 2 test or Fishers exact test when the expected
cell frequencies fell below ve.
The relative risk (RR) with 95% condence interval (CI) for estimated
ovulation and menstrual rates was calculated.
A P 0.05 was considered as statistically signicant. SPSS version 13.0
(Chicago, IL, USA) was used for the statistical analyses. The power analysis
and the sample size calculation were performed using SamplePower
version 2.0.

Results
The ow-diagram of the clinical trial according to the consolidated
CONSORT guidelines (Moher et al., 2001) is shown in Fig. 2. No randomized subject was excluded from the nal analysis, thus the data
analysed according to the per-protocol analysis were the same as
those analysed by the ITT analysis. In all cases, diagnosis of PCOS satised both the ESHRE/ASRM (Rotterdam ESHRE/ASRM-Sponsored
PCOS Consensus Workshop Group, 2004) and the US National Institute of Health (Zawadski and Dunaif, 1992) criteria. At enrolment, all
patients had polycystic ovaries at transvaginal ultrasonography (Balen
et al., 2003). At the start of the study, in all subjects, injection of P
induced withdrawal uterine bleeding.

Figure 2 Flow diagram of subject progress through the phases of a randomized trial according to CONSORT guidelines (Moher et al., 2001).

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Clinical evaluation consisted of calculation of the Ferriman Gallwey score

(Ferriman and Gallwey, 1961) and anthropometric measurements, which
included height, body weight (BW), BMI, waist circumference (WC) and
waist-to-hip ratio (WHR).
At baseline and 2 weeks after the start of the study, and after sonographic evaluation conrmed ovarian quiescence, a venous blood sample
was taken from each participant between 08:00 and 09:00 h after fasting
for 12 h and resting in bed to assess the complete hormonal prole and
fasting glucose and insulin levels. The complete hormonal prole included
the evaluation of levels of FSH, LH, thyroid-stimulating hormone (TSH),
prolactin (PRL), E2, P, 17-OH-progesterone (17-OHP), testosterone,
androstenedione, DHEAS and sex-hormone-binding globulin (SHBG).
In each participant, homeostasis model of assessment of insulin resistance
(HOMA-IR), fasting glucose-to-insulin ratio (GIR) (mg/1024 U) and free
androgen index (FAI) were calculated.
Each participant was instructed to record in a personal daily diary the
onset of any adverse effects, together with their severity, duration and
any possible cause effect relationship with the interventions, and the
quantity of menstrual bleeding, which was evaluated subjectively by using
a rank analogue scale that ranged from 0 (absence of menses) to 5
(normal uterine bleeding) and 10 (severe uterine bleeding).

Palomba et al.

2787

Lifestyle modications and CC-resistance

Clinical and biochemical outcomes

Reproductive outcomes
At 2 weeks after the start of the study, no ovarian response was
detected in any of the patients in Group A, B or C. Therefore, no
patients were excluded after randomization, and all patients continued
with their assigned protocol.
After intervention, the ovulation rate was signicantly (P 0.008)
higher in Group C [12/32 (37.5%)] than in Groups A [4/32
(12.5%)] and B [3/32 (9.4%)] with a RR of 3.9 (95% CI 1.18.3;
P 0.035) and 4.0 (95% CI 1.212.8; P 0.020) for Group C
versus group A and B, respectively.
Only one patient from Group C became pregnant.
The development of multiple follicles was observed in ve patients;
specically, in two patients from Group B and in three from Group
C. In all ve cases, two follicles were observed, and the subjects
were overweight rather than obese.
No statistically signicant (P 0.262) difference in serum P levels
(ng/ml) was detected among ovulatory patients from Groups A, B
and C (15.3 + 4.2, 16.7 + 5.3 and 15.9 + 6.1, respectively). At the

Table I Clinical data at baseline, and at 2- and 6-week follow-ups.

