Nationwide survey on the usage of ovulation-induction agents among obstetricians and gynecologists in China
Ovulation disorders affect millions of women globally, and ovulation-induction therapy is often the first step toward pregnancy for those struggling to conceive. In China, most of these women are treated by general obstetricians and gynecologists (ob-gyns)—not infertility specialists. But how confident are these doctors in providing this care, and what drugs do they rely on most? A 2019 nationwide survey from Peking Union Medical College Hospital sheds light on these critical questions.
The study was led by Yan Deng, Yan-Fang Wang, Shi-Yang Zhu, Wei Xue, Xiao Ma, Rui-Lin Ma, and Ai-Jun Sun from the Department of Obstetrics and Gynecology at Peking Union Medical College Hospital (part of the Chinese Academy of Medical Sciences in Beijing). It involved 1,077 ob-gyns across 20 provinces who treat infertility, either as specialists (24.1%) or general practitioners (75.9%). Most (76.7%) had no formal training in infertility care.
Proficiency: Most Ob-Gyns Feel Unprepared
More than half of the respondents (55.4%) described their experience with ovulation induction as “limited” (20.5%) or “devoid” (34.9%). Only 10.1% felt “proficient,” and 34.4% rated their skills as “average.” Not surprisingly, specialists or those with infertility training were far more likely to feel confident: 24.6% of specialists vs. 5.5% of non-specialists reported being “proficient” or “average,” and 24.3% of trained doctors vs. 5.8% of untrained shared the same sentiment.
Drug Choices: Clomiphene Citrate Remains Top Pick, But Letrozole Gains Traction
Clomiphene citrate—a selective estrogen-receptor modulator used since the 1960s—was the first-line drug for 67% of ob-gyns. Letrozole, an aromatase inhibitor recommended as first-line for polycystic ovary syndrome (PCOS) by the American College of Obstetricians and Gynecologists (ACOG), was chosen by 16.6%.
Specialists were twice as likely to use letrozole: 41.5% of infertility specialists vs. 21.7% of general ob-gyns. Trained doctors also favored letrozole more (37.8% vs. 25% of untrained). This aligns with global trends: a 2013 U.S. survey found 78% of doctors used clomiphene first, while 15% picked letrozole.
Clomiphene Use: Gaps in Standardized Practice
While 85.1% of ob-gyns knew clomiphene should be taken for 5 days, only 43% understood it shouldn’t be used for more than 6 cycles—most (51.1%) thought 3 cycles was the limit. Specialists were more likely to follow the 6-cycle guideline (53.1% vs. 39.8% of non-specialists).
About 70.8% used the correct initial dose (50 mg), but trained doctors were less likely to do so (60.6% vs. 74% of untrained). Higher-ranked physicians (associate chief physicians) were 4 times more likely to use the right dose and duration, suggesting experience plays a key role in proper drug use.
Side Effect Awareness: Critical Knowledge Gaps
Knowledge of clomiphene’s risks was strikingly low:
- Only 50.9% knew it has anti-estrogenic effects.
- 51.1% understood it can thin the endometrium (the uterine lining needed for implantation).
- Just 37% knew it increases the risk of luteinized unruptured follicle syndrome (LUFS)—a condition where the follicle fails to release the egg.
Specialists were more aware of endometrial thinning but less so of LUFS compared to non-specialists.
What Do These Findings Mean?
The study highlights three urgent issues:
- Confidence Gap: Most ob-gyns treating infertility feel unprepared to perform ovulation induction.
- Drug Choice Gaps: While clomiphene is widely used, many don’t follow guidelines (e.g., 6-cycle limit) or use letrozole—even though it’s more effective for PCOS.
- Knowledge Gaps: Half of the doctors don’t understand clomiphene’s side effects, which can harm pregnancy chances (e.g., thin endometrium).
Specialists do better, but they’re a small minority. This means millions of women with ovulation disorders are getting care from doctors who lack the skills or knowledge to provide optimal treatment.
The Way Forward
The solution lies in training. General ob-gyns need pragmatic, evidence-based education on ovulation induction—covering drug choices, standardized use, and side effect management. This would help close the gap between specialist and general care, ensuring all women get safe, effective treatment.
Letrozole’s growing use by specialists is a positive sign, but more doctors need to adopt guideline-recommended practices. For PCOS, letrozole boosts ovulation (27% vs. 19% with clomiphene) and live births (24% vs. 18%)—making it a better first-line option.
References
- Legro RS, Brzyski RG, Diamond MP, et al. Letrozole versus clomiphene for infertility in the polycystic ovary syndrome. N Engl J Med 2014;371:119–129.
- Roque M, Tostes AC, Valle M, et al. Letrozole versus clomiphene citrate in polycystic ovary syndrome: systematic review and meta-analysis. Gynecol Endocrinol 2015;31:917–921.
- ACOG Practice Bulletin No. 194. Polycystic ovary syndrome. Obstet Gynecol 2018;131:e157–e171.
- Malloch L, Rhoton-Vlasak A. An assessment of current clinical attitudes toward letrozole use in reproductive endocrinology practices. Fertil Steril 2013;100:1740–1744.
- Pundir J, Psaroudakis D, Savnur P, et al. Inositol treatment of anovulation in women with polycystic ovary syndrome: a meta-analysis of randomised trials. BJOG 2018;125:299–308.
doi.org/10.1097/CM9.0000000000000450
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