Group A (n 5 32)

Group B (n 5 32)

Group C (n 5 32)

.............................................................................................................................................................................................
Age (year)
Baseline

27.50 + 4.95

26.50 + 4.26

28.43 + 8.31

22.80 + 2.04

22.60 + 2.54

22.14 + 4.88

14 (43.75)/18 (56.25)

17 (53.13)/15 (46.87)

Duration of infertility (m)

Baseline

Proportion of overweight/obese subjects (n, %)

Baseline

15 (46.87)/17 (53.13)

BMI (Kg/m2)
Baseline

31.26 + 2.66

32.32 + 3.73

31.05 + 2.98

Two weeks

31.12 + 2.63

32.37 + 3.70

30.93 + 3.03

Six weeks

28.87 + 2.35*,8

32.26 + 3.54

28.41 + 2.54*,8

BW
Baseline

85.32 + 6.41

87.04 + 6.95

86.21 + 6.98

Two weeks

84.44 + 6.46

86.96 + 6.85

85.93 + 5.89

Six weeks

81.11 + 5.67*,8

86.35 + 6.43

81.79 + 6.02*,8

WC (cm)
Baseline

93.82 + 4.83

95.07 + 3.42

94.67 + 4.68

Two weeks

90.59 + 4.03*,8

94.59 + 4.12

90.25 + 3.03*,8

Six weeks

89.98 + 4.12*,8

94.51 + 4.23

89.75 + 3.55*,8

Baseline

0.89 + 0.05

0.89 + 0.06

0.89 + 0.05

Two weeks

0.86 + 0.06

0.88 + 0.07

0.85 + 0.04

Six weeks

0.80 + 0.04*,8

0.88 + 0.08

0.80 + 0.03*,8

WHR

Ferriman Gallwey score

Baseline

11.85 + 2.58

11.85 + 2.94

12.13 + 2.32

Two weeks

11.70 + 2.49

11.75 + 3.78

12.03 + 3.65

Six weeks

11.72 + 2.61

11.71 + 3.21

11.95 + 3.32

BW, body weight; WC, waist circumference; WHR, waist-to-hip ratio.

*P , 0.05 versus baseline.
8P , 0.05 versus Group B.

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The main clinical and biochemical data for the three groups at enrolment
and after 2 weeks of follow-up are shown in Tables I and II, respectively.
At entry into the study, no difference was detected among the three
groups for any clinical or biochemical characteristics (Tables I and II).
The proportions of overweight and obese subjects did not differ
between the groups (Table I). Four subjects from Group A and three
each from Groups B and C had glucose intolerance.
Two weeks after the study started, WC, testosterone, androstenedione, DHEAS and FAI were reduced signicantly (P , 0.05) in
Groups A and C compared with baseline, and there were no differences between these two groups (Tables I and II). Both WC and
FAI were signicantly (P , 0.05) lower in Groups A and C when compared with Group B (Tables I and II). At the same time, in Groups A
and C, SHBG and GIR were signicantly (P , 0.05) higher, and fasting
insulin levels and HOMA-IR were signicantly (P , 0.05) lower relative
to Group B or their respective baselines (Table II). There were no
differences between Groups A and C.
Anthropometric data obtained at the end of the study are shown in
Table I. At 6 weeks after the start of the study, BMI, BW, WC and
WHR were reduced signicantly (P , 0.05) in Groups A and C

when compared with baseline and Group B, although there were no

differences between Groups A and C (Table I).

2788

Palomba et al.

Table II Biochemical data at baseline and at 2 week

follow-up.
Group A
(n 5 32)

Group B
(n 5 32)

Group C
(n 5 32)

........................................................................................
FSH (mIU/ml)
Baseline

4.51 + 2.48

4.16 + 2.31

5.82 + 3.47

Two weeks

4.85 + 2.78

4.23 + 1.25

4.99 + 3.15

Baseline

8.70 + 2.22

9.17 + 1.76

9.23 + 3.44

Two weeks

8.80 + 2.34

8.27 + 2.76

8.40 + 3.14

LH (mIU/ml)

TSH (mU/ml)
1.39 + 0.69

1.27 + 0.52

1.35 + 0.69

1.54 + 0.58

1.49 + 0.51

1.40 + 0.66

Baseline

2.15 + 0.64

2.00 + 0.56

2.52 + 0.78

Two weeks

2.03 + 0.72

2.10 + 0.87

2.63 + 0.82

PRL (mg/l)

E2 (pmol/l)
Baseline

123.95 + 24.91

119.90 + 26.54

113.00 + 25.89

Two weeks

123.25 + 27.78

125.43 + 26.61

116.57 + 22.76

Baseline

0.93 + 0.48

0.97 + 0.47

1.02 + 0.63

Two weeks

1.02 + 0.44

0.99 + 0.54

1.07 + 0.51

Group A
(n 5 32)

Group B
(n 5 32)

Group C
(n 5 32)

........................................................................................
HOMA-IR
Baseline

1.24 + 0.38

1.15 + 0.57

1.27 + 0.44

Two weeks

1.14 + 0.49*,8

1.21 + 0.62

1.11 + 0.52*,8

TSH, thyroid-stimulating hormone; PRL, prolactin; E2, estrogen; P, progesterone;

17-OHP, 17-OHprogesterone; T, testosterone; A, androstenedione; DHEA-S,
dehydroepiandrosterone sulphate; SHBG, sex hormone-binding globulin; FAI, free
androgen index; GIR, fasting glucose-to-insulin ratio; HOMA-IR, homeostasis model
of assessment of insulin resistance.
*P , 0.05 versus baseline.
8P , 0.05 versus Group B.

end of the study, menstrual bleeding was observed in 4 patients in

Group A (12.5%), 3 in Group B (9.4%) and 11 in Group C (34.4%)
(P 0.012) with a RR of 2.8 (95% CI 1.0 7.7; P 0.055) and 3.4
(95% CI 1.1 11.9; P 0.031) for Group C versus group A and
group B, respectively. In addition, there were no differences in
menstrual quantity among the three groups (data not shown).

P (ng/ml)

17-OHP (nmol/l)
Baseline

0.32 + 0.18

0.33 + 0.22

0.40 + 0.25

Two weeks

0.37 + 0.26

0.36 + 0.26

0.34 + 0.21

T (nmol/l)
Baseline

2.54 + 0.71

2.43 + 0.75

2.55 + 0.61

Two weeks

2.15 + 0.67*

2.51 + 0.97

2.21 + 0.67*

A (nmol/l)
Baseline

3.13 + 0.97

3.17 + 0.93

3.32 + 0.84

Two weeks

2.77 + 0.79*

3.18 + 0.86

2.82 + 0.78*

Baseline

8.60 + 2.30

8.67 + 2.50

8.66 + 2.32

Two weeks

8.39 + 1.88*

8.75 + 2.76

8.24 + 1.67

DHEA-S (mmol/l)

Treatment compliance
Patients in groups A and C showed a similar adherence to the SET and
dietary interventions (P 0.432). Specically, no difference between
Groups A and C was detected with respect to those showing high
adherence [26/32 (81.3%) versus 25/32 (78.1%), respectively], moderate adherence [4/32 (12.5%) versus 5/32 (15.6 %), respectively]
and low adherence [2/32 (6.3%) versus 2/32 (6.3%), respectively]
to SET. None of the patients in Group A or C showed a lack of adherence to the dietary programme. No relevant adverse effect was
observed throughout the study in any of the groups, and none of
the patients dropped out.
Data regarding LTPA levels throughout the study are depicted in
Fig. 3. No difference in LTPA levels was observed between the

SHBG (nmol/l)
Baseline

17.72 + 4.94

17.68 + 4.05

17.94 + 3.57

Two weeks

26.20 + 4.22*,8

17.43 + 3.12

25.37 + 3.23*,8

FAI (%)
Baseline

11.17 + 3.05

11.76 + 3.23

11.57 + 3.09

Two weeks

10.70 + 2.79*

11.64 + 3.76

10.88 + 3.56*

Fasting glucose (mmol/l)

Baseline

4.07 + 1.61

3.97 + 1.33

4.15 + 1.86

Two weeks

4.09 + 1.68

4.02 + 1.57

4.04 + 1.74

17.61 + 3.76

17.59 + 3.95

17.91 + 4.20

15.81 + 3.95*,8

Fasting insulin (mU/ml)

Baseline
Two weeks

16.65 + 5.39
,

14.57 + 4.37* 8

GIR
Baseline

3.66 + 1.42

4.24 + 1.22

3.76 + 1.37

Two weeks

4.88 + 0.82*,8

4.20 + 1.18

4.91 + 1.07*,8

Continued

Figure 3 Total LTPA level at baseline, at 2-week follow-up and at

study end. *P , 0.05 versus baseline; 8P , 0.05 versus group B.

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Baseline
Two weeks

Table II Continued

2789

Lifestyle modications and CC-resistance

groups at baseline. LTPA levels were improved signicantly (P ,

0.05) at 2 weeks after the start of the study and at the end of
the study in Groups A and C, and there was no difference
between these two groups. The LTPA level remained unchanged
in Group B.

Discussion

Authors roles
S.P., A.F. and F.O. participated to the study design, F.G., T.R. and M.R.
participated in the study execution, A.F. and A.T. participated in the
data analysis, S.P., F.Z. and F.O. participated in the manuscript drafting
and critical discussion.

Downloaded from http://humrep.oxfordjournals.org/ by guest on December 1, 2015

The main nding of the present randomized controlled study was that
a short-term lifestyle modication programme of 6 weeks had reproductive benets in overweight and obese patients with PCOS who
were resistant to CC. In particular, 2 weeks of SET and a hypocaloric
diet improved ovarian response to CC, with an ovulation rate of
37.5% and a restoration of menstrual cycle in 34.4% of patients who
were previously anovulatory after administration of a maximal dose
of CC, and with RRs of about 4.0 and 3.4 for ovulation and menstrual
cycle restoration, respectively. In addition, relevant differences in the
ovulation rate were observed between patients who underwent SET
plus a hypocaloric diet for 6 weeks plus one-cycle of CC administration and those who underwent either SET plus hypocaloric diet
or one-cycle of CC administration alone (35.7% versus 12.5% or
9.4%).
Several factors have been hypothesized to be involved in the clinical
efcacy of the lifestyle interventions (Moran et al., 2007a,b; Thomson
et al., 2009). In a previous study, we attempted to characterize the
mechanisms that underlie the efcacy of SET and diet in the restoration of ovarian function (Palomba et al., 2008). Both interventions
induced improvements in BW, BMI, WHR, WC, insulin resistance
index, FAI, and serum testosterone and SHBG levels within 12
weeks, with no further changes over a longer period. Furthermore,
the improvement in insulin sensitivity was hypothesized to be the
pivotal factor involved in the restoration of ovarian function after
SET and the dietary programme, even if this improvement was potentially related to loss of BW.
In the present study, we evaluated the main clinical and biochemical
data at baseline and after 2 weeks of intervention to elucidate potential mechanisms of ovarian sensitization to CC due to SET and a hypocaloric diet. Although the follow-up was only short-term, we observed
a reduction in hyperandrogenaemia and FAI, and an improvement in
serum SHBG and insulin levels, GIR and HOMA-IR.
Previous studies have suggested that weight loss, even though
minimal, could be the main factor involved in the restoration of fertility
(Clark et al., 1995, 1998; Huber-Buchholz et al., 1999; Norman et al.,
2004; Pasquali et al., 2006; Ramlau-Hansen et al., 2007; Palomba et al.,
2008). However, in the current study, there had been no signicant
reduction in BW at the point when CC was administered, which
suggests that the increase in ovulatory response after CC treatment
was unrelated to weight loss, which was only signicant at the end
of the study. In contrast, 2 weeks of SET and a hypocaloric diet
resulted in a signicant improvement in WC, which suggests a potential role of visceral fat reduction in enhancing ovulation. Visceral fat
could change acutely in response to lifestyle modication, and
reduce androgens and insulin resistance independently of BW. In the
current study, SET and the hypocaloric diet alone restored ovarian
function in 12.5% of anovulatory CC-resistant PCOS patients.
These lifestyle interventions have additional benets at short-term
follow-up. In fact, there is unanimous agreement on the advantages

related to improved insulin sensitivity with respect to pregnancy

and long-term risks, particularly in PCOS patients (Hoffman and
Ehrmann, 2008).
The main limitations of lifestyle intervention programmes are the
lack of persistence with major lifestyle changes (Anderson et al.,
2001), and the high rate of dropout of 2335% (Clark et al., 1995,
1998; Stamets et al., 2004; Palomba et al., 2008). In the present
study, the high rate of adherence to the dietary and SET programmes,
with no dropouts, was probably due to sample characteristics and the
protocol design. Our infertile patients had a high level of motivation
because they were all overweight or obese and had not been responsive previously to CC administration. The interventions adopted were
of short duration and easy to follow. In this regard, SET can be performed safely in healthy young subjects without any specic monitoring and specialist supervision even though they were part of the
research protocol in our study.
An important point of discussion regards the economic aspects of a
non-pharmacologic approach to CC resistance. In fact, a therapeutic
intervention that consists of SET and a dietary programme should
be considered as a valid and cheap option for CC-resistant PCOS
patients in sites where a SET programme is already in use, mainly
given the high direct and indirect costs of second-line treatments for
infertility. On the basis of reports from the Italian Diagnosis Related
Groups, the mean overall cost for each SET session in well-equipped
centres is E250. Furthermore, in clinical practice, after a rst daily
ambulatory phase, these patients could be scheduled for home-based
exercise programmes and dietary protocols.
The current randomized study has two main limitations. Firstly, it is
lacking a placebo group for controlling the CC treated patients. Furthermore, our study protocol was designed for testing the hypothesis
that a 6-week intervention consisting of SET and hypocaloric diet
could increases the ovulation rate due to CC administration in
CC-resistant PCOS patients. Therefore, all efforts were made for controlling the experimental intervention, whereas CC-treated groups
were baseline-controlled. In addition, a placebo treatment would be
accepted only with difculty by infertile patients who desire a pregnancy as soon as possible. Secondly, the outcome measure studied,
i.e. rate of ovulation, is not a robust end-point (Legro and Myers,
2004) for reproduction especially with a study design of only one
cycle assessment. Therefore, even if just the short-term observation
is peculiar and of clinical relevance, the present data should be considered preliminary.
In conclusion, in overweight and obese PCOS patients who are
resistant to CC, a 6-week intervention of SET plus hypocaloric diet
is an effective strategy to increase the probability of ovulation under
CC after only one cycle of therapy. Further studies with live birth or
baby-in-arm as the primary end-point are needed to conrm these
encouraging preliminary ndings at short-term follow-up and to
make them clinically relevant.

2790

Acknowledgements
We thank doctor Francesco Manguso for his contribution in the statistical analysis.

References

Moher D, Schulz KF, Altman D; CONSORT Group (Consolidated

Standards of Reporting Trials). The CONSORT statement: revised
recommendations for improving the quality of reports of
parallel-group randomized trials. J Am Med Assoc 2001;285:1987 1991.
Moran LJ, Noakes M, Clifton PM, Norman RJ. The use of anti-mullerian
hormone in predicting menstrual response after weight loss in
overweight women with polycystic ovary syndrome. J Clin Endocrinol
Metab 2007a;92:3796 3802.
Moran LJ, Noakes M, Clifton PM, Wittert GA, Le Roux CW, Ghatei MA,
Bloom SR, Norman RJ. Postprandial ghrelin, cholecystokinin, peptide
YY, and appetite before and after weight loss in overweight women
with and without polycystic ovary syndrome. Am J Clin Nutr 2007b;
86:1603 1610.
Moran L, Pasquali R, Teede HJ, Hoeger KM, Norman RJ. Treatment of
obesity in polycystic ovary syndrome: a position statement of the
Androgen Excess and Polycystic Ovary Syndrome Society. Fertil Steril
2009;92:1966 1982.
National Heart, Lung, and Blood Institute/National Institutes of Diabetes
and Digestive and Kidney diseases. Clinical Guidelines on the Identication,
Evaluation and Treatment of Overweight and Obesity in Adults. The Evidence
Report. Bethesda: National Institutes of Health, 1998;1 228.
National Institute for Clinical Excellence. Fertility Assessment and Treatment
For People with Fertility Problems. A Clinical Guideline. London: RCOG
Press, 2004.
Norman RJ, Noakes M, Wu R, Davies MJ, Moran L, Wang JX. Improving
reproductive performance in overweight/obese women with effective
weight management. Hum Reprod Update 2004;10:267 280.
Palomba S, Orio F Jr, Russo T, Falbo A, Cascella T, Colao A, Lombardi G,
Zullo F. Is ovulation induction still a therapeutic problem in patients with
polycystic ovary syndrome? J Endocrinol Invest 2004;27:796 805.
Palomba S, Russo T, Orio F Jr, Falbo A, Manguso F, Sammartino A,
Tolino A, Colao A, Carmina E, Zullo F. Uterine effects of clomiphene
in women with polycystic ovary syndrome: a prospective case
control study. Hum Reprod 2006a;21:2823 2829.
Palomba S, Orio F Jr, Falbo A, Russo T, Tolino A, Zullo F. Effects of
metformin and clomiphene citrate on ovarian vascularity in patients
with polycystic ovary syndrome. Fertil Steril 2006b;86:1694 1701.
Palomba S, Giallauria F, Falbo A, Russo T, Oppedisano R, Tolino A,
Colao A, Vigorito C, Zullo F, Orio F. Structured exercise training
programme versus hypocaloric hyperproteic diet in obese polycystic
ovary syndrome patients with anovulatory infertility: a 24-week pilot
study. Hum Reprod 2008;23:642 650.
Palomba S, Falbo A, Zullo F. Management strategies for ovulation
induction in women with polycystic ovary syndrome and known
clomifene citrate resistance. Curr Opin Obstet Gynecol 2009;21:465 473.
Pasquali R, Gambineri A, Pagotto U. The impact of obesity on reproduction in
women with polycystic ovary syndrome. BJOG 2006;13:11481159.
Ramlau-Hansen CH, Thulstrup AM, Nohr EA, Bonde JP, Sorensen TI,
Olsen J. Subfecundity in overweight and obese couples. Hum Reprod
2007;22:1634 1637.
Roeykens J, Rogers R, Meeusen R, Magnus L, Borms J, de Meirleir K.
Validity and reliability in a Flemish population of the WHO-MONICA
Optional Study of Physical Activity Questionnaire. Med Sci Sports
Exerc 1998;30:1071 1075.
Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group.
Revised 2003 consensus on diagnostic criteria and long-term health
risks related to polycystic ovary syndrome (PCOS). Hum Reprod 2004;
19:41 47.
Stamets K, Taylor DS, Kunselman A, Demers LM, Pelkman CL, Legro RS.
A randomized trial of the effects of two types of short-term hypocaloric
diets on weight loss in women with polycystic ovary syndrome. Fertil
Steril 2004;81:630 637.

Downloaded from http://humrep.oxfordjournals.org/ by guest on December 1, 2015

Ainsworth BE, Haskell WL, Whitt MC, Irwin ML, Swartz AM, Strath SJ,
OBrien WL, Bassett DR Jr, Schmitz KH, Emplaincourt PO.
Compendium of physical activities: an update of activity codes and
MET intensities. Med Sci Sports Exerc 2000;32:S498 S504.
Anderson JW, Konz EC, Frederich RC, Wood CL. Long-term weight-loss
maintenance: a meta-analysis of US studies. Am J Clin Nutr 2001;
74:579 584.
Balen AH, Laven JS, Tan SL, Dewailly D. Ultrasound assessment of the
polycystic ovary: international consensus denitions. Hum Reprod
Update 2003;9:505 514.
Branigan EF, Estes MA. A randomized clinical trial of treatment of
clomiphene citrate-resistant anovulation with the use of oral
contraceptive pill suppression and repeat clomiphene citrate
treatment. Am J Obstet Gynecol 2003;188:1424 1428.
Brown J, Farquhar C, Beck J, Boothroyd C, Hughes E. Clomiphene and
anti-oestrogens for ovulation induction in PCOS. Cochrane Database
Syst Rev 2009;4:CD002249.
Clark AM, Ledger W, Galletly C, Tomlinson L, Blaney F, Wang X,
Norman RJ. Weight loss results in signicant improvement in
pregnancy and ovulation rates in anovulatory obese women. Hum
Reprod 1995;10:2705 2712.
Clark AM, Thornley B, Tomlinson L, Galletley C, Norman RJ. Weight loss in
obese infertile women results in improvement in reproductive outcome for
all forms of fertility treatment. Hum Reprod 1998;13:15021505.
Cussons AJ, Stuckey BG, Walsh JP, Burke V, Norman RJ. Polycystic ovarian
syndrome: marked differences between endocrinologists and
gynaecologists in diagnosis and management. Clin Endocrinol (Oxf)
2005;62:289 295.
Dickey RP, Holtkamp DE. Development, pharmacology and clinical
experience with clomiphene citrate. Hum Reprod Update 1996;2:483506.
Ferriman D, Gallwey JD. Clinical assessment of body hair growth in
women. J Clin Endocrinol Metab 1961;21:1440 1447.
Gysler M, March CM, Mishell DR Jr, Bailey EJ. A decades experience with
an individualized clomiphene treatment regimen including its effect on
the postcoital test. Fertil Steril 1982;37:161 167.
Hoffman LK, Ehrmann DA. Cardiometabolic features of polycystic ovary
syndrome. Nat Clin Pract Endocrinol Metab 2008;4:215 222.
Huber-Buchholz MM, Carey DG, Norman RJ. Restoration of reproductive
potential by lifestyle modication in obese polycystic ovary syndrome:
role of insulin sensitivity and luteinizing hormone. J Clin Endocrinol
Metab 1999;84:1470 1474.
Imani B, Eijkemans MJC, te Velde ER, Habbema JD, Fauser BCJM.
Predictors of patients remaining anovulatory during clomiphene citrate
induction of ovulation in normogonadotropic oligoamenorrheic
infertility. J Clin Endocrinol Metab 1998;83:2361 2365.
Imani B, Eijkemans MJC, te Velde ER, Habbema JDF, Fauser BCJM.
Predictors of chances to conceive in ovulatory patients during
clomiphene citrate induction of ovulation in normogonadotropic
oligoamenorrheic infertility. J Clin Endocrinol Metab 1999;84:1617 1622.
Kousta E, White DM, Franks S. Modern use of clomiphene citrate in
induction of ovulation. Hum Reprod Update 1997;3:359 365.
Legro RS, Myers E. Surrogate end-points or primary outcomes in clinical
trials in women with polycystic ovary syndrome? Hum Reprod 2004;
19:1697 1704.

Palomba et al.

Lifestyle modications and CC-resistance

The ESHRE Capri Workshop Group. Anovulatory infertility. Hum Reprod

1995;10:1549 1553.
The Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop
Group. Consensus on infertility treatment related to polycystic ovary
syndrome. Hum Reprod 2008;23:462 477.
Thomson RL, Buckley JD, Moran LJ, Noakes M, Clifton PM, Norman RJ,
Brinkworth GD. The effect of weight loss on anti-Mullerian hormone
levels in overweight and obese women with polycystic ovary
syndrome and reproductive impairment. Hum Reprod 2009;
24:1976 1981.
Vigorito C, Giallauria F, Palomba S, Cascella T, Manguso F, Lucci R,
De Lorenzo A, Tafuri D, Lombardi G, Colao A et al. Benecial effects

2791
of a three-month structured exercise training program on
cardiopulmonary functional capacity in young women with polycystic
ovary syndrome. J Clin Endocrinol Metab 2007;92:1379 1384.
Willett W. Food Frequency Methods. Nutritional Epidemiology, 2nd edn.
Oxford, UK: Oxford University Press, 1998.
World Health Organization. Current Practices and Controversies in
Assisted Reproduction. Geneva, Swiss: World Health Organization
Press, 2002.
Zawadski JK, Dunaif A. Diagnostic criteria for polycystic ovary
syndrome; towards a rational approach. In: Dunaif A, Givens JR,
Haseltine F (eds). Polycystic Ovary Syndrome. Boston: Blackwell
Scientic, 1992;377 384.

Downloaded from http://humrep.oxfordjournals.org/ by guest on December 1, 2015